Every finding on record at Woodland Care & Rehab Center

Based on interview and record review, the facility failed to protect one resident (Resident #1) from abuse when facility Certified Nurse Aide (CNA) B spoke and assisted the resident in an aggressive fashion when the resident refused care/assistance. The CNA yelled at the resident and then cursed in front of the resident. The CNA insisted the resident had to get up from bed after refusing, resulting in the resident being visibly upset, saying the CNA was rough with him/her and the CNA had punched him/her in the face. The resident did not have a history of aggressive behaviors or resisting care. The resident wanted to press charges and said he/she would kill the CNA if he/she saw him/her again. The CNA admitted to trying to make the resident get up for breakfast. The resident had multiple bleeding skin tears and blood on his/her face/lip that staff identified as new and not an outcome from normal provision of care. The facility census was 86.The Administrator was notified on 08/12/26, at 6:04 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 08/10/26. On 08/10/26, the Administrator suspended the accused CNA. The Director of Nursing (DON) completed pain and skin evaluations on Resident #1 and evaluated the resident for signs/symptoms of adverse psychosocial effects. On 08/10/26, the Administrator, DON, Assistant Director of Nursing (ADON), and License Practical Nurse (LPN) D interviewed all residents to ensure they felt safe with no negative findings and completed skin evaluations on non-verbal residents with no negative findings. On 08/10/26 and 08/11/26, the DON/designee educated all staff via in-servicing on the facility's abuse prevention policy and procedure, and appropriate de-escalation techniques. Staff began the full abuse investigation and completed interviews on 08/10/26. The facility implemented monitoring to ensure residents remained free of abuse. The IJ was corrected on 08/11/26.Review of the facility policy titled, Abuse, Neglect, and Exploitation, last reviewed 01/20/26, showed the following:-The facility is committed to protecting the residents from abuse, neglect, misappropriation of property, and exploitation by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. This also includes freedom from corporal punishment, involuntary seclusion, physical and/or chemical restraints not required to treat a medical symptom;-Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident;-Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;-Physical abuse/corporal punishment includes, but is not limited to hitting, slapping, punching, biting, and kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to pinching, spanking, slapping of hands, flicking or hitting with an object.1. Review of Resident #1's undated face sheet (a brief resident profile) showed the following:-admitted [DATE];-Diagnoses included dementia, cognitive communication deficit, and obstructive sleep apnea (breathing starting and stopping during sleep).Review of the resident's care plan, initiated on 06/15/26, showed the following:-Resident had an activities of daily living (ADLs) self-care performance deficit and will maintain current level of function with ADLs through the review date;-Resident required one staff assistance with most ADLs, including transfers.Review of the resident's annual Minimum Data Set (MDS-federally mandated assessment tool administered by staff), dated 06/16/26, showed the following:-Moderately cognitively impaired;-Substantial assistance of staff for transfers;-No documented skin conditions.Review of the resident's skin check performed by LPN A on 08/04/26, showed the resident had no current or new skin issues.During an interview on 08/12/26, at 4:24 P.M., Registered Nurse (RN) E said he/she worked on the overnight shift beginning 6:30 P.M. on 08/09/26 and ending 6:30 A.M. on 08/10/26. She provided care for the resident and did not observe any skin tears to his/her hands, arms, or any injuries to his/her face.Review of the facility investigation summary, dated 08/10/26, showed the following:-On 08/10/26, at approximately 7:40 A.M., the resident reported an allegation of physical and verbal abuse by CNA B. The resident said he/she refused to get out of bed, and CNA B forced him/her out of bed, struck him/her in the mouth, scratched his/her arm, and threatened to choke him/her, and gouge his/her eyes out. The resident had a skin tear to the left arm, an injury to the right arm and hand, and a swollen, bloody lip. CNA B denied the allegations stating the resident scratched his/her left arm on a grabbing tool, but had no recollection of the injury to the right arm/hand or swollen, bloody lip. Staff notified the administrator and suspended the alleged employee pending investigation. Staff ordered a right-hand x-ray related to pain with negative findings and psychiatric services are pending for the resident. Staff notified the physician, responsible party, police, and Department of Health and Senior Services of the incident. Staff initiated an investigation immediately and completed it with the allegation of abuse unsubstantiated due to conflicting accounts provided by the resident and CNA B, and the inability to interview CNA B again. Family did wish to have the resident evaluated at the emergency room, where the resident remains at this time.Review of CNA C's written statement, dated 08/10/26, showed the following:-CNA C heard yelling in the resident's room and entered the room;-The resident began to plead for help and demanded CNA B leave the room;-There were wounds and blood all over the resident's arms;-The resident claimed CNA B hurt him/her and tried to kill him/her;-CNA B said f*** this, I'm done, and left the room;-CNA C then began cleaning and assisting nurses to care for resident.During an interview on 08/12/26, at 2:16 P.M., CNA C said the following:-On 08/10/26, he/she asked CNA B to help the resident, and CNA B went into the room;-He/she had not seen CNA B for a while, so he/she walked past the resident's room and heard both the resident and CNA B yelling;-The resident was yelling for help and was saying CNA B was hurting him/her;-CNA B said stop aggressively and said we need to get up for breakfast, you're not laying in bed;-He/she knocked on the door, went inside and saw CNA B sitting in the resident's wheelchair directly across from the resident sitting on the side of his/her bed;-The resident said CNA B was beating him/her up, hurting him/her, and look what he/she did to my arms and punched me in the face;-The resident said he/she wanted to press charges and get this mother f***er out of my room. The resident threatened to kill CNA B;- CNA B said, f*** this, I am leaving. Before he/she left the room, CNA C asked him/her to get the nurse to care for the wounds;-CNA B left the room and LPN A and LPN D came in the room shortly after;-The resident had a small amount of blood dripping from his/her mouth and looked like he/she may have been punched;-The resident's right arm had tears from the wrist to the elbow, and he/she had similar wounds to the back of the left hand;-The skin was separated, and the blood started to coagulate (began to clot to stop bleeding). The blood was still dripping requiring a cloth be placed under his/her arm;-He/she had not seen the resident yet that morning;-The resident usually gets up about 8:00 A.M. and does not generally refuse to get up for him/her and had never been aggressive;-There is no type of care he/she would provide the resident that would result in those types of wounds;-He/she would honor the resident's choice to not get up and come back later to check;-He/she considered what he/she heard and observed between CNA B and the resident to be abuse. CNA B was very angry;-CNA B did not have any visible injuries.Review of CNA B's written statement, undated, showed the following:-CNA C asked me to change the resident;-I went to do so and did not even get in the door, and the resident denied me;-CNA C said it had to be done so I did;-The resident was not wanting to turn and said no when asked, but did want to get up for breakfast, which leads me to believe yes get up for breakfast;- Maybe I am wrong, whatever;- (He/she) never said no (and) never said stop, just called for an attendee which is me.Review of the written statement from the DON regarding an interview with CNA B at 08/10/26, at 8:17 A.M.;-CNA B said CNA C instructed him/her to get the resident up;-CNA B knocked on the resident's door and entered, and the resident began yelling at him/her to get the f*** out;-CNA B left the room to find another staff member to assist in getting the resident up for breakfast. CNA B could not locate assistance and returned to the resident's room;-CNA B explained he/she was attempting to get the resident up for breakfast. The resident declined stating he/she did not want to get up;-CNA B then informed the resident he/she needed to be changed and to get up for breakfast;-CNA B was changing the resident when the resident reached down toward the bottom of the bed and cut the resident's arm on an object/device located on a chair that is used to assist with grabbing items;-When asked if there were any other injuries or anything else occurred during the interaction, CNA B denied any other injuries and stated the incident as described above was all that occurred. Review of the resident's progress note, dated 08/10/26, showed the following:-At 7:45 A.M., LPN D completed wound rounds when LPN A asked for assistance in the resident's room due to obtained skin tears. LPN A walked into the room and observed CNA C trying to assist the resident who was very upset. LPN A obtained images of all the skin tears and approximated the skin and treated the area with steri-strips, triple antibiotic ointment, and Tegaderm (transparent, waterproof, and breathable medical film dressing) per physician order. While cleaning the wounds, LPN A noticed blood under the resident's fingernails. LPN A dressed the wounds. Two police officers were present, and the story changed to CNA B punched the resident and threw him/her down. The resident said he/she hit CNA B with the grabber stick. The resident said he/she was going to kill CNA B if he/she came in the room again. The resident also said he/she was going to get a gun. The resident said CNA B told him/her that he/she was getting up now and was very rough. The resident did not want to get up and was fighting with the staff member. CNA B's phone was found on the floor under the resident's bed. LPN A took CNA B outside. LPN A called the DON, the ADON, and the Administrator to make them all aware of the situation. CNA B was sent home. The resident complained of pain in the right hand, an immediate x-ray was ordered;-At 7:50 A.M., the DON assessed the resident immediately upon her arrival at the facility. The resident had skin tears noted to the left hand, right hand, right forearm, and right side of the lip. The DON observed blood underneath the fingernails of the resident's left hand with no identifiable focal point. The DON also noted dime sized blood on the left arm of the resident's chair that was pushed against the bed approximal to the chair back support as well as small approximate 1-2 millimeter (mm) blood on the call light clip and the resident's reacher tool. The resident reported pain to the right hand, described as sharp and burning, rated four out of ten. The DON offered Tylenol to the resident and the resident refused it at that time. The DON instructed the charge nurse to obtain an x-ray of the right hand, which was negative for acute findings. The wound nurse assessed and addressed the resident's wounds. Staff notified the resident's provider, durable power of attorney, law enforcement, administration, and Regional Nurse Consultant of the incident. Orders received for a psychiatric evaluation to further assess the resident and provide appropriate support.Review of the resident's pain assessment dated [DATE], at 7:50 A.M., showed the following: -Resident described pain to the back of the right hand as sharp and burning on a scale of four out of ten;-Resident stated nothing made the pain better and touching it and movement made the pain increase to seven out of ten scale;-Staff dressed the wound on the hand;-The resident was offered Tylenol and ice and refused both. Review of the resident's progress note, dated 08/10/26, showed the following:-At 12:28 P.M., a late entry showed, at approximately 8:30 A.M., the ADON went to the resident's room to obtain a statement. The resident said CNA B came into the room and told the resident he/she needed to get up for breakfast. The resident informed CNA B that he/she does not get up until 10:30 A.M. CNA B said the resident had to get up and began assisting him/her to the side of the bed and pulled on his/her arm to help the resident up to the side of the bed. The resident said CNA B was rough, and the resident grabbed the pole and began hitting CNA B until the resident knocked CNA B down. While CNA B was down, the resident kicked him/her in the side and put his/her foot on CNA B's throat to try to kill the aide. CNA B then stood up and struck the resident in the mouth and knees with his/her fist. The resident then began calling out for help, and CNA C came into the room to assist. CNA B left the room, and CNA C called out for help from the charge nurse. The charge nurse assessed the situation and requested assistance from the wound nurse in the hall at that time. The wound nurse documented the skin tears and cleansed and dressed the areas to the right forearm and hands per physician orders. The resident was found sitting in a recliner with bandages to the right forearm and both hands, dried blood to the right side of the mouth, and various spots on his/her hands and under the nails. The resident seemed calm at this time and allowed the ADON to assist with cleansing his/her hands and mouth.-The ADON documented on 08/10/26 at 12:00 P.M., he/she went to re-evaluate the resident's condition at 11:30 A.M. The resident's family member asked for bandages to the right forearm and hand to be changed due to soiling. The ADON assisted in cleansing of the areas and changeding bandages. The family member completed a phone call and informed the ADON of wanting the resident to be seen at a local hospital for an evaluation. The family member requested a list of the medications already administered for the day. The ADON obtained the face sheet and medications as requested to have on hand for emergency services arrival. Emergency services arrived at approximately 11:50 A.M. to transport the resident to the hospital.Review of the resident's skin assessment completed on 08/10/26, showed the following:-A skin tear was on the back of the right hand. A new wound, partial flap loss (when trauma separates the top skin layers and part of the tissue flap is missing or lost), was acquired in house on 08/10/26, with a length of 2.96 centimeters (cm), a width of 0.51 cm, depth of 0.10 cm. The area was 1.05 cm, epithelial 10% (damage to layer of cells that cover the body's surface), granulation 90% (new, pink or red connective tissue filled with tiny blood vessels that grows from the base of a wound during the healing process), and a light exudate (fluid) with active bleeding;-A skin tear was on the back of the left hand. A new wound with a total flap loss (skin flap completely missing), was acquired in house on 08/10/26, with a length of 2.11 cm, width of 3.73 cm, depth of 0.10 cm The area was 3.47 cm, epithelial 10%, granulation 90%, and moderate exudate with active bleeding;-A skin tear was on the right outer forearm. A new wound, total flap loss, was acquired in house on 08/10/26, with a length of 9.95 cm, width of 4.76 cm, and a depth of 0.10 cm, and moderate exudate with active bleeding.Review of the resident's current physician orders (POS), as of 08/12/26, showed the following:-An order dated 08/10/26, for wound care to cleanse the area to the left hand with wound cleanser, apply triple antibiotic ointment over the steri-strips, and secure with Tegaderm (clear waterproof and breathable medical film dressing). Change on the day shift every other day;- An order dated 08/10/26, for wound care to cleanse the area to the right hand with wound cleanser, apply triple antibiotic ointment over the steri-strips, and secure with Tegaderm. Change on the day shift every other day;-An order dated 08/10/26, for wound care to cleanse the area to the right lower arm with wound cleanser, apply triple antibiotic ointment over the steri-strips, and secure with Tegaderm. Change on the day shift every other day.Review of the Progressive Discipline Report and Plan, dated 08/11/26, showed the following:-CNA B entered the resident's room to assist with getting the resident up and out of bed. The resident refused to get up, and CNA B was rude and rough with handling the resident while getting him/her up and ready for the day. CNA B was sent home while the incident was investigated and has not responded to calls to assist with the investigation;-Due to CNA B's issues with customer service and attitude, and the failure to provide statements for the investigation, CNA B's employment was terminated.During an interview on 08/12/26, at 1:08 P.M., LPN D said the following:-On 08/10/26, LPN A came to get him/her to take pictures and measurements of the resident's wounds and to get treatments in place;-As soon as he/she walked into the room, he/she said CNA B needed to be out of the room, and he/she went outside;-The resident reported what happened, and he/she began to notify the DON, ADON, and Administrator.-LPN A brought CNA B back in the building and told him/her to leave the building;-He/she obtained supplies for treatment and completed the treatment;-He/she showed pictures of the wounds to the physician who ordered another treatment;-Law enforcement arrived during the second treatment and obtained pictures of the resident's right arm;-His/her initial observation was of the resident yelling and agitated with CNA C in the room attempting to calm the resident;-The resident had skin tears to the backs of both of hands and a skin tear to the right lower arm. He/she took measurements and documented them along with pictures;-He/she did not notice the injury to the resident's face initially because it was small, but the resident pointed it out later. It was a small laceration to the upper right lip with a small amount of dried blood;-The skin tears had been bleeding but were not actively running;-The resident has had only one other skin tear since admission from bumping his/her arm on the table;-The resident's injuries should not happen during normal care;-He/she would consider forcing care to be abuse;-CNA C located CNA B's cell phone under the resident's bed and brought it to him/her. He/She did not realize it was missing.During an interview on 08/12/26, at 2:47 P.M., LPN A said the following:-On 08/10/26, at approximately 7:30 A.M., CNA B came out of the resident's room and asked him/her to look at the resident's arm because there was blood on the arm;-He/she went in the room and observed skin tears on the resident's right arm and left hand;-He/she got the wound nurse to provide care;-LPN D cleaned up the resident's wounds;-He/she escorted CNA B outside from the nurses' station;-The resident said CNA B threw him/her on the bed and was really rough with him/her. CNA B punched him/her in the face. The resident would get a gun and kill CNA B. The resident rubbed the left side of his/her face.;-He/she did not see an injury on the resident's face. The resident had blood on his/her right arm and left hand. He/she would not expect that kind of injury from normal care;-CNA B said CNA C asked him/her to get the resident up. He/she was trying to change the resident and get him/her dressed and the resident started fighting him/her;-The resident reached for something on the side of the wheelchair and when his/her arm came back there was some blood on the resident's arm. The resident then reached for something at the side of the bed or reached for the side of the bed. CNA B saw blood and thought the resident hit a screw on top of a grabber or something;-CNA B said the resident said he/she was not going to get up. He/she was trying to get the resident changed and up for breakfast;-LPN A told CNA B when the resident said no to providing care he/she should have left the room, and he/she should have notified the nurse at the first sight of blood. CNA B said he/she didn't realize and was sorry;-He/she walked CNA B up to complete a statement and clock out to leave. He/she did not observe any injuries on CNA B;-He/she returned to the resident's room with the DON. The resident said CNA B punched him/her in the throat and mouth and attempted to choke him/her. The resident did not state what caused the injuries to the arms;-He/she considers continuing to provide care to a resident once he/she has refused to be abuse;-He/she did not feel comfortable stating this issue was abuse, but it should be reported to management immediately and the state agency within two hours;-He/she performed the last skin check on the resident prior to this incident on 08/04/26, with no current skin tears or wounds present;-He/she had never observed the resident to be aggressive. Review of the ADON's documentation titled, Alleged Abuse, dated 08/10/26, showed the following:-On 08/10/26, at approximately 8:30 A.M. the ADON entered the resident's room to obtain a statement;-The resident said CNA B came into the room and told the resident he/she needed to get up for breakfast;-The resident informed CNA B that he/she does not get up until 10:30 A.M.;-CNA B said the resident has to get up and began assisting the resident to the side of the bed and pulled on the resident's arm to assist the resident up to the side of the bed;-The resident said CNA B was rough with him/her, and the resident grabbed his/her pole and began hitting CNA B with until the resident knocked CNA B down;-While CNA B was down, the resident kicked CNA B in the side and put his/her foot on CNA B's throat to try to kill him/her;-The resident said CNA B stood up and struck the resident in the mouth and knees with his/her fist;-The resident stated he/she began to call out for help;-CNA C came into the room to assist;-CNA B left the room at this time, and CNA C called out for help from the charge nurse;-LPN A assessed the situation and requested assistance from LPN D who was the wound nurse on the hall at the time;-LPN D documented skin tears, cleansed and dressed areas to right forearm and hands per the physician orders.During an interview on 08/13/26, at 2:21 P.M., the ADON said the following: -Staff should always honor resident preferences for care provided, including bed times/morning times;-LPN D notified her of the incident;-The ADON interviewed the resident at approximately 8:30 A.M.;-The resident said CNA B came in his/her room and told him/her it was time to get up. The resident advised CNA B that he/she does not get up until 10:30 A.M. CNA B said we are going to get up and began pulling on the resident. The resident hit CNA B with the reacher about three-four times until CNA B went down, then the resident put his/her foot on the CNA B's throat and tried to kill him/her;-She cleaned up some of the blood on the resident's hands and fingernails and wiped the dried blood from his/her mouth;-She noticed the reacher sitting on his bedside table with dried blood on the handle, the shaft and a few minimal drops on the grabber part;-She notified law enforcement. Review of the DON's written statement, undated, showed the following:-The DON was notified at approximately at 7:40 A.M. of a possible allegation of staff to resident abuse involving CNA B and the resident. Upon notification of the potential allegation of abuse, the resident was immediately made safe, and CNA B was removed from the facility and placed on suspension pending the outcome of the investigation;-Upon the DON's arrival, the resident was immediately assessed;-Skin tears were noted to the left hand, right hand, right forearm, and right side of the lip;-Blood was observed underneath the fingernails of the resident's left hand with no identifiable focal point;-The resident reported pain to the right hand, described as sharp and burning, rated 4/10;-Tylenol was offered and refused at that time;-The charge nurse was instructed to immediately obtain an x-ray of the resident's right hand, which was negative for acute findings;-The resident said CNA B entered the resident's room at approximately 6:00 A.M., to assist with getting him/her out of bed;-The resident reported he/she informed CNA B that he/she does not get out of bed until approximately 10:30 A.M.;-The resident said CNA B insisted he/she get up and began to change the resident;-The resident alleged CNA B became angry when he/she refused to get up, grabbed his/her arm, and scratched down his/her arm;-The resident further alleged CNA B punched him in the face and threatened to choke him/her and gouge his/her eyes out;-The resident also said if CNA B returned to the facility he/she would get a gun and shoot him/her;-It was subsequently verified that CNA B did not arrive to the facility until 6:45 A.M.;-The resident's wounds were assessed and addressed by the wound nurse;-The resident's provider, durable power of attorney, police department, administration, and regional nurse consultant were notified of the incident;-Orders were received for psychiatric evaluation to further assess the resident and provide appropriate support;-The incident remains under investigation and additional findings, interviews, and interventions will be documented as information becomes available.During an interview on 08/12/26, at 3:57 P.M., the DON said the following:-It is a resident's preference to receive treatment or not, to get out of bed or not, to go to breakfast or not;-Staff forcing a resident to get up could be considered abuse;-The facility did not substantiate this incident as abuse due to the resident's story changing and not being able to fully interview CNA B;-Cursing in front of a resident can be considered abuse if the resident considers cursing a violation of his/her rights;-There is no documentation of the resident having aggressive tendencies;-The resident does refuse cares, but she is unsure if this is documented.During an interview on 08/12/26, at 5:13 P.M., the administrator said the following:-A situation where a staff member continues to provide care once a resident refused could be considered abuse, but would depend on the situation and what was occurring;-The resident gave different stories of how the injuries occurred, but was consistent about who caused the injuries;-The injuries the resident sustained should never be caused by care being provided by staff;-Interviews with staff prior to the shift of this incident showed the resident did not have any injuries;-He/she has been told by staff the resident has been combative, but unsure of what staff. Staff have not documented the resident to be combative in the electronic record.During an interview on 08/14/26, at 11:45 A.M., the medical director said the following:-Staff should honor a resident's right to refuse care;-He would consider it abuse for a staff member who continued to provide care a resident had refused;-He observed the wounds from pictures taken prior to wrapping. The wounds would not be a result from any normal type of care provided.Incident 3132427, 3152934Complaint 3154180, 3154260, 315406

Based on interview and record review, the facility failed to update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to develop and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 86. Review of the facility policy/template titled, Requirements of Participation: Facility assessment, revised July 2024, showed the facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. Review of the facility assessment provided showed it had last been reviewed/revised on 11/13/24. During interviews on 08/14/26, at 9:03 A.M. and 12:10 P.M., the administrator said the facility assessment provided as the current one had not been reviewed since 2024. She is currently working on a new one. The management team including herself, the medical director, Director of Nursing, Assistant Director of Nursing assist with the facility assessment. The administrator is responsible for making sure it is updated. The facility assessment should be reviewed/updated annually. If any changes need to be made, it should be completed at that time. It was last reviewed/revised in 2024 or whatever the date showed on there. During an interview on 08/14/26, at 11:55 A.M., the corporate nurse said she provided the facility assessment policy and the template. The administrator is still working on the new facility assessment for the new company.

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of one resident (Resident #2), when staff failed to administer two medications as ordered by the physician and failed to notify the nurse and physician of two medications being unavailable for administration over a period of eight days. The facility failed to ensure staff administering medications used their own usernames and passwords to document medication administration. The facility census was 86. Review of the facility policy titled, Medication Administration and General Guidelines, dated January of 2026, showed the following:-Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in link RX otherwise authorized personnel should refer to drug reference material provided by the facility; -Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications; -Medications are administered in accordance with written orders of the attending physician; -All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR);-Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residence MAR at the time the medication is given. At the end of each medication pass, the person administrating the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medication report off duty without first recording the administration of any medications;-Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the Med must be given 30 minutes prior to 30 minutes after the specified time unless facility policy directs otherwise. Before or after meal orders are administered precisely as ordered unless otherwise specified by the physician routine medications are administered according to the established medication administration schedule for the facility;-The resident's MAR is initialed by the person administrating a medication, in the space provided under the date and on the line for that specific medication dose administration. Or if utilizing an electronic medical record, the initials of the nurse are electronically stamped into the record all licensed personnel/nurses will be assigned a secure password which will not be shared or given out to other personnel;-If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered onto the reverse side of the record provided for as needed (PRN) documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized, the caregiver administering the medication will enter the correct documentation that will then be electronically date slash time stamped with their initials.1. Review of Resident #2's undated face sheet (a brief resident profile) showed the following:-admitted [DATE];-Diagnoses included unspecified paroxysmal atrial fibrillation (intermittent and irregular heart rhythms coming from the upper heart chamber), history of stroke, atrial flutter (an abnormal heart rhythm where the upper chambers beat very fast), type two diabetes mellitus, hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone ), and high blood pressure.Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool) administered by staff, dated 05/05/26, showed the following:-Moderate cognitive impairment;-Required supervision to partial assistance from staff for most activities of daily living (ADLs).Review of the resident's care plan, last revised 07/23/26, showed the following:-Resident had altered cardiovascular status;-Resident will be free from complications of cardiac problems through the review date;-Assess fingers and toes for warmth and color;-Assess for chest pain. Enforce the need to call for assistance if pain starts;-Monitor vital signs and notify physician of significant abnormalities;-Monitor, document, report as needed any changes in lung sounds, swelling, and changes in weight;-Observe for shortness of breath and/or cyanosis (bluish or purplish color of the skin and mucous membranes) and report to physician as indicated.Review of the resident's current physician order showed an order, dated 05/19/26, for Levothyroxine Sodium Oral Tablet 88 microgram (mcg) (used to treat an underactive thyroid), give one tablet one time a day related to hypothyroidism.Review of the resident's August 2026 MAR showed the following:-An order dated 05/19/26, for Levothyroxine Sodium Oral Tablet 88 mcg (used to treat an underactive thyroid), give one tablet one time a day related to hypothyroidism;-Staff documented the resident was out of the facility on 08/01/26, 08/02/26, 08/03/26, and 08/13/26;-Staff documented the medication was not administered on 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/08/26, 08/09/26, 08/11/26, and 08/12/26.Review of the resident's progress notes showed the following:-On 08/04/26, at 5:24 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication not available;-On 08/05/26, at 5:15 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication not available;-On 08/06/26, at 5:02 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication not available;-On 08/07/26, at 5:12 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Not available;-On 08/08/26, at 3:46 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication has been ordered. Waiting on delivery;-On 08/08/26, at 3:46 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication has been ordered. Nurse notified;-On 08/11/26, at 5:33 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication not available;-On 08/12/26, at 5:27 A.M., Levothyroxine Sodium Oral Tablet 88 mcg give one tablet one time a day related to hypothyroidism. Medication not available.Review of the resident's current physician order sheet showed an order dated 08/03/26, for Digoxin oral tablet 125 mcg (used to treat chronic heart failure and control irregular heart rhythms), give one tablet by mouth in the evening for atrial fibrillation. Review of the resident's August 2026 MAR showed the following:-An order dated 08/03/26, for Digoxin oral tablet 125 mcg (used to treat chronic heart failure and control irregular heart rhythms), give one tablet by mouth in the evening for atrial fibrillation;-Staff documented the resident was out of the facility on 08/05/26;-Staff documented the medication was not administered on 08/04/26, 08/06/26, 08/07/26, 08/08/26, 08/10/26, 08/11/26, and 08/12/26;-Staff documented administering the medication on 08/09/26. Review of the resident's progress notes from August of 2026 showed the following:-On 08/03/26, at 5:56 P.M., order entered for Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation;-On 08/04/26 at 5:15 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Drug unavailable. Nurse aware. Waiting on pharmacy. New order;-On 08/06/26, at 3:20 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Medication unavailable. Nurse notified;-On 08/07/26, at 5:15 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Blood pressure is too low 96/48;-On 08/08/26, at 4:46 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Drug unavailable. Nurse aware. Waiting on pharmacy;-On 08/10/26, at 3:23 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Medication unavailable. Nurse notified;-On 08/11/26, at 4:14 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Medication unavailable. Nurse notified;-On 08/12/26, at 3:31 P.M., Digoxin oral tablet 125 mcg give one tablet by mouth in the evening for atrial fibrillation. Medication unavailable. Nurse notified.During an interview on 08/13/26, at 4:04 P.M., Certified Medication Technician (CMT) I said the following:-Staff utilize the MAR for medication administration;-CMTs do not enter orders;-CMTs pass scheduled prescription and over the counter medications, and nurses pass narcotics and insulin;-He/she checks the overflow, medication room, and central supply when a medication is not available;-CMTs do not have access to emergency kits (E-kits);-He/she would notify the nurse if unable to find a medication, and the nurse would pull from the E-kit if available;-If the medication is not available at the facility, staff should notify the pharmacy, and the nurse should notify the physician;-He/she documented administering Digoxin on 08/09/26, which was a documentation error.During an interview on 08/13/26, at 12:49 P.M., CMT G said the following:-If a resident's medication is unavailable, he/she checks the overflow in the medication cart and the medication room;-If cannot locate the medication, reorder from the pharmacy, document in the MAR unavailable, notify the nurse, and the nurse notifies the physician.During an interview on 8/13/26, at 1:47 P.M., Registered Nurse (RN) H said the following:-New orders are entered by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if the physician is in the building. If the order comes from the physician by phone or the medication log, a nurse enters the order;-Staff utilize the MAR for administering medications;-CMTs pass medications such as Digoxin and Levothyroxine and should notify the nurse if the medications are unavailable;-Nurses should call the pharmacy, pull from emergency kit (E-kit), and notify the physician and Administrator if a medication is unavailable.During interviews on 08/13/26, at 2:21 P.M. and 3:52 P.M., the ADON said the following:-The physician enters orders in the MAR when at the facility, and nurses enter handwritten orders in the MAR. DON/ADON confirm the orders;-Staff should utilize the MAR for administering medication;-Nurses administer narcotics, insulin, as needed medications (PRN), and treatments. CMT's administer all other medications;-CMTs should pull medication from the overflow drawer if available. If medication is not in the overflow drawer, the CMT should notify the nurse. Nurses can pull medications from the E-kit;-New orders should be delivered on the same day or by the next morning. If not received by the next morning, staff should call the pharmacy and notify the physician;-She did not know the resident was not receiving the Digoxin or Levothyroxine. During an interview on 8/14/26, at 11:25 A.M., the DON said the following:-Staff use the MAR for medication pass;-CMTs should check overflow at the bottom of the medication cart and medication room for unavailable medications. If the medication is still unavailable, CMTs should notify the nurse to check the E-kit, and then notify the pharmacy;-Levothyroxine and Digoxin are available in the E-kit; -CMTs can call the pharmacy for all medications except narcotics, but it is ultimately the nurses' responsibility to ensure the pharmacy is notified;-Nurses should notify the DON and physician if a medication is not available on the first day it is ordered to be administered.During an interview on 08/14/26, at 11:45 A.M., the Medical Director said the following:-Missing doses of Levothyroxine could cause a resident to feel run down and have constipation;-Missing doses of Digoxin could cause a resident to have an increase in heart rate, which could restart atrial fibrillation, cause loss of consciousness, potential for blood clots and exacerbate heart failure. During an interview on 08/14/26, at 12:11 P.M., the Administrator said the following:-Staff use the MAR to pass medications;-CMTs should check overflow for unavailable medications then notify the nurse to pull from the E-kit and notify the physician;-Residents should never go for eight days without a medication. 2. Review of Resident #2's current physician order showed an order dated 08/03/26, for Digoxin oral tablet 125 microgram (used to treat chronic heart failure and control irregular heart rhythms), give one tablet by mouth in the evening for atrial fibrillation. Review of the resident's MAR for August of 2026 showed the following:-An order dated 08/03/26, for Digoxin oral tablet 125 micrograms (used to treat chronic heart failure and control irregular heart rhythms), give one tablet by mouth in the evening for atrial fibrillation;-Staff used the initials TaSh to document the medication was not administered on 08/10/26, 08/11/26, and 08/12/26;-The long username for the initial's TaSh was the ADON. During an interview on 08/13/26, at 3:28 P.M., CMT G said the following:-He/she began passing medications on or around 07/18/26;-He/she has had no access to the MAR since he/she began passing medications;-He/she has only logged in using the ADON's sign on for passing medications under the CMT MAR.During interviews on 08/13/26, at 2:21 P.M. and 3:52 A.M., the ADON said the following:-CMT G utilized her sign on for the MAR to administer medications on 08/10/26, 08/11/26, and 08/12/26, because she did not have a sign on herself;-CMT G's title changed from CNA to CMT, and he/she has not had his/her own sign on since that time, but CMT G has only used her (ADON) sign on in the MAR to pass medications;-This could be an issue with inaccuracy of records;-She does not believe this is the correct policy, but in order to utilize CMT G in his/her position a sign on is required, which the facility has attempted to obtain from corporate.During an interview on 8/13/26, at 1:47 P.M and 4:13 P.M., RN H said the following:-The user initials on the resident's MAR documentation for 08/10/26, 08/11/26, and 08/12/26, was the ADON's sign on for the MAR;-Staff should not use other staff's sign on for administering meds in the MAR;-He/she did not know CMT G used the ADON's sign on to administer medications.During an interview on 8/14/26, at 11:25 A.M., the DON said the following:-Staff use the MAR to pass medications;-Staff are assigned specific sign-ons to use individually and should not be using another staff member's sign on to pass medications for accuracy of records.During an interview on 08/14/26, at 12:11 P.M., the Administrator said CMTs and nurses should only use their own usernames and passwords to pass medications in the MAR.Complaint #3117233

Based on observation, interview, and record review, the facility failed to post nursing staff information that contained the correct facility name, the total number of hours worked for nursing staff, and consistently include the facility census and accurate shift descriptions for staff directly responsible for nursing care. The facility census was 86.Review of the facility's direct care staff daily report policy, last reviewed 03/12/26, showed the following information:-It will include actual hours and total hours worked;-The staffing coordinator/designee will post direct care staff daily report for all shifts on a daily basis. -Record total number of hours and actual number of hours worked by licensed/unlicensed staff who perform direct care;-Direct care are individuals providing resident care or individuals who are providing supervision to direct care employees;-The staff posting form will be displayed near the front entrance available for residents, families, employees, and the public to review. The posting will be changed daily at the beginning of day shift;-The posting will include facility name, date, census, shifts for 24 hour period, total number of licensed nursing staff worked per shift, total number of unlicensed nursing staff worked per shift, actual time worked for the specific categories of nursing staff.Review of a facility all-staff inservice, dated 05/15/26, showed the facility's new shift hours were 6:30 P.M.-7:00 A.M. and 7:00 A.M.-7:00 P.M.Review of the daily floor staffing sheets, dated 07/01/26 through 07/31/26 showed the facility had two shifts for all general nursing floor staff, day shift (7:00 A.M. to 7:00 P.M.) and Night shift (7:00 P.M. to 7 :00A.M.). The staffing sheet listed the restorative staff hours as 8:30 A.M. to 5:00 P.M. and bath aides as 5:00 A.M. to 1:00 P.M. All other hours would be marked next to the employee's name.Review of the facility's daily staffing roster showed the following information:-Date 07/01/26;-The facility's former name, not the current name. -It did not include the census. -Day shift (7:00 A.M. to 7:00 P.M.): two registered nurses (RNs), one licensed practical nurse (LPN) and three certified medication technicians (CMTs) . -Night shift (7:00 P.M. to 7:00 A.M.): two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.) five certified nursing assistants (CNAs), 1 nursing assistant (NA) ; -Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), seven CNAs;-One restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M.), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staffing roster showed the following information:-Date 07/02/26;-The facility's former name, not the current name;-Census of 88;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), eight CNAs, one NA;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staffing roster showed the following:-Date 07/03/26;-The facility's former name, not the current name;-It did not list the facility census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staffing roster showed the following:-Date 07/04/26,-The facility's former name, not the current name;-It did not list the facility census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, three LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), three LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/05/26;-The facility's former name, not the current name;-It did not show the census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs.Review of the facility's daily staff roster showed the following information:-Date 07/06/26;-The facility's former name, not the current name;-It did not show the census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs, one NA;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/07/26;-The facility's former name, not the current name;-Census of 88;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, three CMTS-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs, one NA;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), five CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Dated 07/15/26;-The facility's former name, not the current name;-Census 89;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/16/26;-The facility's former name, not the current name;-The census was not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPN, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), three LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), five CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/17/26;-The facility's former name, not the current name;-The census was not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/18/26;-The facility's former name, not the current name;-The census was not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/19/26;-The facility's former name, not the current name;-It did not list the census;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), four CNAs;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/20/26;-The facility's former name, not the current name;-It did not list the census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), five CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/21/26;-The facility's former name, not the current name;-Census was 84;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNS, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), eight CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/22/26;-The facility's former name, not the current name;-Census was 84;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs, one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), seven CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/23/26;-The facility's former name, not the current name;-Census was 78;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), eight CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), two bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/24/26;-The facility's former name, not the current name;-Census was 89;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, three LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), three LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/25/26;-The facility's former name, not the current name;-Census not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN and two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/26/26;-The facility's former name, not the current name;-Census not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/27/26;-The facility's former name, not the current name;-Census not listed;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, three LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/28/26;-The facility's former name, not the current name;-Census was 86;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), eight CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), one CNA documented;-Night shift (11:00 P.M. to 7:00 A.M.), seven CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/29/26;-The facility's former name, not the current name;-Census was 86;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, three LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/30/26;-The facility's former name, not the current name;-It did not list the census;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), three LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), five CNAs and one NA;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 07/31/26;-The facility's former name, not the current name;-The census was 86;-Day shift (7:00 A.M. to 7:00 P.M.), two RNs, one LPN, and three CMTS, one orientee (did not designate type);-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs, and one orientee (did not designate type);-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7P, six CNAs and one orientee (did not designate type)-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7P, five CNAs and one orientee (did not designate type);-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 08/01/26;-The facility's former name, not the current name;-Census was 84;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), three LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7A, six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7P, six CNAs;-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), three bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 08/02/26;-The facility's former name, not the current name;-Census was 86;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, three LPNs, and two CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7PM, six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7AM,-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 08/08/26;-The facility's former name, not the current name;-The census was 88;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN, two LPNs, one CMT, and one orientee (did not designate the type);-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7PM, six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7PM, five CNAs and one orientee (did not designate the type);-It did not show the total and actual hours worked for RN, LPN, and CNA staff.Review of the facility's daily staff roster showed the following information:-Date 08/09/26;-The facility's former name, not the current name;-Census was 89;-Day shift (7:00 A.M. to 7:00 P.M.), one RN, two LPNs, and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), two RNs and one LPN;-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7PM, six CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7PM, three CNAs;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.During an interview on 08/12/26, at 10:47 A.M., LPN F said nurses and CNAs work 12 hour shifts, 6:30 A.M. to 7:00 P.M., with the overlap to give report.Observation on 08/14/26, at 8:23 A.M., showed the facility's daily staff roster posted on the window by the receptionist desk upon entry from the front door. It showed the following information:-Date 08/13/26 (previous day);-The facility's former name, not the current name;-Census was 86;-Day shift (7:00 A.M. to 7:00 P.M.), three RNs and three CMTs;-Night shift (7:00 P.M. to 7:00 A.M.), one RN and two LPNs;-Day shift (7:00 A.M. to 3:00 P.M.), staff crossed out 3PM and handwrote 7PM, seven CNAs;-Evening shift (3:00 P.M. to 11:00 P.M.), no staff listed, staff drew a line through the shift;-Night shift (11:00 P.M. to 7:00 A.M.), staff crossed out 11PM and handwrote 7PM, five CNAs-It listed one restorative aide with no shift or hours documented;-For bath aide (5:00 A.M. to 1:00 P.M. shift), two bath aides;-It did not show the total and actual hours worked for RN, LPN, and CNA staff.During an interview on 08/14/26, at 11:25 a.m., the Director of Nursing said she is not involved with the staff posting. The receptionist does the staff posting.During an interview on 08/14/26, at 12:10 p.m. the administrator said the staff posting should include the facility census, amount of staff working that day, and the RN supervisor. It should include the correct shifts. It should include the total hours worked for each type of staff. The receptionist is responsible for completing the form. She collects the schedule daily, makes a copy and takes the staffing from the daily schedule.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurate when staff failed to document medication administrations during a multi-day internet/phone outage for four residents (Resident #1, #2, #3, and #4). The census was 87.Review of the facility's policy titled, Administering Medication, revised 04/19, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions;-Medications are administered in accordance with prescriber orders, including any required time frame;-Medication administration times are determined by resident need and benefit, not staff convenience;-Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders);-If a drug is withheld, refused, or given at a time other the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose;-The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones;-As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug;-Topical medications used in treatments are recorded on the resident's Treatment Administration Record (TAR). Review of the facility's policy titled, Charting and Documentation, revised 07/17, showed the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care;-Documentation in the medical record may be electronic manual or a combination;-The following information is to be documented in the resident medical record, medications administered, treatments or services performed, and changes in the resident's condition;-Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate;-Documentation of procedures and treatments will include care-specific details, including, The date and time the procedure/treatment was provided, named and title of the individual providing the care, and whether the resident refused the procedure/ treatment.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 01/09/25;-Diagnoses included complete traumatic amputation at level between right hip and knee, urinary tract infection, complete traumatic amputation at level between right hip and knee, and type II diabetes. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/25/25, showed the following:-Cognitively intact;-The resident had taken antianxiety, anti-depressant, anticoagulant (prevents the blood from clotting as quickly), diuretic (used to help removed fluid through the kidneys), and insulin medication in the last seven days. Review of the resident's care plan, dated 12/26/25, showed the following:-The resident is on a diuretic due to edema (swelling) or hypertension (high blood pressure);-The resident has a diagnosis of hypothyroidism (thyroid does not provide sufficient thyroid hormone levels in the body);-The resident has diabetes mellitus;-The resident uses an anticoagulant and is at risk of abnormal bleeding, hemorrhage (loss of blood from a damaged vessel), and for increased/easy bruising due to anticoagulant medication.Review of the resident's January 2026 Physicians Order Sheet (POS) showed an order, dated 01/09/25, for aspirin tablet chewable, 81 milligram (mg), one tablet every morning.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/09/25, for aspirin tablet chewable, 81 mg, one tablet every morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, and 01/11/26.Review of the resident's Electronic Medical Record (EMR) MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/09/25, for aspirin tablet chewable, 81 mg one tablet every morning;-Staff did not document administration on 01/08/26 and 01/09/26.Review of the resident's January 2026 POS showed an order, dated 11/13/25, for blood glucose monitoring four times a day.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/13/25, for blood glucose monitoring four times a day;-Staff did not document blood glucose monitoring on 01/07/26 nighttime, 01/08/26, 01/09/26, 01/10/26 nighttime, 01/11/26 nighttime, and 01/12/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 11/13/25, for blood glucose monitoring four times a day;-Staff did not document blood glucose monitoring on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/09/25, for fenofibrate (medication used to treat cholesterol) tablet, 54 mg, administer one tablet, once a morning/Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/09/25, for fenofibrate tablet, 54 mg, administer one tablet, once a morning;-Staff did not document administration on 01/08/26 and 01/09/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/09/25, for fenofibrate tablet, 54 mg, administer one tablet, once a morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, or 01/11/26;Review of the resident's January 2026 POS showed an order, dated 12/28/25 to 01/15/26, for florasave (probiotic) capsule, delayed release, 10 billion cell - 15mg, administer one tablet once every morning, give one tablet for 20 days.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 12/28/25 to 01/15/26, for florasave capsule, delayed release, 10 billion cell -15mg, administer one tablet once every morning, give one tablet for 20 days;-Staff did not document administration on 01/08/26 and 01/09/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 12/28/25 to 01/15/26, for florasave capsule, delayed release, 10 billion cell -15mg, administer one tablet once every morning, give one tablet for 20 days;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 03/06/25, for furosemide tablet (diuretic medication), 40 mg, take once a morning by mouth daily in the morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 03/06/25, for furosemide tablet, 40 mg, take once a morning by mouth daily in the morning;-Staff did not document administration on 01/09/26 and 01/10/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 03/06/25, for furosemide tablet, 40 mg, take once a morning by mouth daily in the morning;-Staff did not document administration on 01/06/25, 01/07/26, 01/08/26, 01/09/26, 01/10/26, or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/13/25, for Novalog (rapid actin insulin) FlexPen U-100 Insulin, Insulin pen 100 unit/ml, administer per the following sliding scale:-If blood sugar is 150 milligrams/deciliter (mg/dL) to 200 mg/dL, administer two units of insulin;-If blood sugar is 201 mg/dL to 250 mg/dL, administer 4 units of insulin;-If blood sugar is 251 mg/dL to 300 mg/dL, administer 6 units of insulin;-If blood sugar is 301 mg/dL to 350 mg/dL, administer 8 units of insulin;-If blood sugar is 351 mg/dL to 400 mg/dL, administer 10 units of insulin;-If blood sugar is 401 mg/dL to 500 mg/dL, administer 12 units of insulin;-If blood sugar is greater than 500 mg/dL, call the physician.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/13/25, for Novalog FlexPen U-100 Insulin, Insulin pen 100unit/ml, administer per the following sliding scale:-If blood sugar is 150 milligrams/deciliter (mg/dL) to 200 mg/dL, administer two units of insulin;-If blood sugar is 201 mg/dL to 250 mg/dL, administer 4 units of insulin;-If blood sugar is 251 mg/dL to 300 mg/dL, administer 6 units of insulin;-If blood sugar is 301 mg/dL to 350 mg/dL, administer 8 units of insulin;-If blood sugar is 351 mg/dL to 400 mg/dL, administer 10 units of insulin;-If blood sugar is 401 mg/dL to 500 mg/dL, administer 12 units of insulin;-If blood sugar is greater than 500 mg/dL, call the physician;-Staff did not document administration on 01/07/26 nighttime, 01/08/26, 01/09/26, 01/10/26 nighttime, 01/11/26 nighttime, and 01/12/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 11/13/25, for Novalog FlexPen U-100 Insulin, Insulin pen 100unit/ml, administer per the following sliding scale:-If blood sugar is 150 milligrams/deciliter (mg/dL) to 200 mg/dL, administer two units of insulin;-If blood sugar is 201 mg/dL to 250 mg/dL, administer 4 units of insulin;-If blood sugar is 251 mg/dL to 300 mg/dL, administer 6 units of insulin;-If blood sugar is 301 mg/dL to 350 mg/dL, administer 8 units of insulin;-If blood sugar is 351 mg/dL to 400 mg/dL, administer 10 units of insulin;-If blood sugar is 401 mg/dL to 500 mg/dL, administer 12 units of insulin;-If blood sugar is greater than 500 mg/dL, call the physician;-Staff did not document administration on 01/06/25, 01/07/26, 01/08/26, 01/09/26, 01/10/26 or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/18/25, for Novalog flexpen U-100 Insulin (Insulin aspart U-100) Insulin pen, 100 unit/ml, 18 units subcutaneous (below the skin).Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/18/25, for Novalog flexpen U-100 Insulin (Insulin aspart U-100), Insulin pen, 100 unit/ml, 18 units subcutaneously;-Staff did not document administration on 01/08/26, 01/09/26 and 01/12/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 11/18/25, for Novalog flexpen U-100 Insulin (Insulin aspart U-100), Insulin pen, 100 unit/ml, 18 units subcutaneous;-Staff did not document administration on 01/06/25, 01/07/26, 01/08/26, 01/09/26, 01/10/26, or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 05/16/25, for levothyroxine tablet (synthetic thyroid hormone), 25 microgram (mcg), oral once a day, give one tablet every morning by mouth.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 05/19/25, for levothyroxine tablet, 25 mcg, oral once a day, give one tablet every morning by mouth;-Staff did not document administration on 01/09/25, 01/10/26, 01/11/26, and 01/12/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 05/19/25, for levothyroxine tablet, 25 mcg, oral once a day, give one tablet every morning by mouth;-Staff did not document administration on 01/06/25, 01/07/26, and 01/08/26.Review of the resident's January 2026 POS showed an order, dated 01/09/25, for Jardiance (antidiabetic medication), 25mg tablet, administer one tablet in the morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/09/25, for Jardiance, 25 mg tablet, administer one tablet in the morning;-Staff did not document administration on 01/09/26 and 01/10/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/09/25, for Jardiance 25mg tablet, administer one tablet in the morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 or 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/09/25, for Plavix (antiplatelet medication), tablet 75 mg, one tablet in the morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order , dated 01/09/25, for Plavix tablet 75 mg, administer one tablet in the morning;-Staff did not document administration on 01/09/26 and 01/10/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/09/25, for Plavix tablet 75 mg to administer one tablet in the morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 or 01/11/26;Review of the residents January 2026 POS showed an order, dated 04/28/25, for Zoloft (anti-depressant) 50 mg tablet, administer one tablet in the morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/28/25, for Zoloft 50 mg tablet, administer one tablet in the morning;-Staff did not document administration on 01/09/26 and 01/10/26.Review of the resident's paper MAR/TAR created 01/06/26, at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/28/25, for Zoloft 50 mg tablet, administer one tablet in the morning, -Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 or 01/11/26.Review of the resident's MARs and TARs showed staff did not document a reason for medication not being administered. Review of the resident's record showed staff did not document paper insulin log.Review of the resident's progress notes showed staff did not document regarding medication administration. 2. Review of Resident #2's face sheet showed the following:-admission date of 01/15/20;-Diagnoses included epilepsy (seizures), type 2 diabetes, congestive heart failure (CHF - the heart cannot pump blood efficiently enough to meet the body's needs), major depression, and anxiety disorder. Review of the resident's quarterly MDS (a federally mandated assessment instrument completed by facility staff), dated 10/23/25, showed the resident was cognitively intact. Review of the resident's care plan, dated 10/23/25, showed the following:-The resident had a history of diabetes mellitus with medications in place as prescribed;-The resident had a history of hypertension (high blood pressure);-The resident required antidepressant medications. Review of the residents January 2026 POS showed an order, dated 04/15/24, for aspirin tablet chewable, 81 mg, one tablet every morning; Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/15/24, for aspirin tablet chewable, 81 mg, one tablet every morning;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26 showed the following:- An order, dated 04/15/24, for aspirin tablet chewable, 81 mg, one tablet every morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 09/11/24, for atorvastatin (used to treat high cholesterol) tablet 20 mg give, one tablet once daily by mouth.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 09/11/24, for atorvastatin tablet, 20 mg, give one tablet once daily by mouth;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26 showed the following:- An order, dated 09/11/24, for atorvastatin tablet, 20 mg, give one tablet once daily by mouth;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 04/11/25, for carvedilol (used to treat heart failure) 25 mg tablet twice daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/11/25, for carvedilol 25 mg tablet twice daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26 showed the following:- An order, dated 04/11/25, for carvedilol 25 mg tablet twice daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 10/20/20, for famotidine (used to treat heartburn) 20 mg tablet by mouth one time daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed an order, dated 10/20/20, for famotidine 20 mg tablet by mouth one time daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 10/20/20, for famotidine 20 mg tablet by mouth one time daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 09/11/24, for gabapentin (treats nerve pain) 300 mg by mouth two times daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 09/11/24, for gabapentin 300 mg by mouth two times daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26 showed the following:-An order, dated 09/11/24, for gabapentin 300 mg by mouth two times daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/13/25, for Humalog KwikPen insulin pen, 100 unit/mL, four times a day per the following sliding scale; -If blood sugar is 150 mg/dL to 199 mg/dL, give 2 units of insulin;-If blood sugar is 200 mg/dL to 249 mg/dL, give 4 units of insulin;-If blood sugar is 250 mg/dL to 299 mg/dL, give 6 units of insulin;-If blood sugar is 300 mg/dL to 349 mg/dL, give 8 units of insulin;-If blood sugar is 350 mg/dL to 399 mg/dL, give 10 units of insulin;-If blood sugar is greater than 399 mg/dL, give 12 units of insulin.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:- An order, dated 11/13/25, for Humalog KwikPen insulin pen, 100 unit/mL, administer four times a day per following sliding scale:-If blood sugar is 150 mg/dL to 199 mg/dL, give 2 units of insulin;-If blood sugar is 200 mg/dL to 249 mg/dL, give 4 units of insulin;-If blood sugar is 250 mg/dL to 299 mg/dL, give 6 units of insulin;-If blood sugar is 300 mg/dL to 349 mg/dL, give 8 units of insulin;-If blood sugar is 350 mg/dL to 399 mg/dL, give 10 units of insulin;-If blood sugar is greater than 399 mg/dL, give 12 units of insulin.-Staff did not document administration on 01/05/26, 01/07/26 overnight dose, 01/08/26, 01/09/26 overnight dose, 01/10/26 overnight dose, 01/11/26, and 01/12/26;Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:- An order, dated 11/13/25, for Humalog KwikPen insulin pen, 100 unit/mL, per the following sliding scale:-If blood sugar is 150 mg/dL to 199 mg/dL, give 2 units of insulin;-If blood sugar is 200 mg/dL to 249 mg/dL, give 4 units of insulin;-If blood sugar is 250 mg/dL to 299 mg/dL, give 6 units of insulin;-If blood sugar is 300 mg/dL to 349 mg/dL, give 8 units of insulin;-If blood sugar is 350 mg/dL to 399 mg/dL, give 10 units of insulin;-If blood sugar is greater than 399 mg/dL, give 12 units of insulin. -Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/02/26, for Lantus solostar U-100 (long actin insulin) insulin pen, 100 unit/ml, administer 40 units at bedtime.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/02/26, for Lantus solostar U-100 insulin pen, 100 unit/ml, administer 40 units at bedtime;-Staff did not document administration on 01/05/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/02/25, for Lantus solostar U-100 insulin pen, 100 unit/ml, administer 40 units at bedtime;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for levetiracetam (used to treat seizures), 500mg, one tablet by mouth each morning.Review of the resident's EMR MAR/TAR, dated 01/26, showed the following:-An order, dated 04/15/24, for levetiracetam, 500 mg, one tablet by mouth each morning;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/15/24, for levetiracetam, 500 mg, one tablet by mouth each morning;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for levetiracetam 750 mg, one tablet by mouth at bedtime.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following-An order, dated 04/15/24, for levetiracetam, 750 mg, one tablet by mouth at bedtime;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/15/24, for levetiracetam, 750 mg, one tablet by mouth at bedtime;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/16/20, for levothyroxine (thyroid medication) 75 mcg, give one tablet by mouth one time daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/16/20, for levothyroxine 75 mcg, give one tablet by mouth one time daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/16/20, for levothyroxine, 75 mcg, give one tablet by mouth one time daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/02/26, for lisinopril (used to treat high blood pressure) 20 mg one tablet once every morning. Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/02/26, for lisinpril 20 mg one tablet once every morning;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/02/26, for lisinopril 20 mg one tablet once every morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 09/11/24, for metoprolol tartrate (used to treat high blood pressure) 50 mg give twice daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/11/24, for metoprolol tartrate 50 mg, give twice daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/11/24, for metoprolol tartrate 50 mg give twice daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26 and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/13/25, for Ozempic (antidiabetic medication) pen injector, administer .5 mg subcutaneous (under the skin) once a morning on Monday.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/13/25, for Ozempic pen injector, administer .5 mg subcutaneous once a morning on Mondays;-Staff did not document administration on 01/05/26 and 01/12/26.Review of the resident's January 2026 POS showed an order, dated 07/23/25, for Zoloft 50mg tablet once daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 07/23/25, for Zoloft 50 mg tablet once daily;-Staff did not document administration on 01/07/26, 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week of 12/29/25 through 01/12/26m showed the following:-An order, dated 07/23/25, for Zoloft 50 mg tablet once daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, and 01/11/26. Review of the resident's blood glucose flow sheet showed the following:-On 01/06/26, staff did not document the evening insulin administration and blood sugar check;-On 01/07/26, staff did not document morning, noon, and evening insulin administration and blood sugar check. Review of the resident's progress notes showed staff did not document regarding medication administration.Review of the resident's MARs and TARS showed staff did not document a reason the medication was not marked as administered.3. Review of Resident #3's face sheet showed the following:-admission date of 11/02/23;-Diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system that primarily affects movement due to the loss of dopamine-producing brain cells), cellulitis (infection of the skin) of right lower limb, delusional disorders, unspecified psychosis, and hypertension (high blood pressure).Review of the resident's quarterly MDS (a federally mandated assessment instrument completed by facility staff), dated 12/11/25, showed the resident was cognitively intact. Review of the resident's care plan, dated 12/11/25, showed the following:-The resident was on diuretic therapy due to edema and hypertension;-The resident was on pain medication due to chronic pain. The resident had complaints of chronic pain and receives scheduled pain medication;-The resident had a diagnosis of hypothyroidism.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for alprazolam, .5 mg tablet, give one tablet by mouth four times daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/15/24, for alprazolam, .5mg tablet, give one tablet by mouth four times daily;-Staff did not document administration on 01/05/26, 01/08/26, 01/11/26 and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/15/24, for alprazolam .5mg tablet, give one tablet by mouth four times daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, and 01/11/26.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for aspirin tablet, delayed release 81 mg, give one tablet by mouth one time daily.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/15/24, for aspirin tablet, delayed release 81 mg, give one tablet by mouth one time daily;-Staff did not document administration on 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/15/24, for Aspirin tablet, delayed release 81 mg, give one tablet by mouth one time daily;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/21/25, for baclofen (muscle relaxant) tablet, 5 mg, administrator once a morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/19/25, for baclofen tablet, 5 mg, administrator once a morning;-Staff did not document administration on 01/08/26, 01/09/26 and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 11/19/25, for baclofen tablet, 5 mg, administrator once a morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26.Review of the resident's January 2026 POS showed an order, dated 11/19/25, for baclofen tablet, 10 mg, administer once at bedtime.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 11/19/25, for baclofen tablet, 10 mg, administer once at bedtime;-Staff did not document administration on 01/05/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26 and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:- An order, dated 11/19/25, for baclofen tablet, 10 mg, administer once at bedtime;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26.Review of the resident's January 2026 POS showed an order, dated 01/11/25, for bumetanide (diuretic) 1 mg tablet, one tablet early morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 01/11/25, for bumetanide 1 mg tablet, one tablet early morning;-Staff did not document administration on 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 01/11/25, for bumetanide 1 mg tablet, one tablet early morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for cholecalciferol (vitamin D) 25 mcg tablet, give two tablets by mouth one time daily in the morning.Review of the resident's EMR MAR/TAR, dated 01/2026, showed the following:-An order, dated 04/15/24, for cholecalciferol 25 mcg tablet, give two tablets by mouth one time daily in the morning;-Staff did not document administration on 01/08/26, 01/09/26, and 01/12/26.Review of the resident's paper MAR/TAR, created 01/06/26 at 8:13 P.M., for the week dates of 12/29/25 through 01/12/26, showed the following:-An order, dated 04/25/24, for cholecalciferol 25 mcg tablet, give two tablets by mouth one time daily in the morning;-Staff did not document administration on 01/06/26, 01/07/26, 01/08/26, 01/09/26, 01/10/26, 01/11/26.Review of the resident's January 2026 POS showed an order, dated 04/15/24, for Culturelle (probiotic) capsule, sprin

Based on observation, interview, and record review, the facility failed to ensure all alleged violations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when the facility failed to report an allegation of resident-to-resident abuse involving two residents (Resident #1 and Resident #2). Four residents were sampled out of a facility census of 89.Review of the facility policy and procedure titled, Abuse and Neglect, revised 07/21/25, showed the following information:-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; -All allegations of abuse must be reported immediately to the Administrator, Director of Nursing (DON), and other officials according to state law;-The Administrator or DON immediately reports his/her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility, the residents representative, the facility medical director, and local law enforcement officials;-Immediately is defined as within two hours of an allegation involving abuse.1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 04/13/20;-Diagnoses included dementia, post-traumatic stress disorder (PTSD- a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or life-threatening event), and major depressive disorder.Review of the resident's care plan, revised 08/19/25, showed the following;-The resident had experienced a traumatic event effecting psychosocial well-being;-Staff to provide a calm environment and offer support and listening;-Staff to encourage the resident to verbalize feelings, concerns, and fears.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 10/15/25, showed the following information:-Intact cognition;-No behaviors or wandering documented;-Independent with dressing, bathing, and mobility.Review of the resident's progress note dated 12/27/25, at 10:40 P.M., showed the following:-Another resident (Resident #2) entered the resident's room;-The resident met Resident # 2 at the door and asked him/her to leave. Resident # 2 grabbed Resident #1's right forearm. Resident #1 asked Resident #2 to let go and he/she did;-The writer (Licensed Practical Nurse (LPN) A) intervened, removed Resident #2 from the room. Resident #1 was assessed for injury with no injuries seen at the time of assessment;-Staff notified administrator.(Staff did not document notification of DHSS.)Review of the resident's progress note dated 12/28/25, at 1:55 P.M., showed LPN B documented the following:-The resident was assessed for follow-up from an altercation with another resident;-He/she said that his/her right forearm was grabbed and there is one small, round, light purple bruise, approximately 0.8 centimeters (cm) seen to the forearm;-No additional redness or edema (swelling) seen;-Vital signs were stable with no complaints of pain. (Staff did not document notification of the DHSS.)Review of the resident's progress note dated 12/29/25, at 3:48 P.M., showed the Social Services Director (SSD) documented the following:-The resident came to the office wanting to speak with her and the Administrator;-The resident told her and the Administrator about the incident with another resident entering his/her room and throwing him/her around by the arm;-The incident was observed by staff and charted that Resident #2 was in the doorway, not in the resident's room;-The Administrator tried to explain to him/her that he/she needed to push the call light and ask the staff for assistance in these situations. Afterwards, the resident began yelling and requested that something be done about Resident #2;-SSD explained to the resident that he/she could not come into the office and yell at her and the Administrator and expect them to move Resident #2 out;-SSD offered the resident to find an alternative facility; -The resident threatened to notify SSA;-The Administrator assessed the residents arm and did not see any injuries at that time.(Staff did not document notification of DHSS of the abuse allegation.) Review of the resident's care plan, revised 12/29/25, showed staff added aggressive behavior and the resident would not approach any resident in a negative manner.Review of DHSS records showed the facility did not self-report the altercation/abuse allegation involving Resident #1 and Resident #2. During observation and interview on 12/30/25, at 11:26 A.M., the resident said the following: -On 12/27/25, he/she was sitting in his/her recliner in his/her room with the door shut. Suddenly, Resident #2 opened his/her door and attempted to enter his/her room;-Resident #1 began yelling at Resident #2 what do you want and get out of here;-Resident #2 grabbed his/her right forearm. He/she asked him/her to let go, to which he/she did. At that time LPN A was present and re-directed Resident #2 away from his/her room;-Observation showed the resident had slight yellow discoloration, approximately dime size, to his/her right forearm;-He/she did report the incident to the Administrator and SSD. He/she had plans of filing a grievance, but SSD did not do that for him/her. Instead, he/she felt as if he/she was verbally attacked for going up to Resident #2 instead of just pressing his/her call light;-He/she felt the Administrator and SSD did not take his/her concerns seriously.During an interview on 12/30/25, at 3:41 P.M., Certified Nursing Assistant (CNA) C said the following:-Any allegations of abuse should be reported to DHSS within two hours;-If a resident reported an abuse allegation to him/her, he/she would report it to the charge nurse, and Administrator.During an interview on 12/30/25, at 12:54 P.M., LPN A said the following:-On the night of 12/27/25, he/she heard Resident #1 yelling, get out. He/she visualized Resident #2 in Resident #1's doorway and began to intervene;-He/she clarified his/her progress note and said he/she did not see Resident #2 grab Resident #1's arm, Resident #1 just reported that to him/her;-Resident #2 was not easy to re-direct. He/she was often confused and was easily agitated on his/her shift. Staff just have to let his/her confusion run its course due to him/her being easily agitated;-He/she did assess Resident #1 for injury and did not see any. Resident #2 was placed on 15-minute checks, and the Administrator was notified;-He/she did not make any additional notifications;-He/She believes there was a two-hour window to report allegations of abuse to DHSS;-He/she does not know if behaviors should be care planned.During an interview on 12/30/25, at 1:15 P.M., LPN B said the following:-He/she came on shift on 12/28/25, day shift and assessed Resident #1 in the afternoon. While assessing the resident, he/she did see a small reddish-purple area on the residents right forearm but did not believe it to be related to the allegations;-Resident #2 did have episodes of agitation, confusion, and wandering. If staff try to remove him/her from what he/she is doing, that causes agitation and he/she will get confrontational and grab you;-Any allegations of abuse should be reported immediately to the Administrator. The administrator will tell the staff what she wants them to do and will report it to DHSS within two hours;-She believed he/she could call DHSS herself, but just left it up to the Administrator, and thought she had done so.During an interview, on 12/30/25, at 2:53 P.M., the Director of Rehab (DOR) said the following:-If a resident were to report any allegations of abuse, she would immediately report it to the SSD and Administrator;-The Administrator should notify DHSS within two hours.During an interview on 12/30/25, at 4:00 P.M., the SSD said the following:-She became aware of the resident-resident incident on 12/29/25, when Resident #1 came and requested to file a grievance regarding the situation;-Any allegations of abuse are typically reported to DHSS within two hours;-While the resident requested to file a grievance, the resident got upset with being educated to turn on his/her call light versus addressed the situation his/herself and left the office so the SSD did not fill it out.During an interview on 12/30/25, at 10:14 A.M., the Administrator said the following:-She was notified on Saturday (12/27/25) of the allegations;-LPN A reported to her that Resident #2 was ambulating via wheelchair and came to Resident #1's doorway. Resident #1 came to the doorway and asked Resident #2 to leave. After asking Resident #2 to leave, he/she grabbed Resident #1 on the forearm. Resident #1 asked Resident #2 to let go, to which he/she did. LPN A re-directed Resident #2 away from Resident #1;-Resident #2 was placed on 15-minute checks and LPN A assessed Resident #1 for injury;-Resident #2 had never been an issue before, which is why she did not report the incident;-She also did not report the incident to DHSS because there was no injury seen;-The resident (Resident #1) did come to her office on 12/29/25 and reported the incident;-She assessed the resident for injuries, and there was nothing there at the time of the assessment;-She told the resident, from now on, if there is another resident at his/her door, that he/she should turn on his/her call light instead of addressing the concern his/herself. The resident was upset with this.#2702852

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standard, physician's order, and resident's preference when the facility failed to order or provide a drop arm commode for one resident (Resident #3), which would increase his/her independence. The facility census was 89. Record review showed the facility did not provide a policy regarding the process of ordering durable medical equipment or the process of handwritten physician orders. 1. Review of Resident #3's face sheet (gives basic profile information) showed the following information: -admission date of 01/09/25 with the last return on 03/25/25;-Diagnoses included complete traumatic (emotional stress) amputation (the surgical removal of a body part) at level between right hip and knee, complete traumatic amputation at level between left hip and knee, absence of left leg above the knee, long-term kidney disease, urinary retention (the inability to completely empty your bladder), severe obesity, major depressive disorder (a serious mood disorder causing sadness, loss of interest, tiredness, sleep and appetite changes, and suicidal thoughts), anxiety (a condition that causes one to worry), and long-term post-traumatic stress disorder (a mental health condition that is developed after experiencing or witnessing an unpleasant event). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/25/25, showed the following information:-Cognitively intact;-Used a motorized and manual wheelchair independently;-Independent with toileting hygiene;-Setup or clean-up assistance for shower/bathing;-Independent with personal hygiene, rolling left and right, going from sit to lying and lying to sitting on side of bed;-Supervision or touch assistance for chair/bed-to-chair transfer, and tub/shower transfers;-At risk of pressure ulcers/injuries.Review of the resident's care plan, last updated 12/26/25, showed the following:-The resident had bladder/urinary incontinence;-He/She will remain free of skin breakdown due to incontinence and brief use;-Had a right above the knee amputation;-Had a left above the knee amputation;-He/She had potential/actual skin impairment to skin integrity related to poor safety awareness, impaired mobility, weakness, and bowel incontinence;-Educate resident/family/caregivers of causative factors and measures to prevent skin injury;-Identify and document potential causative factors for potential/actual skin impairment and eliminate/resolve where possible. Review the resident's Physical Therapy Department record showed no progress notes or records were available. There was a copy of a handwritten physician's order, dated 10/28/25, for may have heavy duty bedside commode with a drop arm to assist with mobility from bed to commode secondary to bilateral (both) amputations. Review of the resident's Physician Order Sheet (POS), dated 10/01/25 through 12/30/25, showed the following:-An order, dated 08/19/25 with a discontinuation date of 12/24/25, for a Hoyer lift (mechanical lift used for non-weight bearing residents) for transfers as needed;-An order, dated 08/19/25, for a sliding board for transfers as needed.(Staff did not have a documented order for the beside commode.) Review of the resident's progress notes, dated 10/13/25 through 12/30/25, showed a nurse's note on 12/27/25, at 3:13 P.M., stating the resident was incontinent of bowel and bladder and wanted to utilize a commode as soon as possible, but he/she needed to be trained by therapy. He/She wore incontinent briefs and needed assistance from staff with changing soiled briefs.Review of the resident's record showed staff did not document follow-up regarding obtaining the bedside commode for the resident. During an interview on 12/30/25, at 12:00 P.M., the resident said the following:-In August of 2025, the Director of Rehab (DOR) asked the facility physician to order a bedside commode for him/her;-In September 2025 or October of 2025, the facility physician gave an order for the facility to order the commode;-The resident asked the social worker about the commode a couple of weeks ago and the social worker informed him/her that he/she she had not had time to order it because he/she had other things to do;-The staff at the facility expect him/her to go to the bathroom in a brief and that made him/her feel embarrassed;-If he/she had a bedside commode it would give him/her more independence and he/she would not have to rely on staff to assist him/her to the bathroom;-He/She used a sliding board to transfer with supervision/minimal help;-The therapy department would need to teach him/her how to use the commode before he/she could use it;-Without a commode, he/she would need to continue using briefs because he/she could not get into the bathroom due to having both legs amputated;-He/She would prefer to use a commode. During an interview on 12/30/25, at 1:20 P.M., Licensed Practical Nurse (LPN) B said the following:-He/She was not aware of the resident requesting a commode;-If a resident wanted a commode the process would be to check with therapy to make sure he/she could use it safely, and if so, the nurses would put in the order for the commode;-The facility had some commodes, but if something different was needed, it would need to be ordered. During an interview on 12/30/25, at 3:00 P.M., the Director of Rehab (DOR) said the following:-The facility physician wrote an order for the resident to have a commode on 10/28/25;-He/she provided the commode order to the Administrator and social worker on 10/29/25 and kept a copy for his/her own file;-He/She printed the type of commode the resident needed from the [NAME] site and gave a copy to the Administrator and the social worker, so they would know what to order;-He/She was not often given an order for equipment, so he/she followed up several times with the social worker regarding the commode, but each time the social worker would say he/she was busy, or he/she did not have time to deal with ordering it;-The therapy department at the facility was a contract company, so the therapy records are not available to facility staff;-The resident not having the commode they requested would lead to a decline in the resident's activities of daily living (ADL) ability;-He/She felt it was also a dignity issue for the resident to be asked to go to the bathroom in a brief when they could use a commode if they had one;-He/She asked the social worker about the resident's commode for the last time on 12/24/25 and the response was the same. He/She was informed by the social worker that he/she was too busy to order it, and he/she would get it ordered when he/she got it ordered;-He/She has checked with the social worker regarding the commode at least every other week since the order was written;-The resident keeps asking him/her if he/she has heard when he/she will get the commode;-The resident will need to be assessed by a therapist for safe use of the commode when the commode comes in;-The resident had been using the sliding board by himself/herself, so he/she believed the resident would be able to get on the commode by himself/herself since it would have a drop arm on it;-The resident should be independent with the use of a commode. During an interview on 12/30/25, at 3:20 P.M., Certified Nurse Aide (CAN) C said the following:-The resident has told him/her that he/she wanted a commode;-He/She heard that one had been ordered, but he/she had not seen it;-The resident had been wanting to use a commode for a while because it's not safe for him/her to use the toilet in his/her bathroom;-The resident used a sliding board with minimal assistance to get from his/her chair to bed;-He/She knew it was frustrating for the resident to not have a commode because the resident had voiced that to him/her;-He/She thought the resident would be able to use the commode by himself/herself if the therapy department showed him/her how. During an interview on 12/30/25, at 4:28 P.M., the Social Services Director (SSD) said the following:-There should be a physician's order for a resident to have a commode;-He/She had not seen an order from the physician stating the resident needed a commode;-If the DOR received an order for a commode, he/she should have turned it into the nursing staff and the nurses would have put the order in the resident's chart;-He/She ordered a commode the beginning of December 2025 for the resident but cancelled the order about two weeks ago because it was going to take 6 to 8 weeks to be delivered. He/She did not have a copy of the cancelled order receipt;-The DOR brought him/her a picture/paper of a commode to order the first of December 2025, but the commode was $600.00, and it would not arrive for 6 to 8 weeks;-He/She had not received the physician's order for the resident to have a commode and he/she did not know when that order would be obtained;-Within the past two to three days, the DOR and the resident told him/her that the resident needed a commode;-He/She found a cheaper commode that he/she ordered this morning, and it should be arrive the next day. During an interview on 12/30/25, at 5:34 P.M., the Administrator said the following:-He/She was informed about a week ago that the DOR asked the social worker to order a commode for the resident;-He/She had not seen a physician's order for the commode;-This would not be the first time the DOR asked staff to order something without an order;-There needed to be a physician's order for a commode or any equipment for a resident;-The SSD did the ordering for the facility;-After the physician writes an order, the nurses should put it into the resident's electronic medical record and provide the order to medical records, who would then give it to the SSD to order;-A commode was ordered for the resident last night or this morning. The SSD said it would arrive tomorrow;-The resident did not ask him/her for a commode or mention it to her;-The DOR had not come to him/her and asked him/her to order it either;-The resident would benefit from a commode;-The commode will have an arm that lifts up and the resident can use it with his/her sliding board;-The resident was getting more independent, and the commode will help him/her with his/her independence more.# 2701833 and 2699831

Based on observation, interview, and record review, the facility failed to ensure all residents were kept as free from accident hazards as possible when staff failed to [NAME] steps to prevent future burns and failed to update the care plan regarding a burn for one resident (Resident #3) who suffered burns after spiling hot soup on him/herself. The facility census was 89.Review showed the facility did not provide a policy related to resident use of microwaves. 1. Review of Resident #3's face sheet (gives basic profile information) showed the following information:-admission date of 01/09/25 with the last return on 03/25/25;-Diagnoses included complete traumatic (emotional stress) amputation (the surgical removal of a body part) at level between right hip and knee, complete traumatic amputation at level between left hip and knee, absence of left leg above the knee, long-term kidney disease, major depressive disorder (a serious mood disorder causing sadness, loss of interest, tiredness, sleep and appetite changes, and suicidal thoughts), anxiety (a condition that causes one to worry), long-term post-traumatic stress disorder (a mental health condition that is developed after experiencing or witnessing an unpleasant event), and peripheral vascular disease (a circulatory problem where narrowed blood vessels outside the heart and brain reduce blood flow to the limbs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/25/25, showed the following information:-Cognitively intact;-Uses a motorized and manual wheelchair independently;-Supervision or touch assistance for chair/bed-to-chair transfer, tub/shower transfers;-At risk of pressure ulcers/injuries. Review of the resident's care plan, last updated 12/26/25, showed the following:-Regular textured diet with thin liquids;-Staff will monitor diet at each meal;-Has a right above the knee amputation;-Has a left above the knee amputation;-He/She had potential/actual skin impairment to skin integrity related to poor safety awareness, impaired mobility, weakness, and bowel incontinence;-Educate resident/family/caregivers of causative factors and measures to prevent skin injury;-Follow facility protocol for treatment of injury;-Identify and document potential causative factors for potential/actual skin impairment and eliminate/resolve where possible;-Monitor/document location, size, and treatment of skin injury and report abnormalities;(Staff did not care plan related to hot liquids or a hot liquid injury or being.) Review of the resident's progress notes showed the following:-A dietary note dated 12/15/25, at 11:21 A.M., stating the resident was independent at meals, ate breakfast in main dining room, and lunch and dinner in his/her room. Resident was on a regular no-added salt diet;-A nurse's note dated 12/18/25, at 5:33 P.M., showed the resident was in wheelchair with a bowl of hot tomato soup. While transporting the tomato soup to his/her room, he/she ran into the door and the tomato soup landed on the resident. Resident to room, undressed, and cool cloths applied to area;-A nurse's note dated 12/18/25, at 5:45 P.M., stated the resident informed the nurse he/she would notify his/her family;-A nurse's note dated 12/18/25, at 6:00 P.M., stating the nurse spoke with on-call physician staff, explained the situation of tomato soup being spilled on the resident, cool cloths applied immediately, and changed out three times. Reddened area was disappearing, and the resident did not have any complaints of pain. Physician instructed to leave open to air, with no treatment. Review of the resident's weekly skin assessment, dated 12/18/25, showed resident poured hot soup on himself/herself, placed cold compress over his/her front multiple times, and cleared up small red area under left breast. Review of the resident's progress note dated 12/20/25, at 7:15 P.M., showed staff notified nurse practitioner on-call for physician of the area on the resident's abdomen where the hot tomato soup was spilled Thursday night was red initially, but now there were multiple areas that had fluid filled blisters, and some blisters had popped. Treatment order received for the burned areas that were obtained from the hot soup spilling on the resident on Thursday. Staff to cleanse areas to abdomen with wound cleanser daily, pat dry, apply Vaseline gauze to the areas of concern, and then cover with Telfa (a sterile wound dressing) or ABD (thick absorbent gauze pad for heavy-draining wounds) dressings daily until healed. Review of the resident's Physician Order Sheet (POS), dated 10/01/25 through 12/30/25 showed the following:-An order, dated 12/20/25 with a discontinuation date of 12/24/25, to cleanse multiple popped blistered areas to abdomen daily with wound cleanser, pat dry, apply Vaseline gauze to the areas, and cover with Telfa dressing daily until healed. Monitor for signs and symptoms of infection and notify provider for any abnormalities, once a day;-An order, dated 12/24/25, to cleanse right lower abdomen blistered area and apply skin prep once a day until healed. Review of the resident's Wound Summary Report showed the following:-A burn to the left chest, identified on 12/24/25, with an Initial measurement of 1 centimeter (cm) in length by 2.5 cm in width and no wound description;-A burn to the bottom-left section of the abdomen (stomach), identified on 12/24/25, with an initial measurement of 3 cm in length by 5 cm in width with no description provided;-A burn to the bottom-right section of the abdomen, identified on 12/24/25, with an initial measurement was 2 cm in length by 1.5 cm in width with no description provided. Review of the resident's record showed no hot food/hot liquid risk assessment completed for the resident.Review of the resident's care plan, last updated 12/26/25, showed staff did not update the care plan with new interventions to prevent future [NAME]. During an interview on 12/30/25, at 12:00 P.M., the resident said the following:-He/She was in his/her wheelchair carrying a hot soup bowl;-The linen cart was in the hall, and it was not in a great place, so he/she got off balance and ran into the corner of it, which caused him/her to spill his/her hot tomato soup;-He/She heats his/her soup up himself/herself in a room that is located on the unit hall where his/her room is and where the ice machine is located;-When he/she spilled the hot soup, he/she yelled, and staff came to assist him/her with cold wet towels;-He/She normally heats his/her own food up because he/she wants to be independent, but he/she is gun shy now about heating foods up by himself/herself;-The facility had not completed a hot food/hot liquid risk assessment with him/her;-The burn wounds were on his/her stomach, and they have healed enough to not need a dressing. During an interview on 12/30/25, at 1:20 P.M., Licensed Practical Nurse (LPN) B said the following:-He/She was not sure about the resident burning himself/herself with hot soup;-Residents are not supposed to use the microwaves in the unit halls without staff assistance;-The microwaves and ice machines are located on each unit/wing of the facility;-He/She was not sure if the room with a microwave on the wing/unit where the resident lived had a door on it or not;-Residents should notify the staff if they need to use the microwave. During an interview on 12/30/25, at 3:15 P.M., LPN D said the following:-There was a microwave near the nurses' station on C hall, but the door to the room where it was located was closed and there was a sign on the door saying it was for employees only;-The door to the room with the microwave was not locked and any resident could potentially go into the room;-He/She had never seen a resident in the room with the microwave;-There was no personal food or drinks kept in that room for residents;-If residents have food, they want heated up they can take it to staff, and the staff will heat it up for them;-The staff do various assessments on residents each month, but he/she had never completed a hot food/ hot liquid assessment on any resident. During an interview on 12/30/25, at 3:15 P.M., Registered Nurse (RN) E said the following:-There was a microwave near the nurses' station on C hall, but the door to the room where it is located is closed and there was a sign on the door saying it was for employees only;-The door to the room with the microwave was not locked and any resident could potentially go into the room;-He/She had never seen a resident in the room with the microwave;-If residents have food, they want heated up they can take it to staff, and the staff will heat it up for them;-The staff do various assessments on residents each month, but he/she had never completed a hot food/hot liquid assessment on any resident. During an interview on 12/30/25, at 3:20 P.M., Certified Nurse Aide (CNA) C said the following:-He/She witnessed the resident spill the hot bowl of soup on himself/herself;-The resident hit the exit door with his/her motorized wheelchair and the hot soup went all over him/her. The resident did not run into the laundry cart as the resident had been telling everyone;-He/She was not sure where the resident got the soup from;-The resident went into the room on the unit hall to use the microwave frequently and his/her wheelchair gets stuck on the little refrigerator when he/she turns around to exit the room. The resident takes the little refrigerator about 6 inches away from the wall when his/her wheelchair back gets caught on the refrigerator;-The resident usually used the microwave to heat up his/her little pizza's that he/she had in his/her room and food supply;-The room in the unit hall that has the microwave did not have a lock on the door;-He/She had not seen other residents besides the resident go into the room with the microwave and refrigerator;-Staff have been instructed to tell the resident that he/she cannot go into the room and use the microwave, but staff do not block or lock the door to prevent the resident from entering;-Any resident could open the door where the microwave is, but the door was hard to open. During an interview on 12/30/25, at 4:28 P.M., the Social Services Director said the following:-He/She was not sure if the facility completed a risk or safety assessment for residents regarding hot food or hot liquids. If so, the nursing staff would do that;-He/She was not aware of the facility staff completing a safety or risk assessment for residents to use a microwave in the facility;-Every unit/hall had a room with a microwave. The door to the room was shut, not locked;-Some residents ignore the employee only sign on the door and sneak in to use the microwave;-He/She reminded residents to let staff help them warm their food and drinks up;-Any resident including those who are confused or who have dementia could open the door and go into the room where the microwave was;-He/She did not know how staff monitor who goes into the rooms with the microwaves;-The facility does not care plan resident use of a microwave;-He/She was not sure where the resident heated his/her food up at prior to being burned;-The resident was not supposed to be in the room with the microwave or using the microwave;-He/She was not aware of any microwave use policies for residents. During an interview on 12/30/25, at 5:34 P.M., the Administrator said the following:-He/She had never seen a hot foods/hot liquids assessment completed at the facility;-Technically, residents are not supposed to use the microwaves in the unit halls and there is a sign on the doors saying the area is for employees only;-For the most part, the resident ignores the signs on the doors and enter the rooms to use the microwaves anyway;-There was one microwave on each unit/wing and staff used them to heat up resident meals;-He/She had told staff that residents are not allowed to go into the rooms and use the microwaves;-He/She was not aware of the resident's wheelchair getting caught on the small refrigerator located in the room with the microwave;-He/She is not aware of any confused residents going in the rooms with the microwaves, but none of the rooms are locked, so anyone could go in there;-The facility kept the doors to the rooms with the microwaves closed and all of the rooms have a sign on the door saying the rooms are for staff only;-The facility did not do a care plan assessment for resident microwave use;-He/She was not aware of a resident microwave use policy at the facility.

Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) spoke disrespectfully and did not honor the resident's sleeping preferences for one resident (Resident #1) in a selected sample of four residents. The facility census was 89.Review of the facility's Dignity and Quality of Life Policy, updated 02/13/25, included the following information:-The facility will promote care for the residents in a manner and in an environment that maintains and enhances each resident's dignity, quality of life and respect in full recognition of his or her individuality. Facility staff will respect and promote the rights of the resident to exercise his or her autonomy regarding what the resident considers important facets of his or her life. The facility staff will provide services in a manner which enhances/maintains a dignified existence for our residents;-Staff must carry out activities in a manner which assist the residents to maintain and enhance his/her self-esteem and self-worth;-Maintaining a resident's dignity includes the respecting resident social status, speaking respectfully, listening carefully, and always treating residents with respect.-Respect residents by speaking respectfully. 1. Review of Resident #1's face sheet (a document that contains a summary of a resident's personal and demographic information) showed the resident admitted to the facility on [DATE]. His/her diagnoses included diabetes, heart failure, severe obesity, anxiety disorder, and depression. Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 9/20/25, showed the following:-No cognitive impairment;-Dependent on staff for transfers, bed mobility and toilet use. Review of the resident's care plan, last reviewed 09/22/25, showed the following information:-Honor resident's lifestyle and customary routines;-Allow resident to establish or maintain personal sleeping patterns;-Respect resident's preferences at all times. Review of a statement dated 11/29/25, at 7:25 A.M., showed an anonymous individual said the resident asked to go to the bathroom and CNA A went into the resident's room and said I am not about to help the resident. He/she got my back hurting from last night. CNA A also slammed the door when he/she left the room. During an interview on 11/29/25, at 3:20 P.M., the resident said the following:-Last night (11/28/25), CNA A and CNA B entered his/her room to assist him/her to bed from his/her recliner;-CNA A said that he/she was not going to hurt his/her back on the resident;-This was not the first time the CNA made this type of comment regarding the resident hurting the aide's back;-The CNA eventually helps the resident each time he/she makes these comments, but he/she is very vocal about it;-When the CNA says this, it hurts the resident's feelings.-When he/she reached the bed, he/she sat down quickly, which apparently upset CNA A because he/she stormed out of the room;-CNA A was disrespectful and rude, The resident did not know why he/she acted that way. The resident tried to get along with everyone;-The resident had told other staff about CNA A's demeanor towards him/her, and they told the resident he/she should tell administration, but the resident did not want to get anyone into trouble. During an interview on 11/29/25, at 3:35 P.M., CNA C said the following:-The resident had told him/her that CNA A was disrespectful when the CNA did not allow the resident to wear an incontinent brief to bed; -CNA A told the resident that it was healthier for him/her to sleep without a brief. The resident was upset because he/she wanted to wear an incontinent brief, but he/she did not want to tell anyone because he/she was afraid of retaliation from CNA A;-CNA C said it appeared as though the night shift staff did not provide incontinent care to the resident all night and he/she told the nurse about the lack of care provided by CNA A. During an interview on 11/29/25, at 3:55 P.M., CNA D said the following:-There were some issues with night shift staff, specifically CNA A, not wanting or allowing the resident to sleep with an incontinent brief;-CNA A told the resident that it was better for him/her to sleep without anything covering his/her bottom, but the resident wanted to sleep in a brief;-The resident told CNA D that sleeping without a brief made him/her feel like he/she did not matter, like staff did not care, and it made him/her feel bad. During interviews on 11/29/25, at 3:45 P.M. and 5:25 P.M., the resident said the following:-He/she wanted to wear a brief to bed but CNA A told him/her it was better to not wear anything to bed;-The resident did not want to cause trouble, but he/she hated incontinence and many times the aides at night either did not change him/her often or sometimes they did not come in at all;-The resident sighed and said he/she guessed that CNA A let him/her decide if he/she wore a brief or not but really CNA A would just keep at him/her until the resident relented and because the resident just wanted to get along with everyone, he/she did not argue.-The resident said no other staff really had an issue with cleaning him/her, only CNA A. During an interview on 11/29/25, at 5:27 P.M., Licensed Practical Nurse (LPN) E said if staff heard another staff member be disrespectful or rude to a resident, they should report it to the charge nurse or Director of Nursing (DON). He/she had not directly heard CNA A be disrespectful to any residents but heard stories from other CNAs like not providing incontinent care as often as he/she should. The LPN thought it was typical shift to shift rivalry. Staff should not tell residents that assisting them hurts their backs. During an interview on 11/29/25, at 5:45 P.M., LPN F said the following:-If he/she heard a staff member be disrespectful to a resident, he/she would stop the interaction, talk to the staff member then let administration know;-He/she had heard CNA A's tone get a little sharp with residents before. And there was a situation with a newer resident where the new resident did not want CNA A in his/her room. The resident would not tell the LPN specifics about what happened, but then a short time later he/she allowed the CNA back into his/her room;-Resident #1 had not said anything to the LPN about CNA A;-It would not be appropriate for any CNA to tell a resident that assisting him/her hurt their back nor would it be appropriate for staff to continue to try to change a resident's mind once they made a decision about something. During an interview on 11/29/25, at 6:00 P.M., CNA A said the following:-Staff should not be disrespectful or treat residents in an undignified manner.-If he/she heard or noted staff treating residents in this manner, he/she would notify the charge nurse or administration.-The CNA said he/she may have said that his/her back hurt, but he/she did not say that the resident caused his/her back pain;-Sometimes the resident did not want to wear incontinent briefs to bed, and sometimes he/she did. During an interview on 11/29/25, at 7:10 P.M., the Administrator said it was not appropriate to tell a resident that the resident caused the staff member to hurt their back and if a resident wanted to wear a brief to bed, staff should not guilt a resident into doing something they did not want to do. Staff should tell administration if a resident told them or if they heard staff being disrespectful to residents. Complaint 2679768

Based on observation, record review, and interview, the facility staff failed to ensure all food was protected from possible contamination when the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the inside of the ice machine clean. The facility census was 85. Review of the facility's policy titled Cleaning instructions, Ice Machine, and Equipment, dated 2021, showed the following: -Ice machine will be cleaned and sanitized on a regular basis; -Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. Pay close attention to the crevices. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch 1. Observations on 06/09/25, beginning at 9:00 A.M., and on 06/11/25, at 11:50 A.M., of the kitchen showed a brown substance along the top of the ice deflector shield and four or five pin size spots of green on the left side of the ice deflector shield. Review of the facility's nightly shift check off list showed no task for cleaning the inside of the ice machine. During an interview on 06/12/25, at 10:11 A.M., Dietary Aide (DA) K said the following: -He/she was not sure who was supposed to clean the inside of the ice machine; -He/she knew the ice was supposed to be melted, drained, and cleaned inside but he/she was not sure how often. There should not be a brown or green substance in the ice machine; -The kitchen had a daily task list for the day and night staff. During an interview on 06/12/25, at 10:15 A.M., DA J said the following: -The other maintenance director used to dump the ice machine and clean it in the inside; -He/she didn't know how often, or when it was cleaned last; -The inside needed to be clean. During an interview on 06/12/25, at 10:20 A.M., DA L said the following: -Maintenance cleaned the inside of the ice machine; -He/she didn't know how often it was cleaned, but it shouldn't be dirty inside. During an interview on 06/12/25, at 10:25 A.M., the Maintenance Director said he/she did de-lime the inside and clean it one time per month. He/she did not know the deflector shield had a brown and green substance on it. During an interview on 06/12/25, at 2:30 P.M., the Dietary Manager said maintenance cleans the inside of the ice machine one time per month. They drain and clean the inside and the deflector shield. He/she didn't know it had a brown and green substance on it. During an interview on 06/13/25, at 1:50 P.M., the Administrator/Interim DON said the following: -Maintenance was responsible for cleaning the inside of the ice machine; -He/she believed it was drained last month and cleaned; -He/she was not aware of there being brown and green on the deflector shield. It should be clean.

Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the outside of the ice machine clean and when the fans located in the walk-in refrigerator has lint and a black substance. The facility census was 85. Review of the facility's policy titled Cleaning Instructions, Ice Machine,and Equipment, dated 2021, said the following: -Clean the exterior of the machine with detergent solution daily; -Rinse and allow to air dry. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean 1. Observations on 06/09/25, beginning at 9:00 A.M., and on 06/11/25, at 11:50 A.M., of the kitchen showed the following: -Several white streaks down the left and right sides of the freezer, from the section where the top and bottom of the ice machine meet, all the way to the bottom of the ice machine; -White and brown crusted build up where the top and bottom of the ice machine meet. During an interview on 06/12/25, at 10:11 A.M., Dietary Aide (DA) K said he/she didn't know if there was a schedule for cleaning the outside of the ice machine, but he/she tried to wipe down the outside often. He/she knew there were white streaks from the hard water. During an interview on 06/12/25, at 10:15 A.M., DA J said he/she wiped down the outside of the ice machine when he/she remembered. He/she didn't know if there is a schedule on how often. During an interview on 06/12/25, at 10:20 A.M., DA L said he/she wiped off the outside of the ice machine pretty often. He/she wasn't sure if it was on the check list. During an interview on 06/12/25, at 10:25 A.M., the Maintenance Director said the kitchen usually wiped down the outside of the ice machine. He/she will do that as well when he/she cleans the inside one time per month During an interview on 06/12/25, at 2:30 P.M., the Dietary Manager said the following: -He/she purchased vinegar to clean the outside of the ice machine. The one side constantly drips and that's where the white lime buildup mainly occurs. -The crevices where the top and bottom meet have a lot of build up too; -They try to wipe down the outside every couple of days. It's not listed on the check off list. During an interview on 06/13/25 at 1:50 P.M., the Administrator/Interim Director of Nursing (DON) said the following: -The kitchen should be wiping down the outside of the ice machine so it doesn't have lime buildup or drips; -The dietary manager had a check off list and should be monitoring. 2. Review of the facility's policy titled Cleaning instructions, Refrigerators, dated 2021, said the following, the refrigerators will be cleaned thoroughly inside and outside with detergent and followed by sanitizer at least once every month, or as needed. Observations on 06/09/25, beginning at 9:00 A.M., and on 06/11/25, at 11:50 A.M., of the kitchen showed the two fans located in the walk-in refrigerator both had a black substance on them. Review of the facility's nightly shift check off list, showed no task for cleaning the fans in the walk in refrigerator. During an interview on 06/12/25, at 10:11 A.M., DA K said the following: -He/she used sanitizer water and wipes off the outside of the fans twice per month; -He/she had never seen maintenance take the covers off of the fans and clean them; -The fans should not have black substance on them. During an interview on 06/12/25, at 10:15 A.M., DA J said maintenance was responsible for cleaning the fans in the walk in refrigerator. They should not have black mold on them. During an interview on 06/12/25, at 10:20 A.M., DA L said the following: -Maintenance cleans the fans in the walk in refrigerator; -He/she didn't notice them having a black substance on them; -When maintenance needed to fix something, they were to write down what needs to be addressed on the clipboard by the back door. Most of the time the Maintenance Director came through the kitchen and they verbally let him/her know what's going on. During an interview on 06/12/25, at 10:25 A.M., the Maintenance Director said maintenance cleans the fans, but he/she hasn't been here long and hasn't done this task. When something needed to be done in the kitchen the staff usually tell him/her. During an interview on 06/12/25, at 2:30 P.M., the Dietary Manager said the following: -The kitchen staff wipe the outside of the fans every couple of weeks; -Maintenance was responsible for taking off the covers and cleaning the black substance. During an interview on 06/13/25, at 1:50 P.M., the Administrator/Interim DON said the following: -Maintenance should be cleaning the fans inside of the refrigerator. He/she doesn't know if maintenance is aware it's his/her responsibility; -The fans should not have a black substance on them.

Based on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to have ordered medications available for staff administration resulting in five residents (Resident #8, #77, #18, #68, and #70) not receiving medications as ordered. The facility census was 85. Review of the facility's policy titled Administering Medications, revised April 2019, showed the following: -Medications are administered in a safe and timely manner and as prescribed; -Medications are administered in accordance with prescriber's orders, including any required time frames. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; -Diagnoses included quadriplegia (loss of movement in all four limbs) and depression (persistent feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS-federally mandated assessment instrument completed by facility staff), dated 03/05/25, showed the resident had no cognitive impairment. Review of the resident's care plan, last reviewed on 05/21/25, showed staff will administer medications as ordered. Review of the resident's April 2025 through June 2025 Physicians Order Sheet (POS) showed the following: -An order, dated 05/12/25, for prostat liquid oral (a medical food, specifically a concentrated sugar free liquid protein supplement) 30 milliliters (ml), one time per day at 8:00 A.M. Review of the resident's June 2025 Medication Administration Record (MAR) showed the following: -On 06/02/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item unavailable; -On 06/03/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/04/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/05/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/06/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Refused; -On 06/07/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/08/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/09/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/10/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/11/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable; -On 06/12/25, at 8:00 A.M., staff documented the dose of prostat as Not Administered: Drug/Item Unavailable. Review of the resident's June 2025 progress notes showed staff did not document physician notification of the missed doses of prostat. During an interview on 06/11/25, at 2:48 P.M., the resident said he/she had not refused any medications. 2. Review of Resident #77's face sheet showed the following: -admission date of 08/19/24; -Diagnoses included chronic kidney disease (kidneys are damaged and cannot filter blood), vascular dementia (reduced blood flow causing memory problems), and peripheral vascular disease (circulatory problem where blood vessels narrow and reduce blood flow to the limbs and organs). Review of the resident's quarterly MDS, dated [DATE], showed severe cognitive impairment. Review of the resident's April 2025 through June 2025 POS showed an order, dated 08/30/24, for prostat liquid oral 30 ml, one time per day at 8:00 A.M. Review of the resident's June 2025 MAR showed the following: -On 06/02/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/03/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/04/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/05/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/06/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/07/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/08/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/09/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/10/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/11/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable; -On 06/12/25, at 8:00 A.M., staff documented the prostat as Not Administered: Drug/Item Unavailable. Review of the resident's April 2025 through June 2025 POS showed an order, dated 04/21/25, for lidocaine (pain relief) adhesive patch, medication 4%, topical, apply patch to posterior neck in AM. Review of the resident's June 2025 MAR showed the following: -On 06/03/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/04/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/05/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/06/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/07/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/08/25, at A.M. med pass, staff documented the lidocaine patch as Not Administered: Drug/Item Unavailable; -On 06/09/25, at A.M. med pass, staff documented the lidocaine patch as Not administered: Refused. Review of the resident's June 2025 progress notes showed staff did not document physician notification of the missed doses of prostat and lidocaine. During an interview on 06/11/25, at 3:00 P.M., the resident denied refusing any medications. 3. Review of Resident #18 ' s face sheet, showed the following: -admission date of 10/29/19; -Diagnoses included chronic atrial fibrillation (persistent irregular and often very rapid heart rate that can lead to blood clots in the heart), chest pain, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and malignant neoplasm of colon (cancerous tumor that develops in the colon, the longest part of the large intestine). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident take an anti-coagulant medication (reduces blood clotting). Review of the resident's care plan, last reviewed 08/01/24, showed the following: -Resident had a history of stroke; -Resident received Eliquis (medication used to reduce risk of stroke and blood clots in person with atrial fibrillation) 2.5 milligram (mg - unit of measurement) daily for stroke; -Staff should administer medications per physician orders. Review of the POS, current as of 06/13/25, showed the following: -An order, dated 04/07/25, for Eliquis tablet 2.5 mg, give one tablet by mouth two times daily for diagnosis of chronic atrial fibrillation; -An order, dated 05/13/25 with end date of 05/17/25, for doxycycline (antibiotic used to treat a wide variety of bacterial infections) hyclate capsule 100 mg, give one capsule by mouth twice per day, no diagnosis provided for order. Review of the resident's May 2025 MAR showed the following: -On 05/13/25, at the A.M. Med Pass, staff documented doxycycline hyclate capsule 100 mg as Not Administered: Drug/Item Unavailable ; -On 05/13/25, at the Evening Med Pass, staff documented doxycycline hyclate capsule 100 mg as Not Administered: Drug/Item Unavailable ; -On 05/22/25, at the at bedtime Med Pass, staff documented Eliquis tablet 2.5 mg as Not Administered: Drug/Item Unavailable ; -On 05/23/25, at the at bedtime Med Pass, staff documented Eliquis tablet 2.5 mg as Not Administered: Drug/Item Unavailable . 4. Review of Resident #68's face sheet showed the following: -admission date of 01/09/25; -Diagnoses included complete traumatic amputation (total [NAME] of a limb or body part from the rest of the body, where there is no remaining connection of tissue, muscle, or ligaments) at level between right hip and knee, complete traumatic amputation at level between left hip and knee, peripheral vascular disease, and local infection of skin and subcutaneous tissue (the layer of fat and connective tissue that lies just beneath the skin). Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact/ -Review of the resident's care plan, last reviewed 04/22/25, showed staff will administered medications as the physician has ordered. Review of the resident's nursing progress note dated 03/27/25, at 2:03 P.M., showed staff documented new orders received and noted for Iron Glycinate (form of iron supplement used to treat or prevent iron deficiency anemia and to support healthy hemoglobin levelsgive two tablets every other day and vitamin C 1000 mg give one tablet daily. Order was faxed to the pharmacy. Review of the resident's POS, current as of 06/13/25, showed an order, dated 03/27/25, Iron Glycinate caplet, administer two tablets by mouth once every other day, no diagnosis provided. Review of the resident's April 2025 MAR, showed the following -On 04/04/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/06/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/08/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/10/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/12/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/14/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/16/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/18/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/20/25, at 8:00 A.M., staff documented the dose as Refused; -On 04/22/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/24/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/26/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 04/28/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable. Review of the resident's May 2025 MAR, showed the following -On 05/02/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/04/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/06/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/10/25, at 8:00 A.M., staff documented the dose as Refused; -On 05/12/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/16/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/18/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/22/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/24/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable; -On 05/28/25, at 8:00 A.M., staff documented the dose as Refused. Review of the resident's June 2025 MAR, showed the following: -On 06/01/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable ; -On 06/03/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable ; -On 06/05/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable ; -On 06/07/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable ; -On 06/11/25, at 8:00 A.M., staff documented the dose as Not Administered: Drug/Item Unavailable . 5. Review of Resident #70's face sheet, showed the following: -admission date of 11/08/23; -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), deficiency of other vitamins (occurs when the body doesn't get enough of a specific vitamin to function properly), and vitamin D deficiency (Can lead to various issues including bone pain). Review of the resident's significant change in condition MDS, dated [DATE], showed mild Cognitive impairment. Review of the resident's care plan, last reviewed 04/18/25, showed the following: -Resident was on a regular diet; -Resident was taking Prostat 30 ml daily; -Resident received Vitamin C, Zinc, and Magnesium as a dietary supplement. Review of the resident's POS, current as of 06/13/25, showed the following: -An order, dated 09/11/24, Citracal-D3 Maximum plus (Calcium-D3,Copper-Manganese - combinations of essential minerals and vitamins) give one tablet two times per day, for diagnosis of deficiency of other vitamins; -An order, dated 04/16/24, Wild Alaska Fish Oil (dietary supplement rich in Omega-2 fatty acids), give one capsule by mouth one time daily - family to provide, for diagnosis of deficiency of other vitamins; -An order, dated 04/16/24, 1,000 mg Vitamin C, D, and Zinc give as directed per package instructions, family to provide, for diagnosis of deficiency of other vitamins; -An order, dated 04/16/24, for Pro-Stat Sugar Free liquid, 15-100 kcal/20 ml, give 30 ml by mouth once daily for diagnosis of deficiency of other vitamins. Review of the resident's June 2025 MAR, showed the following related to Citracal-D3 Maximum Plus tablet; 325 mg-12.5 mcg-2.75 mg: -On 06/01/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/01/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/02/25, at the Evening Med Pass, staff documented as refused; -On 06/03/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/03/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/04/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/04/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/05/25, at the AM Med Pass, staff documented administered; -On 06/05/25, at the Evening Med Pass, staff documented as administered; -On 06/06/25, at the AM Med Pass, staff documented as refused; -On 06/06/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/07/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/07/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/08/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/08/25, at the Evening Med Pass, staff as not Administered: Drug/Item Unavailable; -On 06/09/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/09/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/10/25, at the Evening Med Pass, staff documented as refused; -On 06/11/25, AM Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/11/25, at the Evening Med Pass, staff documented as not Administered: Drug/Item Unavailable; -On 06/12/25, at the AM Med Pass, staff documented administered; -On 06/12/25, at the Evening Med Pass, staff documented as administered; -On 06/13/25, at the AM Med Pass, staff documented as not Administered: Drug/Item Unavailable. Review of the resident's June 2025 MAR, showed the following related to Equate 1,000 mg Vitamin C, D, and Zinc: -On 06/01/25 and 06/02/25, at the AM (morning) Med pass, staff documented as administered; -On 06/03/25, at the AM Med Pass, staff documented as Not Administered: Refused; -On 06/04/25, at the AM Med Pass, staff documented as Not Administered: Refused; -On 06/05/25, at the AM Med pass, staff documented as administered; -On 06/06/25, at the AM Med Pass, staff documented as Not Administered: Drug/Item Unavailable; -On 06/07/25 and 06/08/25, at the AM Med pass, staff documented as administered; -On 06/09/25, at the AM Med Pass, staff documented as Not Administered: Refused; -On 06/10/25, at the AM Med Pass, staff documented as Not Administered: Refused; -On 06/11/25, at the AM Med Pass, staff documented as Not Administered: Refused; -On 06/12/25, at the AM Med pass, staff documented as administered; -On 06/13/25, at the AM Med Pass, staff documented as Not Administered: Refused. Review of the resident's June 2025 MAR, showed the following related to Pro-Stat Sugar Free liquid 15-100 gram: -On 06/01/25, at the AM Med pass, staff documented as administered; -On 06/02/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/03/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/04/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/05/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/06/25 and 06/07/25, at the AM Med pass, staff documented as administered; -On 06/08/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/09/25, at the AM Med Pass, staff documented as Not Administered: Drug/Item Unavailable ; -On 06/10/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/11/25, at the AM Med Pass, staff documented as Not Administered: Drug/Item Unavailable ; -On 06/12/25, at the AM Med Pass, staff documented as Not Administered: Refused ; -On 06/13/25, at the AM Med Pass, staff documented as Not Administered: Refused . 6. During interviews on 06/12/25, at 10:58 A.M., and on 06/13/25, at 9:22 A.M., Certified Medication Tech (CMT) M said the following: -He/she reordered non narcotic medications; -He/she usually reordered when the resident was down to five doses; -The lidocaine patches were ordered on the computer; -Prostat was ordered by the front office. He/she told them when they're running low; -He/she told two charge nurse's they were out of prostat. They have been out several days as he/she has been off the last six days and they were out before he/she left. During an interview on 06/13/25, at 9:26 A.M., the CMT M said the following: -He/she did not apply lidocaine patches to residents; -He/she wasn't sure who reordered the lidocaine patches. He/she thought it was whoever reordered the stock meds; -If the medication was not available, he/she clicked that it was unavailable and let the nurse know. During an interview on 06/13/25, at 9:26 A.M., the Licensed Practical Nurse (LPN) D said the following: -He/she waited until there's about five doses of a medication left before reordering from the pharmacy; -Liquid prostat wasn't something he/she orders and he/she wasn't sure who ordered the liquid protein; -He/she did reorder the lidocaine patches and it depended on how many were left; -If the MAR said the medication wasn't administered due to being unavailable, he/she would think the medication is not available. During an interview on 06/13/25, at 10:40 A.M., the LPN A said the following: -The nurses reorder the narcotics and that's done by calling the pharmacy. After ordering a medication he/she documented that in the progress notes; -He/she didn't order prostat and the CMTs administer the medication; -He/she didn't know who ordered the prostat and he/she was not aware of it being out. He/she knew it was prescribed to help wounds heal; -He/she did reorder the lidocaine patches. He/she was not aware that Resident #77 is out of lidocaine patches. During an interview on 06/12/25, at 9:40 A.M., LPN F said the following: -If a medication was not available in the medication cart when staff was preparing to administer there was an emergency kit in the medication room, as well as several over-the-counter medications in the medication room; -Staff should look for the item and if not available the staff should contact the pharmacy and notify the charge nurse; -The charge nurse should notify the physician and check if there was alternate option or other orders related to the medication not available; -He/she had not been notified from the CMT of any not available medications. He/she thought there would be some iron tablets, Pro-Stat, and other vitamins available in the medication room in the excess cabinet. During an interview on 06/13/25, at 12:02 P.M., the Social Services Director (SSD) said the following: -Over the counter medications are kept in the central supply; -He/she did an inventory and ordered the medication at the first of the month; -He/she had not been told the prostat or lidocaine patches were out; -The meds could also be refilled through the pharmacy if they're needed quickly; -Staff are supposed to get the meds from the central supply room and if they're out, they need to let him/her know; -The MAR shouldn't say not available as the medications should be here. During an interview on 06/13/25, at 2:53 P.M., the Administrator/Interim Director of Nursing (DON) said the following: -When CMTs are passing meds and they're not available, they should be looking in the central supply to see if it's in there; -The SSD orders over the counter meds at the beginning of the month and as needed; -The medications can be ordered through the pharmacy as well; -If a medication is not available, the staff should be contacting the doctor and looking in the ekit; -He/she didn't believe they've been out of prostat, but the staff aren't looking for it in central supply; -He/she was not sure if they're out of lidocaine patches, but they buy those at local as they're cheaper, the staff need to notify us; -If staff are not administering as prescribed, it would be a med error.

5. Review of Resident #58's face sheet showed the following: -admission date of 05/16/24; -Diagnoses included metabolic encephalopathy (brain dysfunction often caused by illness or organ dysfunction), weakness, swelling, restless leg syndrome, insomnia, and obstructive sleep apnea (breathing disorder while asleep). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Upper extremity impairment to one side; -Dependent on others for toileting hygiene, showers, dressing, and bed mobility. Review of the resident's care plan, last updated/reviewed 05/19/25, showed the following: -Used side rail to assist in repositioning, mobility device; -Ensure valid consent on chart prior to use of side rails; -Quarterly review of safety for the device. Observation on 06/10/25, at 10:27 A.M., showed the resident's right side rail in the raised position. The left side rail was lowered and the bedside table was against the resident's left side. During the interview the resident said he/she wasn't able to utilize the right side rail as much as he/she would like, due to the paralysis on that side. He/she had to reach across with his/her left arm. He/she didn't want the left side rail raised because it got in the way of his/her rolling table. Observation on 06/10/25, at 2:45 P.M., showed the resident lay in bed. His/her right side rail was in the raised position, and the left side rail was lowered; the rolling bedside table was up close to the resident's left side. Observation on 06/12/25, at 10:50 A.M. showed the resident lay in bed. His/her right side rail was in the raised position; the left side rail was in the lowered position, and the bedside table was positioned close to the resident's left side. Review of the resident's record showed staff did not document regular inspections of all bed frames, mattresses, and side rails 6. During an interview on 06/11/25, at 10:04 A.M., the Medical Records staff gave the surveyors a maintenance log showing residents' newly added side rails. He/she said the previous Maintenance Director did the safety gap measurements when he/she installed the side rails. Medical Records did not think the new Maintenance Director was doing the measurements now and could not locate documentation of any safety gap measurements or routine safety rechecks. During an interview on 06/11/25, at 10:07 A.M., the Maintenance Director said he/she installed side rails upon request by nursing. He/she followed the guidelines for checking the gaps in the rails and between the mattress and rails, but didn;t document the specific measurements for each resident's bed. Maintenance tells the MDS Coordinator when the rails are installed and ready for use. The Maintenance Director said he/she did not do routine safety checks on side rails, but the nursing staff would notify him/her if any rails were loose or in disrepair. During an interview on 06/13/25 at 2:53 P.M., the Administrator/Interim Director of Nursing (DON) said the following: -Measurements are completed when the rails are installed and then monthly assessments of the side rails should be done to ensure safety; -Maintenance installs the side rails, and completes the initial gap measurements. He/she is also responsible for completing monthly checks and nursing follows behind to ensure the assessments have been completed; -The former DON was doing this, and he/she is no longer here; the responsibility then changed to the previous maintenance director; -The Administrator/Interim DON said he/she had not checked to see if the newer Maintenance Director was completing and documenting the safety gap measurements. 3. Review of Resident #12 's face sheet showed the following: -admission date of 06/25/24; -Diagnoses included cerebrovascular disease (group of conditions that affect the blood vessels and blood flow to the brain), rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility), polyosteoarthritis (arthritis that affects multiple joints characterized by the breakdown of cartilage in the joints, leading to pain, stiffness, and reduced mobility), polyneuropathy (condition where multiple peripheral nerves throughout the body are damaged simultaneously), pain in left shoulder, and pain in right shoulder. Review of the resident's nursing progress notes showed on 10/23/24, at 8:26 A.M., staff documented the resident had requested side rails for his/her bed, particularly on the side next to the wall so he/she could use it to reposition in the bed once staff assisted with laying down. Upon assessment if he/she would be able to utilize for repositioning and it was concluded as per the assessment that the side rails would function for positioning and not a restraint. Notified maintenance with order to place rails on bed. Family notified of the new order. Review of the resident's MDS, dated [DATE], showed the following information: -Cognitively intact; -Resident required substantial to maximal staff assistance for shower and dressing; -Resident required supervision or touching assistance of staff for personal hygiene. Review of the resident's care plan, last reviewed on 05/28/25, showed the following: -Resident used side rail to assist in repositioning as mobility devices; -Staff should ensure valid consent on chart prior to use of side rails; -Staff should review safety device quarterly. During observation and interview on 06/09/25, at 1:01 P.M., showed the resident in bed with a one-half side rail on the left side of the bed. The resident said he/she used to reposition in bed. Review of the resident's record showed staff did not document regular inspections of all bed frames, mattresses, and side rails 4. Review of Resident #68's face sheet showed the following: -admission date of 01/09/25; -Diagnosis included complete traumatic amputation (sudden and often unexpected loss of a body part, usually a limb) at the level between the right hip and knee, complete traumatic amputation at the level between the left hip and knee. Review of the resident's care plan, updated 04/22/25, showed the following: -Resident used side rail to assist in repositioning as a mobility device; -Staff should ensure valid consent was on the chart prior to use of side rails; -Staff should complete a quarterly review of the safety device. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Lower extremity impairment on both sides; -Dependent on staff for toileting, showers, dressing, and transfers. During observation and interview on 06/09/25, at 10:52 A.M., the resident was in a wheelchair in his/her room. The bed had bilateral half side rails in the upright position. The resident said he/she used to reposition in the bed. Review of the resident's record showed staff did not document regular inspections of all bed frames, mattresses, and side rails Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for five residents with side rails (Residents #8, #77, #12, #68, and #58) out of 26 sampled residents. The facility's census was 85. Review showed the facility did not provide a policy regarding the use of bed side rails. Review of the facility's checklist titled Restraints: Bed Rail Safety Check showed the following: -When using bed rails close attention must be given to the design of the rails and the relationship between rails and other parts of the bed; -The seven areas in the bed system that have a potential for entrapment are within the rail, under the rail, between the rail supports or next single rail support, between the rail and mattress, under rail, at ends of rail, between the rails, between end of rail and side edge of head or foot board and between the head or foot board and mattress end; -Regularly inspect each of the seven areas on each bed with restraints. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; -Diagnosis of quadriplegia (loss of movement in all four limbs), depression (persistent feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS-federally mandated assessment instrument completed by facility staff), dated 03/05/25, showed the following: -No cognitive impairment; -Dependent upon staff for toileting hygiene, showers, lower body dressing and rolling left to right; -substantial assistance with personal care, upper body dressing. Review of the resident's care plan, reviewed on 05/21/25, showed the following: -Had seizures related to epilepsy; -Used bed rails to assist themselves with self care; -Perform bed rail assessment at least quarterly or as per facility protocol. Observations and interviews showed the following: -On 06/09/25 at 10:04 A.M., resident laid in bed with a grab bars on the right and left sides in the up position. The resident said the bars were on his/her bed to keep him/her from falling out; -On 06/10/25 at 9:00 A.M., resident laid in bed with the grab bars on the right and left sides, in the up position. Review of the resident's record showed staff did not document regular inspections of all bed frames, mattresses and side rails 2. Review of Resident #77s face sheet showed the following: -admission date of 08/19/24; -Diagnosis of vascular dementia (reduced blood flow causing memory problems), and peripheral vascular disease (circulatory problem where blood vessels narrow and reduce blood flow to the limbs and organs). Review of the resident's quarterly MDS assessment, dated 04/23/25, showed the following: -Severe cognitive impairment; -Dependent upon staff for toileting hygiene, showers, and lower body dressing; -Substantial assistance with upper body dressing and personal hygiene; -Supervision with rolling from left to right. Review of the resident's care plan, reviewed on 05/29/25, showed the following: -Resident used side rail to assist in reposition and as a mobility device; -Ensure quarterly review of safety device and removal of equipment when not in use after evaluation. Observations and interviews showed the following: -On 06/09/25, at 9:50 A.M., resident laid in bed with 1/2 grab bars in the upward position on each side of the bed; -On 06/11/25, at 8:27 A.M., the resident said he/she didn't use the side rails, but he/she liked them on his/her bed. Review of the resident's record showed staff did not document regular inspections of all bed frames, mattresses, and side rails

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent possible urinary tract infection (UTI - infection in any part of the urinary system, the kidneys, bladder) when staff failed to ensure the catheter drainage tubing (tubing that drains urine from the bladder to a collection bag) of one residents (Resident #68) did not sit or drag on the floor; and when the facility failed to ensure the staff entered a catheter order that included the size of catheter to be used for three residents (Resident #68, #8, and #42). The facility had a census of 85. Review of the facility policy titled Urinary Catheter (flexible tube inserted through the urethra into the bladder to drain urine) Care, dated August 2022, showed the following: -The purpose of the procedure was to prevent urinary catheter-associated complications, including urinary tract infections; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Review and document the clinical indication for catheter use prior to inserting; -Use aseptic technique when handling or manipulating the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #68's face sheet, showed the following: -admission date of 01/09/25; -Diagnoses included retention of urine (inability to fully empty your bladder). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 04/04/25, showed the following: -Cognitively intact; -Had an indwelling catheter. Review of the resident's care plan, last updated 04/22/25, showed the following: -Resident had indwelling catheter; -Staff should change the catheter as ordered by the physician; -Staff should position catheter bag and tubing below the level of the bladder, on the bed frame, or back of wheelchair, and in a privacy bag; -Staff should ensure tubing was anchored to the resident's leg or linens so that tubing was not pulling on the urethra (duct by which urine is comes out of the body from the bladder). Review of the resident's Physician Order Sheet (POS), current as of 06/13/25, showed the following: -An order, dated 04/15/25, to change indwelling catheter as needed for leaking or blockage; -No size of catheter (common sizes range from 14 French to 24 French (the unit of measurement for the catheter's outer diameter)) or balloon size (5 to 30 ml sizes - inflated with sterile water and used to prevent the catheter from slipping out of the bladder) in the order. Observation on 06/09/25, at 11:58 A.M., showed the resident seated in his/her wheelchair with catheter bag below the wheelchair. Approximately one foot of the catheter tubing was noted to be on the floor in the dining room. Staff were in the dining room serving meal trays. No staff stopped to correct the catheter tubing. 2. Review of Resident #8's face sheet showed the following: -admission date of 12/29/23; -Diagnosis of quadriplegia (loss of movement in all four limbs). Review of the resident's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Indwelling catheter; -Diagnoses included neurogenic bladder (bladder control problems caused by nerve damage). Review of the resident's care plan, last reviewed on 05/21/25, showed the following: -Resident had suprapubic catheter; -Staff should change the catheter as ordered by the physician. Review of the resident's POS, current as of 06/13/25, showed the following: -An order, dated 02/04/24, to change foley catheter as needed for leaking or blockage; -An order, dated 02/04/24, for foley catheter care each shift; -No size of catheter or balloon size in the order. Observation on 06/09/25, at 12:25 P.M., showed the resident in his/her room, seated in his/her wheelchair with catheter bag below the wheelchair. 3. Review of Resident #42's face sheet showed the following: -admission date of 06/08/21; -Diagnoses included overactive bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate to severe cognitive impairment; -Always incontinent of bowel and bladder; -Dependent on others' assistance for toileting needs. Review of the resident's POS, dated 05/13/25 to 06/13/25, showed the following: -An order, dated 05/21/25, for may have a foley catheter for wound healing process of bilateral lower extremities (the order did not contain the tube and balloon sizes for the catheter); -An order, dated 05/21/25, to assure catheter bag is hanging from bed frame or under wheelchair in a dignity bag; -An order, dated 05/21/25, to provide catheter care every shift; -An order, dated 05/21/25, to change foley catheter as needed for leaking or blockage; -An order, dated 05/21/25, to irrigate foley catheter with 100 cc of normal saline as needed for sediment. Review of the resident's care plan, last updated 05/22/25, showed the following: -Incontinent of urine, wears briefs, and currently has a catheter to aide with wound healing; -Indwelling catheter related to wound healing; -Manage catheter appropriately; -Assess urine every shift, monitor, and document intake and output as per facility policy. Document any change in color, odor, or increased sediment noted; -Avoid obstructions in the drainage, check tubing for kinks, and maintain the drainage bag off of the floor; -Change the catheter as ordered by physician; -Flush catheter as ordered by physician; -Keep catheter system a closed system as much as possible. Observation on 06/09/25, at 12:05 P.M., showed the resident sat in a motorized wheelchair at a table in the main dining room. A catheter bag was inside a dignity cover and hanging from the lower part of the chair. Observation on 06/12/25, at 11:51 A.M., showed the resident in bed, awake. A catheter bag was hanging on the lower rail of the bed facing the window. The bag contained very dark urine. During the observation, the resident said he/she did not have any problems with the catheter. 4. During an interview on 06/13/25, at 1:14 P.M., Licensed Practical Nurse (LPN) A said a catheter required an order for a certain sized before it could be placed. During an interview on 06/12/25, at 9:40 A.M., LPN F said catheter orders should include the size of the catheter and the size of the balloon for staff to use. The catheter tubing should not be on the floor to keep the tubing clean and free of bacteria. During an interview on 06/13/25, at 11:05 A.M., LPN D said catheter orders should include catheter size and balloon size. He/she said that catheter tubing should not be on the floor at any time. He/she said once the nurse had placed the catheter the nurse should amend the order to include the sizes for next catheter changes. During an interview on 06/13/25, at 2:50 P.M., Administrator/Interim DON said that staff should be getting a physician order for catheter use that included when to change the catheter, the size of catheter and size of balloon and how to care for the catheter.

Based on record review, interviews, and review of facility policy, the facility failed to complete quarterly care plan meetings for four residents (Residents #8, #1, #44, and #58). The facility census was 85. Review of the facility's policy titled, Resident Participation-Assessment/Care Plans, revised February 2021, showed the following: -The resident and his or her legal representative were encouraged to attend and participate; -It is the resident/representative's right to participate in the development and implementation of his/her plan of care; -The care planning process included an assessment of the resident's strengths and his/her needs as well as incorporating the resident's personal and cultural preferences; -The facility holds care planning meetings at times of day when the resident and representative and family members can attend, provide sufficient notice of the care plan meeting; -The Social Services Director (SSD) is responsible for notifying the resident and representative and for maintaining records of such notices. Review of the facility's care plan packet showed the following: -Template letter that was mailed to the resident's representative indicating the time and date of the care plan; -Information on the various departments involved in care planning; -Care conference prep meeting guide; -List of areas for discussion, including code status, side rails, and diagnoses. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; -Diagnoses of included quadriplegia (loss of movement in all four limbs) and depression (persistent feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS-federally mandated assessment instrument completed by facility staff), dated 03/05/25, showed the following: -No cognitive impairment; -Dependent upon staff for toileting hygiene, showers, lower body dressing, and rolling left to right; -Substantial assistance with personal care, upper body dressing; Review of the resident's care plan, reviewed on 05/21/25, showed the following: -Resident was a quadriplegic and used a baclofen pump related to muscle spasms; -Resident had seizures related to epilepsy and chronic pain; -The last care plan conference was on 06/24/24. During an interview on 06/10/25, at 2:43 P.M., the resident said he/she didn't remember having a care plan meeting for a long time. 2. Review of Resident #1's face sheet showed the following: -admission date of 07/18/97; -Diagnoses included focal (limited to a specific area), partial symptomatic epilepsy (seizure disorder) and epileptic syndromes (seizure types and specific findings on an electroencephalogram (EEG- a test that measures and records electrical activity of the brain) with complex partial seizures (a type of seizure that begins in one area of the brain and impairs consciousness, causing the individual to appear awake but not fully aware of their surroundings), unspecified injury of head, atresia of foramina of Magendie and Luschka (congenital malformation where the opening that allows cerebrospinal fluid to flow out of the fourth ventricle are either absent or abnormally developed), major depressive disorder, single episode (persistent feelings of sadness), contracture of muscle, cognitive communication deficit, chronic pain, mechanical complication of ventricular intracranial shunt, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebrovascular disease, feeding difficulties, muscle wasting and atrophy, low vision in both eyes, and congenital malformation of brain. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Dependent on staff for toileting hygiene, showers/bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, chair/bed to chair transfer, toilet, and tub/shower transfer; -Partial/moderate assist for eating; -Substantial/maximal assist with oral hygiene; -Used a manual wheelchair. Review of the resident's care plan, reviewed/revised on 06/13/25, showed the following: -Required a Hoyer mechanical lift for transfers; -Dependent on one-person assistance with dressing, bathing, toileting, and hygiene due to right-sided weakness from a previous stroke; -Required cues and reminders often and supervision in decision-making; -High risk for falls; -Had impaired vision but could read large print with glasses on; -Needed one person assist with oral care; -At risk for pressure ulcers -Has frequent bladder incontinence; -Occasional incontinence of bowel; -Had verbal behavioral symptoms directed towards others; -Resident makes sexually inappropriate comments toward staff; -Had experienced weight loss; -Restorative therapy in place to assist in maintaining function, mobility, self-care and to educate resident on proper mechanics for activities of daily living; -Refused to use foot pedal when up in wheelchair; -Had wound(s), indwelling medical device(s), multi-drug-resistant organism-colonization/infection regardless of multi-drug-resistant organism colonization status; -Last care plan conference was on 05/26/24. During an interview on 06/10/25, at 11:15 A.M., the resident said he/she did not attend care plan meetings, and he/she did not know what the care plan meeting was about. 3. Review of Resident #44's face sheet showed the following: -admission date of 02/25/21; -Diagnoses included epilepsy (seizure), pain, hypertension (high blood pressure), muscle wasting and atrophy (decrease in muscle mass and strength), cerebrovascular disease (a condition that impacts the brain's blood vessels and blood flow), auditory hallucinations (a perception of hearing something that was not actually there), suicidal ideations, difficulty walking, left artificial hip joint, osteoarthritis (arthritis that occurs when tissue at the ends of the bones wear down), schizoaffective disorder (a mental health disorder), anxiety, spastic diplegic cerebral palsy (a type of cerebral palsy that affects the legs), atrophy of thyroid (shrinking of the thyroid gland), major depressive disorder single episode(a mental health condition causing sadness, a loss of interest in activities, and impacts how a person feels, thinks, and handles daily life), bipolar disorder (mental health condition that causes extreme mood swings), reduced mobility, dysphagia (difficulty swallowing), muscle weakness, cognitive communication deficit (difficulties in communication), personality disorder (mental health disorder that involves long-term patterns of thoughts and behaviors that lead to unhealthy coping), and other symptoms and signs involving the nervous system (the body's control and communication network, responsible for coordinating actions and transmitting signals between different body parts). Review of the resident's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Supervision or touching assistance for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear, personal hygiene, rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking; -Partial to moderate assistance with shower/bathing. Review of the resident's care plan, reviewed/revised on 06/13/25, showed the following: -Resident had epilepsy related to seizure disorder; -Unsteady gait related to cerebral palsy; -History of cerebral vascular accident; -Diagnosis of hypertension; -History of anxiety with medications in place as directed; -At risk for potential skin tear, laceration, or abrasion due to weakness, unsteady gait upon transition, fragile skin, poor safety awareness, cognitive impairment; -At risk for increased pain and discomfort related to diagnosis, cognitive deficit, weakness, decreased mobility; -Had restorative therapy in place to assist in maintaining function, mobility, and self-care and to educate resident on proper mechanics for activities of daily living; -Had impaired vision related to glaucoma and wears reading glasses; -Recently experienced the recent loss of his/her spouse; -Wishes to have lifestyle and customary routines followed; -Preferred to stay in his/her room and watch TV, talk on the phone, and go out frequently with family; -Needs supervision with activities of daily living and transfers and may need one person's assistance when experiencing increased weakness and unsteady gait; -Would like to lose weight and has contemplated gastric bypass surgery. Also spoke with the dietician and agreed to receive a regular low-calorie sweeteners diet with 1/2 portions and fruit only for dessert; -Is at high risk for falls due to an unsteady gait and balance during transfers and ambulation, history of falls, decreased visual acuity, use of multiple psychotropic medications and weakness; -Last care plan conference was on 07/11/24. During an interview on 06/10/25, at 3:15 P.M., the resident said he/she had never had a care plan meeting, and he/she was not familiar with what the care plan meeting was. 4. Review of Resident #58's face sheet showed the following: -admission date of 05/16/24; -Diagnoses included chronic obstructive pulmonary disease (COPD: breathing disorder), metabolic encephalopathy (brain dysfunction often caused by illness or organ dysfunction), congestive heart failure, bladder dysfunction with indwelling catheter (tubing inserted into the bladder for draining), weakness, swelling, history of blood clots, colostomy status (tubing inserted directly into the abdomen for bowel elimination, spinal disorder, chronic kidney disease, gastro-esophageal reflux disease (GERD - stomach acid backs up into the throat, chronic wound to the back, gout (arthritis build-up in a joint), muscle spasms, chronic osteomyelitis (persistent bone infection ), thyroid disorder, major depressive disorder, anxiety disorder, restless leg syndrome, insomnia, obstructive sleep apnea (breathing disorder while asleep, hearing loss in both ears, and high blood pressure. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Upper extremity impairment to one side; -Dependent on others for toileting hygiene, showers, dressing, and bed mobility. Review of the resident's care plan, last updated/reviewed 05/19/25, showed the following: -Fall risk; -New order for thickened liquids and resident signed waiver related to adding ice; -Indwelling catheter; -Side rail to assist in repositioning as a mobility device; -Existing pressure ulcer related to immobility and incontinence; -Chronic pain; -Preferred independent activity in room and participates in activities of choice; -Restorative therapy as directed; -Hearing loss. During an interview on 06/11/25, at 2:33 P.M., the resident said he/she had not been invited to attend a care plan meeting since he/she was admitted to the facility. During an interview on 06/12/25, at 1:21 P.M., the MDS Coordinator said he/she had not yet held a care plan meeting for the resident. 5. During an interview on 06/12/25, at 1:14 P.M., the MDS Coordinator said he/she has only been in the position about four weeks and just began having care plan meetings last week; -The prior MDS Coordinator had not been holding care plan meetings for the last six to eight months; -Care plan meeting should be held quarterly; -He/she called family to set up a time to have the meeting and he/she then mailed a reminder letter. During an interview on 06/13/25, at 2:53 P.M., Administrator/Interim Director of Nursing (DON) said the following: -MDS Coordinator should be scheduling care plan meetings quarterly. The last MDS Coordinator only wanted to hold 15 minute care plan meetings; -The resident and the families were invited and a follow up letter is mailed to the family. He/she didn't know if the invitations were documented in the resident's records.

Based on interview and record review, the facility failed to ensure all residents' drug regimens were free from unnecessary drugs when staff failed to provide a stop date or rationale for extending the order for one as needed (PRN) medication for one resident (Resident #47). The facility census was 85. Review of the facility policy titled Medication Therapy, , dated April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; -All medication orders will be supported by appropriate care processes and practices; -Upon or shortly after admission, and periodically thereafter, the staff and practitioner, assisted by the consultant pharmacist, will review an individual's current medication regimen, to identify whether there is a clear indication for treating that individual with the medication; the dosage is appropriate; the frequency of administration and duration of use are appropriate; and potential or suspected side effects are present; -Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regiment for continued indications, proper dosage and duration, and possible adverse consequences; -The Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when clinically significant adverse consequence is confirmed or suspected; -The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. Review of the facility provided policy titled Administering Medications, dated April 2019, showed the following: -If a resident used PRN medications frequently, the attending physician and Interdisciplinary Care Team (IDT), with support from the consultant pharmacist as needed, shall re-evaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent as needed use, and consider whether a standing dose of medication is clinically indicated. 1. Review of Resident #47's face sheet (brief information sheet about the resident), showed the following: -admission date of 12/827/21; -Diagnosis 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, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and generalized anxiety disorder (excessive anxiety and worry about a variety of events or activities that occurs more days than not, for at least 6 months). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/19/25, showed the following: -Moderate cognitive impairment; -Received antipsychotic (medication used to treat psychotic disorder (delusions - thoughts or beliefs that are unlikely to be true)), antianxiety (medications that are used to prevent or relieve anxiety), and antidepressant medications (medications used to treat depression). Review of the resident's care plan, reviewed 06/04/25, showed the following: -Resident had a diagnosis of anxiety; -Staff should notify the physician of any changes in the resident's level of anxiety and follow any orders received; -The resident had a history of anxiety with medications in place as directed; -Staff should give antianxiety medications ordered by the physician. Review of the residents' physician orders, current as of 06/13/25, showed an order, dated 02/13/24, for lorazepam (medication used to relieve symptoms of anxiety) 0.5 milligram (mg) give one-half tablet (0.25 mg) by mouth every six hours as needed for anxiety. The order did not contain an end date. Review of the pharmacy medication regimen reviews performed on 01/14/25, 02/13/25, 03/18/25, 04/29/25, and 05/23/25, showed the following: -Lorazepam 0.5 mg, give one-half tablet (0.25 mg) by mouth every six hours as needed; -Diagnosis was anxiety; -Stop date was needed. Review of the Pharmacist Recommendation to the Prescriber, dated 11/13/24, showed resident receiving Lorazepam 0.25 mg every six hours PRN, with a stop date needed, last utilized on 11/08/24. Review of the resident's progress and nursing notes showed staff did not document a stop date or rationale for continued use of lorazepam PRN. During an interview on 06/13/25, at 11:05 A.M., Licensed Practical Nurse (LPN) D said staff should follow physician orders related to PRN medications. He/she had not been asked to review pharmacy recommendations and was not aware of need for PRN use to have a stop date. During an interview on 06/13/25, at 12:50 P.M., LPN F said he/she had not seen stop dates on any PRN medications. He/she had not been asked to review any pharmacy recommendations. During an interview on 06/13/25, at 2:50 P.M., Administrator and Interim DON said the monthly pharmacy recommendations had been reviewed by the previous DON and would now be the responsibility of the new MDS Coordinator. She said that she printed off the monthly medication reviews and would put them in the physician's box for review. Once the physician completed the response would then be taken to the MDS Coordinator to complete any needed actions. The PRN medications normally were written for 14 days. If there was no stop date, the physician was required to do face-to-face visit with the resident and put the reasoning for continuing on the orders. She was not aware there was no stop date or rationale for continued use on lorazepam for the resident.

Based on record review and interview, the facility failed to develop and implement a baseline care plan with 48 hours of admission for two residents (Residents #132 and #281) of 26 sampled residents. The facility census was 85. Review showed the facility did not provide a policy specific to baseline care plans for residents upon admission. 1. Review of Resident #132's face sheet (gives basic profile information) showed the following: -admission date of 05/28/25; -On hospice services on admission to facility; -Diagnoses included history of transient ischemic attack (TIA - mini-stroke) and stroke with resulting weakness and difficulty with speech and swallowing, history of falls, dementia with agitation, cognitive communication deficit, major depressive disorder, generalized anxiety disorder, high blood pressure, heart disease, gastro-esophageal reflux disease (GERD - stomach acid backs up into the throat), chronic inflammation of the pancreas (causes abdominal pain), and unsteady on feet/lack of coordination. Review of the facility admission checklist, dated 04/17/25, showed the following: -Nursing staff is responsible for completing a baseline care plan, printing it off, having the resident sign it, and placing it in the medical records box; -Recheck that all of the nurse responsibilities listed on the admission checklist have been completed and place the completed checklist paper in the Director of Nursing's (DON's) box. 2. Review of Resident #281's face sheet showed the following: -admission date of 05/28/25; -Diagnoses included enterocolitis (small and large intestine's inflammatory response to an injury or illness) due to clostridium difficile (inflammation of the colon caused by bacteria), stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, congestive heart failure (chronic condition where the heart does not pump blood as well as it should), and a third degree burn of the lower leg. Review showed the facility did not have a documented base-line care planned documented within 48 hours of admission. During an interview on 06/12/25, at 1:14 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said there was no baseline care plan was completed for the resident. 3. During an interview on 06/13/25, at 1:08 P.M., Licensed Practical Nurse (LPN) D said the admitting nurse should start the care plan (baseline) using information given by the previous facility or location (hospital, another nursing facility, etc.). The baseline care plan should include care needs, hospice services, skin issues/wounds, and anything specific about the resident that staff might need to know. During an interview on 06/12/25, at 1:14 P.M., the MDS Coordinator said the following: -The admitting nurse should complete the (baseline) care plan; -Baseline care plans should be completed within 24-hours of admission. During an interview on 06/13/25, at 2:55 P.M., the Administrator/Interim DON said the admitting nurse should do a baseline care plan for the resident. The baseline care plan should include information staff needs to be aware of; such as special care needs, assistance required for transfers, eating, and personal care, ability to ambulate, toileting needs, and hospice agency involvement.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for two residents (Resident #8 and #49) . The facility census was 85. Review of the facility's policy titled Protocol for Bathing/Shower/Tub, revised September 2021, showed the following information: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Document the date and time of the shower, name and title of the individual assisting, and assessment of the individual. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; -Diagnoses included quadriplegia (loss of movement in all four limbs) and depression (persistent feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 03/05/25, showed the following: -No cognitive impairment; -Dependent upon staff for showers; -Substantial assistance required with personal care. Review of the resident's care plan, last reviewed on 05/21/25, showed the following: -Honor resident's lifestyle and customary routines. Discuss with staff how to honor resident's preferences; -Required total care for daily living skills. Review of the resident's April 2025 shower sheets showed the following: -On 04/03/25, resident received a shower; -On 04/09/25, the resident received a shower (six days after the prior shower); -On 04/11/25, resident received a shower; -On 04/18/25, the resident received a shower (seven days after the prior shower); -On 04/25/25, the resident received a bed bath. Staff noted reason of resident just wanted to sit up in his/her wheelchair (seven days after prior shower); -On 04/30/25, staff noted on shower sheet that they went to get resident for a shower, but due to power outage on 4/29/25, he/she was already in his/her chair. Staff told resident they would try to get his/her shower in on 5/01/25. Review of the resident's April 2025 notes showed staff did not document any additional showers or shower refusals by the resident. Review of the resident's May 2925 shower sheets showed the following: -On 05/02/25, the resident received given a shower (seven days after the bed bath); -On 05/09/25, the resident received a bed bath, per resident's request (seven days after the last shower); -On 05/16/25, the resident received a shower (seven days after the last shower). Review of the resident's May 2025 nursing notes showed staff did not document any additional showers or shower refusals by the resident. Review of the resident's shower sheets, dated 06/01/25 to 06/13/25, showed on 06/03/25, the resident received a shower (18 days after the last shower). Observation and interview on 06/09/25, at 12:25 P.M., showed the following: -The resident's hair appeared oily; -The resident said his/her skin gets itchy when he/she doesn't have a shower often; -He/she would like to have a shower two times per week and he/she isn't sure of the last shower, but thinks it's been around a week; -Sometimes staff give him/her a bed bath and he/she would prefer a shower. Review of the resident's shower sheets, dated 06/01/25 to 06/13/25, showed on 06/10/25. the resident received a shower (seven days after the last shower). Review of the resident's June 2025 nursing notes showed staff did not document any additional showers or shower refusals by the resident. 2. Review of Resident #49's face sheet showed the following: -admission date of 04/07/20; -Diagnoses included unspecified visual loss and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Required substantial/maximum assistance for showers/bathing. Review of the resident's care plan, last reviewed on 05/23/25, showed the following: -Resident needed extensive assist of one with bed mobility and bathing, and supervision with most transfers, and activities of daily living; -Assist of one staff with transfers and activities of daily living, as needed; -Resident was legally blind. Review of the resident's April 2025 shower sheets showed the following: -On 04/02/25, the resident received a shower; -On 04/08/25, the resident received a shower (six days after the prior shower); -On 04/11/25, resident received a shower; -On 04/18/25, the resident received a shower (seven days after the prior shower); -On 04/22/25, staff noted shower not received. The certified nurse aide (CNA) noted staff knocked on door and called out resident's name three times and could not get resident to respond to me; -On 04/23/25, resident received a shower; -On 04/25/25, resident received a shower; -On 04/30/25, resident received a shower. Review of the resident's April 2025 nursing notes showed staff did not document any additional showers or shower refusals by the resident. Review of the resident's May 2925 shower sheets for showed the following: -On 05/02/25, the resident received a shower; -On 05/06/25, the resident received a shower; -On 05/09/25, the resident received a shower; -On 05/13/25, the resident received a shower; -On 05/16/25, the resident received a shower; -On 05/19/25, the resident received a shower; -On 05/23/25, the resident received a shower; -On 05/27/25, the resident received a shower; -On 05/30/25, the resident received a shower. Review of the resident's shower sheets, dated 06/01/25 to 06/13/25 showed on 06/03/25, resident received a shower. -No additional shower sheets provided by the facility. Review of the resident's nursing notes, dated June 2025, showed staff did not document any additional Observation and interview on 06/09/25, at 11:48 A.M., showed the following: -Most of the resident's hair was secured in a cap, but the small amount of hair that was showing outside the cap appeared oily; -The resident was crying and stated that he/she wanted a shower because he/she had not received a shower since last Tuesday (06/03/25); -He/she used to get a shower on Monday, Wednesday, and Friday, but now his/her scheduled shower days are Tuesday and Friday. -Sometimes he/she received a shower two times per week or one time per week, but most weeks, he/she was not receiving even one shower per week; -He/she tried to clean themselves in his/her room sink, but it was not the same as getting a shower; -It has been a recent problem for showers to not be given. During an interview on 06/12/25, at 10:05 A.M., the resident said the following: -On 06/11/25, he/she used his/her cell phone to call the facilities front desk to request a shower since he/she had not had a shower in over a week; -The shower aide came to his/her room shortly after the call and took him/her down the hall for a hurried-up shower; -The resident did not feel that he/she received as good of a shower as needed. 3. During an interview on 06/12/25, at 2:26 P.M., CNA G said the following: -They have a shower aide per hall Monday through Friday; -Residents are offered showers two times per week; -The shower aide does get pulled to the floor. He/she has been pulled to the floor a few times in the last four weeks he/she has been here. During an interview on 06/12/25, at 11:33 A.M., CNA H said the following: -He/she was the shower aide for B hall, and he/she worked Monday through Friday; -He/she offered residents showers two times per week, some Monday and Thursday, the other's Tuesday and Friday. Some only want them one time per week so they get them Wednesday and it's also a make up day; -If a resident refused a shower, he/she offered a bed bath; -He/she was pulled to work the floor three times last week, and one time this week; -He/she has received several complaints from residents about not getting showers. During an interview on 06/13/25, at 10:58 A.M., Certified Medication Technician (CMT) B said the following: -The facility has shower aides for each hall; -The residents are offered showers two times per week; -The residents have complained as the shower aide keeps getting pulled to work the floor so he/she doesn't have time to do showers; -The resident have an option of a bed bath or shower. During an interview on 06/13/25, at 11:15 A.M., CNA C said the following: -The residents are offered showers two times per week; -Sometimes the shower aide gets pulled to the floor and showers stop. The shower aide does try to make them up; -A resident can choose whether they receive a bed bath. During an interview on 06/12/25, at 10:59 A.M., CNA O said the following: -Residents usually receive a shower two times per week if the shower aide is not pulled to the floor to work; -Recently, the shower aide has not been pulled to work on the floor as much. During an interview on 06/12/25, at 11:00 A.M., CNA P said the following: -Residents receive a shower three times per week; -The shower aide is seldomly pulled to the floor to work. During an interview on 06/12/25, at 11:30 A.M., Licensed Practical Nurse (LPN) D said the following: -There was a shower aide for each wing; -The shower aide has a shower sheet for each resident; -The shower aide is supposed to complete five to 10 showers in a day; -The shower aide gets pulled to the floor to work, sometimes three times per week; -He/she does not know what the shower schedules were; -He/she has heard some residents complain that the shower aid takes other residents for a shower ahead of them. During an interview on 06/13/25, at 2:53 P.M., the Administrator and Interim DON said the following: -Residents should be offered a shower two times per week, or when requested; -There was a shower aide on each hall Monday through Friday and staff will provide as requested on the weekends; -If the resident refuses they should be signing a paper; -He/she was not aware of residents complaining or not getting showers regularly; -He/she has given residents showers per there or the families request; -Residents should be offered a shower, if they do not want a shower a bed bath should be care planned.

Based on interview and record review, the facility failed to implement policies to prevent possible abuse when staff failed to follow-up on results for a criminal background check (CBC) requested on one staff member (Maintenance Assistant E). The facility census was 85. Review of the facility's Abuse and Neglect Policy and Procedure, updated 03/22/25, showed the following: -It was the policy and the right of each resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -All potential employees will have CBC prior to hiring. 1. Review of the personnel file for Maintenance Assistant E showed the following: -Hire date of 03/16/25; -Staff did not document completion or result of a CBC. During an interview on 06/12/25, at 11:38 A.M., the Receptionist said he/she sends an employee's information to the corporate office to request a CBC. If the person is already listed on the state's Family Care Safety Registry (FCSR - a state registry that provides multiple checks on staff including a CBC), the background check was run through the FCSR. If the person was not registered with the FCSR, the facility either sent in the $15 registration processing fee (paid by the applicant), and the request was submitted for the CBC, or the facility requested a CBC through the state highway department. The Receptionist said the corporate office contacted the FCSR and was told they sent an email to the applicant requesting additional or corrected information. The CBC had not been completed to date. The Receptionist spoke to the employee, who said he/she had not seen the email from FCSR and was not aware that the CBC had not been completed pending the requested information. During an interview on 06/13/25, at 2:55 P.M., the Administrator/Interim Director of Nursing (DON) said the facility Receptionist sent a request to the corporate office to run an employee background check. They also check the EDL, sex offender list, and the state Nurse Aide Registry. Rechecks are done every 90 days. The Administrator/Interim DON said the Receptionist had informed her that they had requested the FCSR background check that day for Maintenance Assistant E (still employed at the facility) as it had not been completed previously.

Based on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff) assessment for one resident (Resident #14) was completed timely as required. The facility had a census of 85. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; -The annual assessment ARD is the ARD of previous OBRA comprehensive assessment plus 366 calendar days, and ARD of previous OBRA Quarterly assessment plus 92 days. Review of a facility policy entitled Resident Assessments, revised March 2022, showed the following information: -A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements; -The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to requirements, including an Annual Assessment; -The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments; -A comprehensive assessment includes completion of the MDS, completion of the care area assessment (CAA) process; and development of the comprehensive care plan. Review of a facility policy entitled Comprehensive Assessments, revised October 2023, showed the following information: -Comprehensive MDS assessments are conducted to assist in developing person-centered care plans; -The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the RAI specified by CMS; -A comprehensive assessment included completion of the MDS; completion of the care area assessment (CAA) process; and development of the comprehensive care plan; -The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (within 366 days of the previous assessment). Its completion dates (MDS/CAA(s)/care plan) depend on the most recent comprehensive and past assessments' ARDs and completion dates; -Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals on the interdisciplinary team. 1. Review of Resident #14's face sheet (gives basic profile information) showed an admission date of 06/29/09. Review of the resident's submitted reports showed the following information: -Annual assessment ARD of 05/08/24; -Quarterly assessment ARD of 08/08/24; -Quarterly assessment ARD of 10/22/24; -Quarterly assessment ARD of 01/08/24; -Staff did not submit a subsequent comprehensive or annual assessment within 366 days of the most recent annual assessment. During an interview on 06/12/25, at 1:27 P.M., the MDS Coordinator said he/she started working at the facility less than four weeks prior. The corporation was still in process of setting him/her up for accessing all of the MDS reports. Prior to the survey he/she was not aware of any late reports, including Resident #14's Annual assessment. He/she would be sending in a quarterly assessment for Resident #14 the following day based on a current care plan meeting held this week. During an interview on 06/13/25, at 2:55 P.M., the Administrator/Interim Director of Nursing (DON) said staff should submit MDS assessment reports on admission, 7 days after admission, quarterly, and annually. Assessments should also be completed and submitted if the resident has a change of condition or admits to hospice services. The Administrator/Interim DON said the former MDS Coordinator might have been behind on submitting some assessments and the new MDS Coordinator was in the process of ensuring all MDS assessments were completed and submitted per requirements.

Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR-process of providing rescue ventilation to maintain circulation of blood) certified staff were scheduled and present in the facility 24 hours a day, seven days a week; failed to develop and implement a policy addressing CPR requirements for the staff; failed to ensure the transporter for the facility had been CPR certified; and failed to maintain documentation of CPR certifications for staff members. The facility had 28 residents with full code status (residents request to have full resuscitation efforts/CPR in the event of respiratory or [MEDICAL CONDITION]). The facility census was 88. 1. Record review on [DATE] at 8:25 A.M., of the facility's file of CPR certifications showed the staff did not have documentation on-site of current CPR certification for any facility staff. The facility provided CPR certifications for three agency certified nurse assistants (Certified Nurse Aide (CNA) O, CNA P, and CNA Q). During an interview on [DATE] at 8:25 A.M., the administrator said the following: -The last CPR class was completed in (MONTH) (YEAR) at the facility; -They planned to have a CPR class at the facility, but none had been scheduled; -The facility's corporate office sent the administrator a tracking report for the nurses' licenses, the certified medication technicians (CMT's), and the certified nurse assistant (CNA's) certificates with their expiration dates; -This tracking report did not include CPR certifications; -No one had been tracking CPR certificates to make sure they were current. During an interview on [DATE] at 9:10 A.M., the front office staff member (receptionist) said the only facility staff member he/she was aware of having a current CPR certificate on file was the van driver who was the only facility van driver. During an interview on [DATE] at 9:50 A.M., the van driver said the following: -She had been the van driver since [DATE]; -She became CPR certified on [DATE]; -She worked Monday through Friday, hours varied depending upon the residents' scheduled appointments, but usually worked from 7:30 A.M. until 4:00 or 5:00 P.M.; -She was in the facility approximately two hours on his/her scheduled work days; -She was the only facility van driver. Record review on [DATE] of the CPR certification for the van driver showed she became certified on [DATE]. During an interview on [DATE] at 2:00 P.M., the Assistant Director of Nursing (ADON) said the following: -She had worked at the facility full time for seven years; -If a resident required a resuscitation attempt, she would check the code status book (a binder containing the list of residents with their advance directives, such as full code or a do not resuscitate status); -She would assess a resident if an emergency situation occurred and get the doctor's orders for treatment; -She received her CPR certification in (YEAR); -CPR certificates were good for two years; -She did not realize her CPR certification expired in (MONTH) of (YEAR); -No one tracked the staff's CPR certification expiration dates; -She was responsible for the daily staff scheduling; -She did not know of the requirement to have a CPR certified staff member in the facility at all times; -The facility did not have a CPR certified staff member scheduled to work after 3:00 P.M. today. Record review of the facility's file of CPR certifications showed the ADON received her certification on [DATE]. The renewal was due in (MONTH) (YEAR). During an interview on [DATE] at 2:20 P.M., Licensed Practical Nurse (LPN) G said the following: -If he/she found a resident not breathing or unresponsive, he/she would check the do not resuscitate (DNR) status and start or not start CPR on the resident based on their status; -His/Her CPR certification expired [DATE]. Record review of LPN G's CPR certification showed his/her certification expired in (MONTH) (YEAR). During an interview on [DATE] at 2:45 P.M., CMT M said the following: -If he/she found a resident unresponsive and not breathing, he/she would check the resident's DNR status and call a code if they were a full code status; -Would get the code cart while staff began CPR; -He/She was currently certified in CPR, but did not have proof of the CPR certification. During an interview on [DATE] at 4:55 P.M., the ADON said the following: -She confirmed the facility did not have a CPR policy for the staff; -There were no CPR certified staff scheduled to work on [DATE] from 3:00 P.M. until 7:00 A.M. on [DATE]. During a telephone interview on [DATE] at 5:44 P.M., the facility Medical Director said the following; -He was not aware until yesterday when the Director of Nursing (DON) told him, the facility did not have CPR certified staff in the building at all times; -He was unaware if anyone had been tracking the staff CPR certifications; -He did not know if the facility had a CPR policy; -If a resident suffered an arrest (loss of spontaneous breathing or heart function), he would expect the staff to look at the code status book to determine the resident's resuscitation order; -The staff members should have CPR certifications. During an interview on [DATE] at 5:48 P.M., the DON said the following: -She was not currently CPR certified; -The facility had no CPR policy; -She expected to have CPR certified nurses and CMT's, because they monitor the dining room areas; -The last facility CPR training was in (YEAR); -She thought Registered Nurse (RN) H or the receptionist tracked the CPR certifications. During an interview on [DATE] at 6:02 P.M., the administrator said the following: -The facility did not have a CPR policy; -No one had been tracking, or been assigned to track the staff's CPR certifications status; -The DON had been trying to find a CPR certified staff member to work tonight ([DATE]); -If a resident suffered an arrest, she would expect the staff to follow the resident's code status and to initiate resuscitation if appropriate. During an interview on [DATE] at 2:05 P.M., RN H said he/she did not track CPR certifications. Record review on [DATE] of the facility's daily staffing schedule and CPR certification cards acquired by the facility showed on the night shift on [DATE] and [DATE], no CPR certified staff were scheduled. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy K level. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit the facility began obtaining CPR certifications of staff, began scheduling CPR certification classes, and reviewed the staffing schedule to ensure CPR certified staff were present in the facility on all shifts. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to an E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and neglect and failed to ensure the safety of two residents (Resident #1 and #2), when a witnessed physical spanking of a resident by Certified Nursing Assistant (CNA) A was reported and when CNA A and Nurse Aide (NA) B failed to report one resident's (Resident #1) unwitnessed fall to the nurse resulting in a delay in assessment of the resident. The facility also failed to report the allegations and findings to the Department of Health and Senior Services (DHSS) as required. The facility was 90 residents. 1. Record review of the facility's Policy and Procedure for Abuse and Neglect, not dated, showed the following information: -It is the policy of the facility that all residents be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. -Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. -Sexual abuse includes but not limited to sex harassment, sexual coercion, or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. -Mental abuse includes, but is not limited to, humiliation, harassment, treats of punishment or deprivation. -The policy did not define neglect. -The policy did not give specifics regarding the steps staff were to follow when completing an investigation. - The policy did not have specific time frames for reporting all allegations of abuse, neglect, misappropriation or injury of unknown origin to DHSS. -The policy did not have specific time frames for reporting investigative findings to DHSS. 2. Record review of Resident #2's face sheet (admission data) showed the facility admitted the resident on 01/27/09, with [DIAGNOSES REDACTED]. Record review of the facility's abuse/neglect investigation showed on 12/18/15, staff completed an investigation that showed the following information: -On 12/18/15, staff reported CNA A was speaking very loudly to a resident in the dining room. A resident was putting peas in a soda can and CNA A jerked the soda can away from the resident and said I told you no. CNA A grabbed both of the resident's wrists really hard and the reporter considered it abuse. -CNA A said he/she walked into the dining room noticed a resident putting food in a soda can. He/She told the resident no and took the soda can away from the resident. The resident was going to hit him/her and CNA A placed his/her hands on the resident's wrists and moved his/her arms down. Staff assessed the resident for bruising and injuries and none were observed. -CNA A had a verbal counseling with the Director of Nursing (DON) over tone of voice and removing self from situation when a resident is agitated. The DON had CNA A re-sign the abuse and neglect policy. Record review of a written statement by CNA A, dated 12/18/15, showed he/she walked into the dining room. A resident was putting food in a soda can. The resident raised his/her hand to hit CNA A. CNA A grabbed the resident's wrist and lowered them. CNA A admitted to getting loud with the resident. CNA A proceeded to remove the can from the resident's hand and the resident did put up a fight. The resident was agitated with him/her. 3. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/04/16, showed the following information: -Severely cognitively impaired; -Extensive assistance needed for bed mobility, transfers, dressing toilet use, personal hygiene, and bathing; -Limited assistance needed for locomotion on and off unit and eating; -Rejects care one to three times weekly. Record review of the resident's care plan, dated 03/07/16, showed the following information: -Resident had memory impairment which put him/her at risk for alteration in mood, judgement, and behavior; -Staff needed to allow her/him to have control over situations, if possible; -Maintain a calm environment and approach; -Assess for mood/behavior problems. -Resident had a [DIAGNOSES REDACTED]. -Cognitive loss/dementia; -Allow ample time to absorb and respond to information and questions. Record review of the facility's investigation, dated 05/09/16, showed the following information: -An allegation was made regarding CNA A spanking Resident #2. The allegation was reported to the Assistant Director of Nursing (ADON) by Certified Medication Technician (CMT) E. -The administrator spoke with the CMT who explained what he/she witnessed. He/she observed CNA A putting the resident to bed and stated he/she observed him/her holding the resident's wrists as the resident was combative. CMT E verbalized seeing him/her spank the resident. -The administrator spoke with CNA A regarding the allegations made. CNA A said from where CMT E was standing it may have looked as though he/she spanked the resident. CNA A said the resident's wrists were held to keep him/her from hitting. The CNA was trying to pull his/her pants down at the same time. CNA A was made aware when a resident is combative, stop and approach the resident later and to have another person assisting with cares. -Other residents were interviewed by the ADON, however no statements were attached to the investigation. (These statements were provided by the administrator at a later time.) -The administrator signed the investigation on 05/09/16. -Staff did document completing any interviews with additional staff members. -Staff did not document what steps were put in place to protect the resident during the investigation. -Staff did not document notification of DHSS of the allegation and investigation. During an interview on 05/27/16, at 11:00 A.M., CNA A said the DON instructed CNA A to remove him/herself from the situation and come back later if the resident is agitated, referring to the 05/09/16 incident. On 05/09/16, CNA A was called into the office concerning the allegation of spanking a resident. While assisting Resident #2, CNA A was getting agitated with the combative resident. The resident tried to hit CNA A. He/she asked CMT E for assistant. CNA A went around the bed to the other side. CNA A said he/she was agitated and reached up and pulled the resident's pants down fast. It looked like he/she spanked the resident. CMT E stayed in the room until the resident was completely dressed and placed in bed. CMT E left the room right before the covers were pulled up. During an interview on 05/27/16, at 12:02 P.M., CMT E said approximately two weeks ago CNA A asked him/her to assist with Resident #2. While assisting, CNA A slapped Resident #2's hand. CMT E said this was reported to the DON and the Administrator. One week later while placing Resident #2 in bed, the resident was agitated and tried to bite CNA A. CNA A grabbed the resident's wrists hard enough to make the resident hands discolor. On 05/9/16, CNA A asked CMT E to assist providing care to Resident #2. While removing the resident's clothes the resident became agitated. The resident tried to kick CNA A. CNA A slapped the resident on his/her uncovered bottom. CMT E reported this situation to the ADON. The ADON took CMT E to the Administrator's office. CNA A was called to the office afterwards, visited with the Administrator and came back to the floor. The CMT was not aware of any investigation of the slapped hand. During an interview on 05/27/16, at 8:45 A.M., the ADON said CMT E came to him/her to report what he/she witnessed. CMT E said he/she needed to report what he/she observed, CNA A slapping Resident #2 on his/her uncovered bottom. The resident was agitated and combative and CNA A held the resident arms, because CNA A did not want to be hit by the resident. CNA A, while trying to remove the resident's pants, slapped the resident on his/her uncovered bottom and removed the pants. The ADON said he/she interviewed approximately eight residents and there were complaints about CNA A. The ADON said he/she did not interview any staff members concerning CNA A. The ADON said CNA A was reported to the administrator several times about his/her attitude. He/she feels CNA A has an attitude problem. The ADON was very concerned about CNA A and followed his/her chain of command to report. Residents made complaints about his/her rudeness and roughness and written statements were turned in to the Administrator. During record review and interview on 05/31/16, at approximately 10:00 A.M., Resident #3 confirmed his/her written statement. The written statement said CNA A has changed, he/she is hateful, rough, and upset about being pregnant. I just don't say anything to him/her anymore. During record review and interview on 05/31/16, at approximately 10:10 A.M., Resident #4 confirmed his/her written statement. The written statement said CNA A use to be my favorite, but he/she is not friendly anymore. CNA A can't lift the resident because he/she is pregnant. CNA A got on to the resident and said you know I can't lift you. During an interview on 05/27/16, at 5:55 A.M., CNA E said he/she would report any abuse to the charge nurse, and if needed, follow the chain of command. He/she was aware CNA A acted in a mean manner towards Resident #2. CNA E has observed CNA A being rude and talking down to residents. CNA E said he/she reported this to the DON and Administrator. During an interview on 05/26/16, at 4:30 P.M., NA B said if he/she heard about abuse he/she would observe for him/herself. He/She was aware that CNA A was rough with Resident #2. The NA said he/she never reported CNA A for rudeness or roughness. During an interview on 05/26/16, at 4:30 P.M., CNA I said CNA A told him/her that he/she was turned in by CMT E for rudeness and roughness towards Resident #2. Resident #2 can at times become combative with care and it is all in the approach. CNA I said CNA A slapped the resident trying to protect his/herself. CNA I said he/she reported this to the DON. During an interview on 05/27/16, at 8:00 A.M., the DON said he/she was unaware CNA A had an allegation of spanking a resident. The DON said the Administrator dealt with the situation. During an interview on 05/27/16, at 9:05 A.M., the Administrator said staff had reported CNA A's behavior before. It wasn't until yesterday, he/she realized there were patterns concerning CNA A abuse allegations. No residents voiced concerns about CNA A during the 12/18/15 investigation. The administrator did not know there were two alert and oriented residents that complained about CNA A on the 05/09/16 investigation. The resident interviews were not attached to the investigation report. The Administrator said he/she would have to look for them. CNA A said the resident was combative and he/she held the resident's wrist. He/she said CNA A was re-educated about combative residents to leave the area and come back later and always have two staff members in the room with this resident. The resident had episodes of combative behavior and one staff should not have put him/her to bed. 4. Record review of the Resident #1's face sheet (admission data) showed the facility admitted the resident on 03/30/16, with [DIAGNOSES REDACTED]. Record review of the resident's admission MDS, a federally mandated comprehensive assessment tool completed by staff, dated 04/12/16, showed the following information: -Cognitively intact; -Extensive assistance needed for bed mobility, transfers, walking in room, dressing, eating, and toilet use; -No falls or skin problems; -Anticoagulant therapy (medication used to prevent the blood from clotting. Staff must monitor for bleeding due to resident's potential to bruise and bleed easier). Record review of the resident's care plan, dated 04/18/16, showed the following information: -One person extensive assistant required with transfers and activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) related to weakness, and unsteady gait. -Urinary: incontinent; -High risk for falls related to weakness, unsteady gait/balance, use of medications, and history of falling. Record review of the resident's nurse's note dated 05/17/16 at 11:40 P.M., showed the night shift Licensed Practical Nurse (LPN) C documented that night shift CNA D reported that Resident #1 had fallen earlier in the evening (about 7:45 P.M.). CNA A reported the fall to CNA D. CNA A told CNA D that the resident slid out of his/her chair to the floor, the resident had no injuries and CNA A had not reported the fall to the charge nurse. LPN C notified the DON and faxed the physician. The LPN assessed the resident and the resident was resting in bed. The resident had no complaints and was fully aware of his/her surroundings. The resident was able to say he/she slid to the floor. His/her blood pressure was 150/80; he/she had no bruising. Staff did not document notifying the resident's family of the fall. Record review of the resident's medical records showed the first nursing assessment performed on the resident by a licensed nurse after the reported time of the fall was on 05/17/16 at 11:45 P.M. (four hours after the reported fall happened). Record review of the facility's investigation, dated 05/18/16, showed LPN C called the DON, at 11:00 P.M., and said CNA D was told by CNA A and NA B in report at shift change that Resident #1 slid out of his/her chair onto the floor. CNA A and NA B looked the resident over and he/she was fine, but failed to report the fall to the nurse. LPN C talked with the agency nurse working on the hall with Resident #1 and confirmed the nurse was unaware the incident occurred. LPN C assisted with the fall procedures with the agency nurse. The DON came in the next day and interviewed CNA D about how the charge nurse became aware of the fall. Both CNA A and NA B made it very clear the charge nurse did not receive a report concerning the fall. CNA A and NA B both admitted the fall occurred and told CNA D without reporting the fall to the nurse. CNA A and NA B both received a written warning for not following the facility's policy. An inservice was planned for all staff on 06/06/16 (20 days after the resident's fall). The investigation did not indicate interviews with other residents, did not show what steps were taken to protect the resident during the investigation and did not indicate staff notified DHSS of the investigation or the findings. Record review of CNA A's written statement, dated 05/18/16, showed the CNA and a NA had a resident fall while they were in his/her room. Neither aide reported the fall to the nurse. The CNA and NA told the on-coming shift nursing assistant that the resident had fallen and they had checked him/her out and he/she was okay. The night shift aide reported the fall to the nurse. During an interview on 05/27/16, beginning at 11:00 A.M., CNA A said he/she and NA B found the resident on the floor at approximately 7:45 P.M. on 5/17/16. They did not witness the fall. He/she had told other facility staff that he/she witnessed the resident slide out of his/her chair. None of the facility staff started baseline vital signs, neurological checks or assessments right after the fall because no licensed nurses knew about the fall. CNA A said he/she asked NA B to help remove the resident from the floor and place him/her in bed. CNA A and NA B did not use a gait belt. CNA A said he/she did not tell the charge nurse. CNA A said he/she knew he/she should not have moved the resident to bed until the charge nurse assessed the resident. CNA A said at the time of the incident three call lights sounded and he/she was about to go on break. CNA A and NA B both entered the resident's room at the same time, but did not see the resident immediately. When they found the resident, he/she was in a seated position upright on the floor getting sick in the trash can. The resident told CNA A he/she slid out of the chair onto the floor. CNA A said the resident reached for his/her trash can and this caused him/her to fall. CNA A said the resident told the two nursing assistants to put him/her to bed. The fall happened before their meal break, approximately 7:45 P.M. During the course of the interview, at 11:20 A.M., the CNA said when he/she and NA B entered the room the resident lay on the floor. The resident was trying to push him/herself up placing most of her/his weight on the right hip Record review of the written statement, dated 05/18/16, showed NA B, with another CNA, had a resident fall in their room and they never reported the incident to the nurse. They told the on-coming shift nursing assistant that the resident fell , they checked him/her out (no bruising or skin tears) and he/she was okay. They never told the charge nurse. The night shift nursing assistant reported the incident to the nurse. During an interview on 05/27/16, at 12:50 P.M., NA B said he/she was new to the facility and on 5/17/16 CNA A trained him/her. NA B did not see the resident fall. The resident lay face-up along the side of the bed with his/her head toward the head of the bed. NA B followed CNA A that night and CNA A asked NA B to help put the resident to bed. NA B said he/she knew the nursing assistants should not move the resident after a fall until the nurse completed an assessment. Neither the CNA nor the NA used a gait belt when they assisted the resident back to bed. NA B asked CNA A if they should notify the nurse; CNA A said no. NA B did not say why he/she moved the resident. Neither CNA A nor NA B started getting baseline vital signs for the resident after the fall. NA B said the facility provided one-on-one training on 05/26/16, nine days after the fall. During an interview on 05/27/16, at 5:55 A.M., LPN C said CNA A and NA B found Resident #1 on the floor and did not report it. The CNA and NA moved the resident from the floor before a nursing assessment. The nurse should have assessed the resident before the move. LPN C was working on a different hall when a CNA approached the LPN and said Resident #1 slid out of his/her chair. CNA A and NA B failed to report the fall to the charge nurse. LPN C assisted with the assessments and paperwork. LPN C said he/she reported the incident to the DON. During an interview on 05/27/16, at 6:00 A.M., CNA D said during shift change report, on 5/17/16 at 11:00 P.M., CNA A told CNA D that he/she needed to keep an eye on Resident #1 because he/she fell and CNA A did not tell the nurse. CNA A told CNA D he/she assessed the resident (no bruises or skin tears) and transferred him/her to bed. NA B said the resident was on the floor face down. Record review of the resident's nurses' notes, dated 05/19/16, showed the following: -At 10:30 A.M., staff observed bruising on the resident's left upper back and shoulder area. The resident complained of stiffness during range of motion. -At 5:25 P.M., the resident's family member reported to the charge nurse the resident had difficulty speaking. He/she had trouble getting the right words out. He/she could not count to ten. Neurological checks were intact, grips were equal, and eyes were reacting to light. The resident could stick his/her tongue out and smile. The resident's speech seemed slower than normal along with his/her movement (signs of a possible head injury). -At 5:30 P.M., the off going shift said the resident was slow to respond and find words to express thoughts. Staff notified the nurse practitioner and received orders to transfer the resident to the hospital for evaluation. -At 06:00 P.M., the resident was transferred to the hospital by paramedics. Record review of the resident's hospital History and Physical, dated 05/19/16, showed the resident's chief complaint was trauma after fall; subdural hematoma. The resident fell two days ago, but was not brought in for evaluation at that time. The resident received Eliquis (blood thinner). The resident started having difficulty speaking and the facility sent him/her to the emergency room (ER). ER staff reported the resident had a [MEDICAL CONDITION] while in the ER. A cat scan (CT) done showed findings suggestive of a subdural hematoma for which trauma surgery was consulted. The resident was admitted to the intensive care unit (ICU) with orders to hold blood thinners, hold blood-clotting [MEDICATION NAME] and obtain a consultation from neurosurgery. Record review of the neurosurgeon's progress note, dated 05/20/16, showed the resident had a fall on 05/17/16, from a standing height. CT results showed a left frontal subdural hematoma ([MEDICAL CONDITION] in which a buildup of blood occurs) which measured one centimeter in thickness. The resident's neurological system was intact with a continued headache and continued to be alert to person and place with confusion. During an interview on 06/01/16, at 7:45 A.M., the resident's physician said he assessed the resident after the resident returned from the hospital. The resident still had a hematoma to the right side of his/her head. The resident had to hit his/her head hard to cause a subdural hematoma. The physician would expect staff to follow policy and have a nurse assess the resident before moving the resident. During an interview on 05/27/16, at 8:45 A.M., the ADON said staff did not see Resident #1 fall. The two nursing assistants moved the resident off the floor and placed him/her in bed without telling the nurse. Staff should have started neurological checks and vital signs automatically. The resident had to hit his/her head really hard to cause a subdural hematoma. Even if CNA A told NA B not to do vital signs, there was no reasons for him/her to follow the CNA's instructions. The facility did not have in-service training's planned concerning the fall; they will be in the works. The facility trained all staff members not to move a resident after a fall until a nurse completed assessments. During an interview on 05/27/16 at 8:00 A.M., the DON said that on 05/17/16, LPN C told her Resident #1 slid to the floor. DON said staff members were assisting the resident and he/she slid to the floor. The DON spoke to both CNA A and NA B concerning policy. Both failed to report to the charge nurse. Both CNA A and NA B said they were in the resident's room when this happened. CNA A and NA B told the night CNA the resident slid to the floor. The resident fell sometime around 8:00 P.M. The DON expected staff not to move a resident after a fall or sliding to the floor before the nurse made an assessment. The DON interviewed CNA A, NA B, LPN C and CNA D. The DON said he/she did not believe the resident slid to the floor causing that severe of a head injury (subdural hematoma). The DON said all staff members were trained not to move a resident from the floor after a fall until the nurse assessed and to obtain baseline vital signs after a fall. The DON did not say why a further investigation was not completed after the resident went to the hospital. During an interview on 05/27/16, at 9:05 A.M., the Administrator said the facility trained all CNAs not to move a resident from the floor after a fall. All CNAs needed to report to the charge nurse that a resident had fallen or slid from his/her chair. The nurse needed to assess the resident and obtain neurological assessments. The Administrator declined to make a statement if sliding from a chair would cause a severe head injury, subdural hematoma. The DON took care of this situation and made written warning on both staff members. Complaint #MO 4967 and #MO 5123 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included immediate in-servicing of staff on the facility's updated abuse and neglect policy, which included time frames for reporting and investigation of abuse allegations and instructed staff on the investigation process. The facility staff were instructed that any staff member an allegation of abuse was received on were to be removed from the facility during the investigation process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 05/27/2016, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to protect one resident (Resident #1) from neglect, when Certified Nursing Assistant (CNA) A and Nurse Aide (NA) B (who were responsible for the resident's direct care) did not report the resident fell for at least three hours and 15 minutes, resulting in a delay in assessment of the resident. The CNA and NA moved the resident back to bed prior to clinical assessments (including neuro checks and a baseline blood pressure reading) of the resident for injuries. The resident was later sent to the the hospital and diagnosed with [REDACTED]. The facility census was 90 residents. Record review of the facility's Abuse and Neglect Policy and Procedure, not dated, showed the following information: -It is the policy of the facility that all residents be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. -Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. -It is the policy of the facility that any known or suspected abuse or neglect will be reported immediately to the administrator, assistant administrator or the Director of Nursing without fear of reprisal from any party. -Remove resident immediately to provide protective oversight. -Reports may be made in person, by phone or in written form. -All reports will be investigated within 48 hours of the report being made. -If the reporter makes their identity known, they may receive feedback on the outcome of the investigation if the administrator, assistant administrator or the Director of Nursing feels that it is appropriate. -A log of reports and investigations will be kept by the administrator or assistant administrator. - The policy listed the Missouri Department of Health and Senior Services (DHSS) Abuse Hot-line number, but did not give direction to call. -The policy did not define neglect. -The policy did not give specifics regarding the steps staff were to follow when completing an investigation. - The policy did not have specific time frames for reporting all allegations of abuse, neglect, misappropriation or injury of unknown origin to DHSS. - The policy did not instruct staff to report all allegations of mistreatment, neglect, abuse and misappropriation of resident property to DHSS within 24 hours, and did not instruct staff to provide DHSS their completed investigation within five days. Record review of the facility's Fall Management Protocol, dated 11/17/09, showed the following information: -The goal is to address the needs of the resident who has fallen and for the highest quality of life possible for the resident. -If a fall occurs staff will do the following: -The physician and family will be notified; -Staff will implement any new orders and interventions in a timely manner; -The charge nurse will alert the Director of Nursing (DON) and the Assistant Director of Nursing (ADON); -The charge nurse will document the fall in the nurses notes and document any interventions; -Nursing staff will observe the resident for safety by licensed nursing staff including pain assessment, monitoring of blood pressure, and vital signs for 72 hours. 1. Record review of Resident #1's face sheet (admission data) showed the facility admitted the resident on 03/30/16, with [DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 04/12/16, showed the following information: -Cognitively intact; -Extensive assistance needed for bed mobility, transfers, walking in room, dressing, eating, and toilet use; -No falls or skin problems; -Anticoagulant therapy (medication used to prevent the blood from clotting. Staff must monitor for bleeding due to resident's potential to bruise and bleed easier). Record review of the resident's care plan, dated 04/18/16, showed the following information: -One person extensive assistance required with transfers and activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) related to weakness and unsteady gait. -Urinary: incontinent; -High risk for falls related to weakness, unsteady gait/balance, use of medications, and history of falling. Record review of the resident's nurse's note dated 05/17/16, at 11:40 P.M., showed the night shift Licensed Practical Nurse (LPN) C documented night shift CNA D reported Resident #1 had fallen earlier in the evening (about 7:45 P.M.). CNA A reported the fall to CNA D. CNA A told CNA D that the resident slid out of his/her chair to the floor, the resident had no injuries and CNA A had not reported the fall to the charge nurse. LPN C notified the Director of Nursing (DON) and faxed the physician. The LPN assessed the resident and the resident was resting in bed. The resident had no complaints and was fully aware of his/her surroundings. The resident was able to say he/she slid to the floor. His/her blood pressure was 150/80; he/she had no bruising. Staff did not document notifying the resident's family of the fall. Record review of the resident's medical records showed the first nursing assessment performed on the resident by a licensed nurse after the reported time of the fall was on 05/17/16, at 11:45 P.M. (four hours after the reported fall happened). Record review of the facility's investigation, dated 05/18/16, showed LPN C called the DON, at 11:00 P.M., and said CNA D was told by CNA A and NA B, in a report at the change of shift, that Resident #1 slid out of his/her chair onto the floor. CNA A and NA B looked the resident over and he/she was fine, but failed to report the fall to the nurse. LPN C talked with the agency nurse working on the hall with Resident #1 and confirmed the nurse was unaware the incident occurred. LPN C assisted with the fall procedures with the agency nurse. The DON came in the next day and interviewed CNA D about how the charge nurse became aware of the fall. Both CNA A and NA B made it very clear the charge nurse did not receive a report concerning the fall. CNA A and NA B both admitted the fall occurred and told CNA D without reporting the fall to the nurse. CNA A and NA B both received a written warning for not following the facility's policy. An in-service was planned for all staff on 06/06/16 (20 days after the resident's fall). Record review of CNA A's written statement, dated 05/18/16, showed the CNA and a NA had a resident fall while they were in his/her room. Neither aide reported the fall to the nurse. The CNA and NA told the on-coming shift nursing assistant that the resident had fallen and they had checked him/her out and he/she was okay. The night shift aide reported the fall to the nurse. During an interview on 05/27/16 at 11:00 A.M., CNA A said he/she and NA B found the resident on the floor at approximately 7:45 P.M. on 5/17/16. They did not witness the fall. He/she had told other facility staff that he/she witnessed the resident slide out of his/her chair. None of the facility staff started baseline vital signs, neurological checks or assessments right after the fall, because no licensed nurses knew about the fall. CNA A said he/she asked NA B to help remove the resident from the floor and place him/her in bed. CNA A and NA B did not use a gait belt. CNA A said he/she did not tell the charge nurse. CNA A said he/she knew he/she should not have moved the resident to bed until the charge nurse assessed the resident. CNA A said at the time of the incident, three call lights sounded and he/she was about to go on break. CNA A and NA B both entered the resident's room at the same time, but did not see the resident immediately. When they found the resident, he/she was in a seated position upright on the floor getting sick in the trash can. The resident told CNA A he/she slid out of the chair onto the floor. CNA A said the resident reached for his/her trash can and this caused him/her to fall. CNA A said the resident told the two nursing assistants to put him/her to bed. The fall happened before their meal break, approximately 7:45 P.M During the course of the interview, at 11:20 A.M., the CNA said when he/she and NA B entered the room the resident lay on the floor. The resident was trying to push him/herself up placing most of his/her weight on the right hip. Record review of the written statement, dated 05/18/16, showed NA B, with a CNA, had a resident fall in their room and they never reported the incident to the nurse. They told the on-coming shift nursing assistant that the resident fell , they checked him/her out and he/she was okay. They never told the charge nurse. The night shift nursing assistant reported the incident to the nurse. During an interview on 05/27/16, at 12:50 P.M., NA B said he/she was new to the facility and on 5/17/16, CNA A trained him/her. NA B did not see the resident fall. The resident lay face-up along the side of the bed with his/her head toward the head of the bed. NA B followed CNA A that night and CNA A asked NA B to help put the resident to bed. NA B said he/she knew the nursing assistants should not move the resident after a fall until the nurse completed an assessment. Neither the CNA nor the NA used a gait belt when they assisted the resident back to bed. NA B asked CNA A if they should notify the nurse; CNA A said no. NA B did not say why he/she moved the resident. Neither CNA A nor NA B started getting baseline vital signs for the resident after the fall. NA B said the facility provided one-on-one training on 05/26/16 (nine days after the fall). During an interview on 05/27/16, at 05:55 A.M., LPN C said CNA A and NA B found Resident #1 on the floor and did not report it. The CNA and NA moved the resident from the floor before a nursing assessment. The nurse should have assessed the resident before the move. LPN C was working on a different hall when a CNA approached the LPN and said Resident #1 slid out of his/her chair. CNA A and NA B failed to report the fall to the charge nurse. LPN C assisted with the assessments and paperwork. LPN C said he/she reported the incident to the DON. During an interview on 05/27/16, at 6:00 A.M., CNA D said during shift change report, on 5/17/16 at 11:00 P.M., CNA A told CNA D that he/she needed to keep an eye on Resident #1, because he/she fell and CNA A did not tell the nurse. CNA A told CNA D he/she assessed the resident and transferred him/her to bed. NA B said the resident was on the floor face down. Record review of the resident's nurses' notes, dated 05/19/16, showed the following: -At 10:30 A.M., staff observed bruising on the resident's left upper back and shoulder area. The resident complained of stiffness during range of motion. -At 5:25 P.M., the resident's family member reported to the charge nurse the resident had difficulty speaking. He/she had trouble getting the right words out. He/she could not count to ten. Neurological checks were intact, grips were equal, and eyes were reacting to light. The resident could stick his/her tongue out and smile. The resident's speech seemed slower than normal along with his/her movement (signs of a possible head injury). -At 5:30 P.M., the off going shift said the resident was slow to respond and find words to express thoughts. Staff notified the nurse practitioner and received orders to transfer the resident to the hospital for evaluation. -At 06:00 P.M., the resident transferred to the hospital by paramedics. Record review of the resident's hospital History and Physical, dated 05/19/16, showed the resident's chief complaint was trauma after fall; subdural hematoma. The resident fell two days ago, but was not brought in for evaluation at that time. The resident received Eliquis (blood thinner). The resident started having difficulty speaking and the facility sent him/her to the emergency room (ER). ER staff reported the resident had a [MEDICAL CONDITION] while in the ER. Cat Scan (CT) showed findings suggestive of a subdural hematoma for which trauma surgery was consulted. The resident was admitted to the intensive care unit (ICU) with orders to hold blood thinners, hold blood-clotting [MEDICATION NAME], and obtain a consultation from neurosurgery. Record review of the neurosurgeon's progress note, dated 05/20/16, showed the resident had a fall on 05/17/16, from standing height. Head CT results showed a left frontal subdural hematoma measured one centimeter in thickness. The resident's neurological was intact with a continued headache and continued to be alert to person and place with confusion. During an interview on 06/01/16, at 7:45 A.M., the resident's physician said he assessed the resident after the resident returned from the hospital. The resident still had a hematoma to the right side of his/her head. The resident had to hit his/her head hard to cause a subdural hematoma. The physician would expect staff to follow policy and have a nurse assess the resident before moving the resident. During an interview on 05/27/16 at 8:45 A.M., the Assistant Director of Nursing (ADON) said staff did not see Resident #1 fall. The two nursing assistants moved the resident off the floor and placed him/her in bed without telling the nurse. Staff should have started neurological checks and vital signs automatically. The resident had to hit his/her head really hard to cause a subdural hematoma. Even if CNA A told the NA B not to do vital signs, there were no reasons for him/her to follow the instructions. The facility did not have in-service training planned concerning the fall; they will be in the works. The facility trained all staff members not to move a resident after a fall until a nurse completed assessments. During an interview on 05/27/16, at 8:00 A.M., the DON said that on 05/17/16, LPN C told her Resident #1 slid to the floor. The DON said staff members were assisting the resident and he/she slid to the floor. The DON spoke to both CNA A and NA B concerning policy. Both failed to report to the charge nurse. Both CNA A and NA B said they were in the resident's room when this happened. CNA A and NA B told the night CNA the resident slid to the floor. The resident fell sometime around 8:00 P.M The DON expected staff not to move a resident after a fall or sliding to the floor before the nurse made an assessment. The DON interviewed CNA A, NA B, LPN C, and CNA D. The DON said he/she did not believe the resident slid to the floor causing that severe of a head injury (subdural hematoma). The DON said all staff members were trained not to move a resident from the floor after a fall until the nurse assessed and obtained baseline vital signs. The DON did not say why further investigation was not completed after the resident went to the hospital. During an interview on 05/26/16, at 3:57 P.M., Registered Nurse (RN) H, who was also the CNA instructor, said he/she was aware of Resident #1's fall. She instructed all new staff members in the first 16 hour of orientation not to move or reposition a resident after a fall until a nurse could assess. CNA A and NA B both knew not to move the resident and to notify the charge nurse. During an interview on 05/27/16, at 9:05 A.M., the Administrator said the facility trained all CNAs not to move a resident from the floor after a fall. All CNAs needed to report to the charge nurse that a resident had fallen or slid from his/her chair. The nurse needed to assess the resident and obtain neurological assessments. The Administrator declined to make a statement if sliding from a chair would cause a severe head injury, subdural hematoma. The DON took care of the situation and made written warning on both staff members. During an interview on 05/26/16, at 9:00 A.M., the resident's spouse said the facility did not call him/her the night the resident fell . The next day staff notified him/her the resident slid from his/her chair. Approximately two days later the resident started having neurological issues and had to be transferred to the hospital. During an interview on 05/27/16, at approximately 1:00 P.M., the resident's spouse said the resident had a subdural hematoma. Complaint #MO 4967 and #MO 5123 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included immediate in-servicing of staff on the facility's updated abuse and neglect policy, instructed staff on the investigation process, and the facility's fall protocol. The facility staff were instructed that any staff member an allegation of abuse was received on were to be removed from the facility during the investigation process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 05/27/2016, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, record review and interview, the facility failed to ensure a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when staff did not provide the necessary services and interventions such as a pressure relieving cushions, position changes, proper incontinent care and timely treatment to one resident (Resident #6) with a history of pressure ulcers. The deficient practice resulted in the development of multiple Stage II (pressure ulcers in a very short period of time. Fifteen residents were sampled out of a facility census of 87. 1. Record review of Resident #6's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 2/03/12, showed the following: - Non-ambulatory; - Requires assistance of two staff for toilet and transfers; - Always incontinent of bowel and bladder; - Moderately impaired cognitive skills and decision making; - Resident at risk for developing pressure ulcers; - Pressure relieving device in chair; - Turning and repositioning program; -Staff assessed the resident had no pressure ulcers. Record review of the resident's care plan, dated 2/07/12, instructed staff to: -Provide two staff assistance for transfers and toileting; -Turn and reposition resident every two hours; -RoHo (a pressure-relief cushion designed to constantly adjust to a client's body movement) cushion in chair; -Assess resident's skin during bed baths and while providing peri care (the cleansing of skin in the genital area when it becomes wet from urine and or feces); -Provide resident with pericare after each episode of incontinence using warm wet washcloth, body wash, then dry skin well; -Keep pressure points free of pressure; -Resident at risk for potential skin breakdown but has no pressure ulcers. Record review of nursing notes showed an assessment of the following skin condition: -On 2/10/12, staff assessed that the resident had a pressure ulcer of his/her left buttock; -On 2/20/12, staff measured the pressure ulcer as 0.4 cm x 0.4 cm (centimeters); -On 3/9/12, staff measure the pressure ulcer as 0.4 cm x 0.4 cm. Record review of the May 2012 physician order [REDACTED]. -Apply Triad cream (barrier cream) twice daily and as needed; -Place RoHo cushion in wheelchair and check for placement every shift, as needed. Record review of the Wound Nurse Progress Note dated 5/3/12, showed pressure points clear and free of skin breakdown. During interview on 5/8/12 9:55 A.M., Registered Nurse (RN) F said he/she does most of the dressing changes to pressure sores (ulcers). When a nurse assistant discovers a pressure ulcer, they inform the RN of that unit. That RN will assess and communicate with the physician to obtain an order to treat the pressure ulcer. Observation on 05/08/12, at 3:00 P.M., showed nurse aide (NA) M and certified nurse aide (CNA) N transferred the resident to bed from his/her wheelchair. The wheelchair did not contain a pressure-relieving device. The resident's gown was heavily soiled with urine and feces. The feces on his/her buttocks was dry. The dried feces covered over 50% of the resident's left buttock. The remainder of the area of the buttocks was covered with feces of an oatmeal consistency. The resident's right buttock had an red, raw open pressure ulcer (Stage II) the size of a golf ball. The entire area around the anus was bright red. The nurse aides cleaned the feces off the resident, wiping over the raw, open areas. The aides did not apply the Triad cream to the resident's red buttocks, as ordered by the physician. The nurse aides applied an incontinent brief, dressed the resident in clean, dry clothes and transferred him/her to a red motorized wheelchair that contained only an incontinence pad. The RoHo cushion was in the blue electric wheelchair in the resident's room. The resident did not have a roommate. According to Federal guidelines on pressure sore staging, a Stage II pressure sore presents as a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater. During an interview on 05/08/12, at 3:15 P.M., NA M and CNA N said they turn residents every two hours and provided peri-care with a change of incontinent brief every two hours and as needed. Observations and interviews on 5/9/12 showed the following: -At 07:50 A.M., the resident sat on an incontinence pad in the red electric wheelchair at the nurses station. Staff had not placed pressure-relief cushion in the red wheelchair. The Ro-Ho cushion was in the blue electric wheelchair in the resident's room; -At 10:43 A.M. NA P said the resident has used the red electric wheelchair for the past month "ever since I started working here" (April 2012) because the blue electric wheelchair was not working properly; -At 10:45 A.M., the resident's blue electric wheelchair remained in the room with the RoHo cushion in the seat. The resident remained in the red electric wheelchair without the RoHo cushion; -At 12:15 P.M., the resident sat in red electric wheelchair in the main dining area awaiting diet. The resident sat on an incontinence pad with no pressure-relieving cushion. -At 2:18 P.M. the resident remained in the red electric wheelchair, at the nurses station, slumped forward, sitting on incontinence pad and no RoHo cushion. Record review on 5/9/12 at 1:20 P.M. of nursing notes showed the nurses had not made any notation of pressure ulcers staff observed on 5/8/12 during peri-care. Observations and interviews on 5/10/12 showed the following: -At 8:15 A.M., the resident sat in the red electric wheelchair at nurses station on a incontinence pad and no RoHo cushion. -At 8:45 A.M., CNA O and NA P transferred the resident to bed to change his/her clothing due to incontinence. The resident's clothes and incontinent brief were saturated with urine. The area around the anus was red. The resident's right buttock had red, raw open pressure ulcers (Stage II) the size of two conjoined golf balls. The left buttock had an open pressure ulcer that was raw and red (Stage II); the size of half dollar. Although the incontinent brief was saturated with urine, the nurse aides did not clean urine off the resident, leaving urine on the open pressure ulcers. CNA O and NA P did not apply the Triad cream to the resident's red perineal area or buttocks. The nurse aides applied an incontinent brief, dressed the resident and transferred the resident to the red electric wheelchair that had no pressure relief cushion. The RoHo cushion sat on the seat of the blue electric wheelchair. - At 9:05 A.M., when asked if staff cleanse his/her private area after incontinence event, the resident said, "Only if I have a bowel movement." During interview on 5/11/2012 8:30 CNA J said when he/she discovers a pressure sore he/she reports the findings to the charge nurse. Record review of nurses notes for 5/8/12, 5/9/12, and 5/10/12 at 10:15 showed nurses had not documented any assessment of the pressure ulcers on the resident's buttocks or made notation they had notified the physician. Record review on 5/10/2012 at 10:15 of the physician order [REDACTED]. During interview on 5/10/12 at 10:45 A.M., LPN D said the RoHo cushion should normally be in the resident's room if not in the chair. It is the responsibility of staff that is taking care of the resident to place it in wheelchair. During interview on 5/10/12 at 3:30 P.M.., the Assistant Director of Nursing (ADON) said staff notified the physician and family of the resident's pressure ulcers and staff were now addressing the ulcers. The RoHo cushion was now in the resident's red wheelchair. Record review of physician orders [REDACTED]. During interview and observation on 5/11/12 at 9:47 A.M., the resident was in bed. RN K cleaned the pressure ulcers with normal saline. RN K said the pressure ulcer on the right buttock was oblong and measured 1 X 4 cm and was a Stage II pressure ulcer. The pressure ulcer on the left buttock was the size of a half dollar and was a Stage II pressure ulcer. The area around the anus was red. The RN applied the [MEDICATION NAME] to the pressure ulcers. Record review of the facility's Policy on Pressure Ulcer Care and Prevention effective 4/15/09 included the following: keep resident dry and clean, toilet as needed Pad bony prominences turn and reposition at least every two Apply barrier cream to incontinent residents; If staff identify an area, they must notify the DON or ADON.