Chariton Park Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #88), who was under guardianship, resided on a locked behavior unit, and had a history of elopement and polysubstance abuse, in a review of 30 residents, to ensure the resident did not leave the facility without staff's knowledge. Staff identified the resident was at risk for elopement. Staff reported they were to conduct 15-minute checks, and the resident's care plan identified staff were to ensure the resident was in view when outside in the courtyard. Staff did not consistently document 15 minute checks were completed. On 2/13/26, a resident notified staff he/she observed Resident #88 leave the facility through the plexiglass window in his/her room, hopped the fence, got into a car with someone in the parking lot, then came back in the same way he/she went out. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one resident (Resident #79), in a review of 30 sampled residents, with dignity and respect when staff did not provide reasonable accommodation with toileting and told the resident to urinate and defecate in his/her bed. The facility census was 85. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #4) was free from physical abuse when Resident #3 hit Resident #4 in the head multiple times. The facility also failed to ensure one resident (Resident #7) was free from verbal abuse and intimidation when Residents #3, #5, and #6 entered Resident #7's room and verbally intimidated and threatened to harm Resident #7 if he/she snitched on them for doing drugs and/or bringing drugs into the facility. The facility census was 111. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies, to ensure residents on the secured locked unit were not witness to or personally affected by one resident's (Resident #5's) known, sexually inappropriate behaviors when Resident #5 made sexual comments to other residents, exposed his/her genitals to residents, and rubbed his/her genitals on other residents. Residents were upset by Resident #5's actions. The facility failed to investigate an incident involving three residents (Resident #3, #5 and #6) to identify and address the root cause for their behaviors after the residents intimidated and verbally threatened to harm one resident (Resident #7). A sample of eight residents was selected for review. The facility census was 111. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date, seal or cover food items, ensure the ice/water dispensing machines were free of a buildup of debris, to cover all facial hear with beard restraints, and to ensure the floor next to the kitchen ice machine was free of a buildup of debris. The facility census was 116. 1. Review of the undated facility policy, Food Storage, showed the following:-Label and date all storage containers as follows;-The date received should already be on it;-Date opened;-Date the item expires. Observation on 04/26/26 at 9:58 A.M. showed the following:-A refrigerator contained six pitchers of lemonade (one dated 4-25) and eight undated pitchers of tea;-A refrigerator contained ten uncovered and undated bowls of pudding and brownies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' disease) that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to follow current infection control standards for multiple residents, in a review of 30 sampled residents, and one additionally sampled resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff placed call lights within the resident's reach for five residents (Residents #48, # 12, #71, #11, and #79), in a review of 30 sampled residents, as directed in the resident's plan of care and per facility policy. The facility census was 116. Review of the facility policy, Call Lights Accessibility and Timely Response, revised on 04/30/24, showed the following:-The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment, keeping the floors, walls, privacy curtains and windows in good repair and working order in the facility. The facility census was 116. Review of the facility's undated policy, Environment, showed the following:-The facility will be maintained in a safe, clean, comfortable and homelike setting;-Housekeeping and maintenance service in the dietary department will maintain a sanitary, orderly and comfortable dining area;-A homelike environment will be maintained with attractive tables, decor, and a pleasant dining area atmosphere. Review of the facility's policy, Safe and Homelike Environment, revised 06/05/24, showed the following:-In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report a resident-to-resident altercation for two residents (Resident #88 and #23), in a review of 30 sampled residents, to the Administrator when Resident #23 struck Resident #88, per the facility's abuse policy. The facility census was 116. Review of the facility policy, Abuse and Neglect, updated 06/12/24, showed the following:-It is the policy of this facility to ensure all allegations of abuse are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Abuse is the willful infliction of injury which can include certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for three residents (Residents #2, #70 and #10), in a review of 30 sampled residents. The facility census was 116. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, Chapter 1, revised October 2025, showed the following:-Comprehensive MDSs include admission, annual, significant change in status assessment and significant change in prior assessment;-The Resident Assessment Instrument (RAI) process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive, person-centered care plan for four residents (Residents #71, #79, #105, and #2), in a review of 30 sampled residents, when staff did not develop a care plan to address pertinent care areas, including pain, a pressure ulcer, smoking, and a urinary catheter. The facility census was 116. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise resident care plans to accurately reflect current care needs for five residents (Residents #10, #13, #70, #2 and #79), in a review of 30 sampled residents. The facility census was 116. Review of the facility's policy, Comprehensive Care Plans, revised on [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete an assessment to identify the history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for three residents (Residents #88, #6 and #23), in a review of 30 sampled residents. The facility census was 116. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four nurse aides completed a nurse aide (NA) training program within four months of their employment in the facility. The census was 116. Review of the facility's policy, Nurse Aide Training Program, revised 05/18/24, showed the following:-Purpose: This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides;-The facility, with oversight from the Director of Nursing, shall be responsible for the coordination and/or provision of nurse aide education. Review of the facility's' undated Hospitality Aide Duties, showed the following:-Purpose: The Hospitality Aide position is a way to ensure there is extra support within the facility to help assist with non-nursing duties. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued and course completed medications, stored in the Station One medication storage room, were destroyed within 30 days according to the facility policy, for one resident (Resident #12), in a review of 30 sampled residents, and for three additional residents (Residents #37, #45 and #87). The facility census was 116. Review of the facility's Medication Destruction Policy, revised 6/26/24, showed the following:-Purpose: The purpose of this policy is to ensure medications that cannot be returned to the dispensing pharmacy are destroyed;-Medications should be destroyed weekly if possible but at a minimum of monthly;-The DON is responsible for ensuring that the medications that are no longer needed are being kept securely and destroyed properly. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nourishing and well-balanced diet to meet dietary needs when staff failed to follow the recipe when preparing the lunch entree on 04/27/26 and failed to ensure staff prepared sufficient food to serve all residents the food items on the lunch menu for 04/27/26. The facility census was 116. Review of the Diet Spreadsheet on 4/27/26 for the lunch meal showed the meal was to include ravioli bake (one slice), cauliflower, breadstick, and apple orchard bar. Observation on 4/27/26 between 12:00 P.M. and 12:45 P.M. during the lunch meal service showed Dietary Staff M served ravioli bake, cauliflower, rolls and canned fruit. Observation on 4/27/26 at 12:46 P.M. during the lunch meal service showed the kitchen ran out of the ravioli bake entree and rolls. Staff served three residents on the 500 Hall the entree. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food items to conserve nutritive value, flavor, appearance and temperature. The facility census was 116. Review of the undated facility policy, Food Temperatures, showed the following:-Foods will be served at proper temperature to ensure food safety;-Take the temperature of each pan of product before serving;-Acceptable serving temperatures are: -Cereal, gravy, casseroles, meat, entrees, potatoes, pasta, soup, pureed foods, hot pureed foods, cold vegetables, coffee: >140 degrees but preferably 160-175 degrees; -Hazardous salads and desserts <41 degrees; -Eggs 140-155 degrees;-If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discarded out of temperature range foods. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated residents' allergies, intolerances, and preferences, when staff served fish to one resident (Resident #120), who had an allergy to fish and seafood which resulted in an allergic reaction of a rash and itching skin that required medication. The facility failed to provide food/drink items to one resident (Resident #5), in a review of 30 sampled residents, and one additional resident (Resident #55) per their preference. The facility census was 116. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure compliance with the Federal requirement for nurse aide training when the facility charged nurse aides, employed by the facility, for the cost of the nurse aide training program. The facility census was 116. Review of the Code of Federal Regulation, 42 CFR 483.152 Requirements for approval of a nurse aide training and competency evaluation program, showed the following:(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program (including any fees for textbooks or other required course materials). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system was audible to ensure staff were alerted to the residents' request for assistance. The facility census was 116. Review of the facility policy, Call Lights Accessibility and Timely Response, revised on [DATE], showed the following:-The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide sufficient seating in the Station One dining area to accommodate all residents for dining. Fifty-eight residents lived on the 100, 200, and 300 halls and shared the Station One dining area. The facility census was 116. Observation on 04/26/26 at 12:10 P.M., of the Station One dining area showed the following:-Twelve standard height dining room chairs;-Ten tall chairs were placed along the back wall with no tables in front of them and three tall chairs were placed between two shorter dining tables along a half wall. The chairs were taller than the tables;-One resident turned one of the tall chairs around to use at the shorter table for dining service. The was not a standard height dining room chair available for him/her;-Two residents with wheeled walkers sat in tall chairs with no table to eat from. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's abuse and neglect policy to protect two residents (Residents #23 and #88), who were involved in a resident-to-resident altercation, when staff did not implement measures to remove the residents from contact with one another and evaluate and monitor the residents to prevent further incidents. The facility census was 116. Review of the facility policy Abuse and Neglect, updated 06/12/24, showed the following:-It is the policy of this facility to report all allegations of abuse reported immediately to the Administrator of the facility;-Abuse is the willful infliction of injury which can include certain resident-to-resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight and complete 15 minute safety checks (procedure for staff to verify the resident's location) as directed for one resident (Resident #1), in a review of seven residents. Resident #1 was a known elopement risk and was on 15 minute face checks for safety when the resident removed the security block from the windowsill (a rubber block screwed into the windowsill preventing the slide window from opening more than five inches) in his/her room, opened the window, removed the screen and climbed through the window to the exterior fenced courtyard. The resident pushed a picnic table next to the building, stood on the picnic table and climbed onto the roof, crossed the roof, and then jumped down into an open area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, with diagnoses of mental illness and a history of trauma, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The medical record showed on 02/10/26 at 5:48 P.M the resident's guardian/parent said the resident had voiced self-harm ideations. Two days later, on 02/12/26, the resident repeatedly asked for his/her television to watch Animal Planet, a known coping mechanism. Staff failed to provide additional interventions or a television to watch while supervising the resident one-on-one. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow proper immediate discharge procedure for one resident (Resident #10), in a review of eight sampled residents, by not identifying a proper discharge location. Resident #10 experienced increased aggressive behaviors and was sent to the hospital for psychiatric evaluation on 12/19/25. Once the resident was at the hospital, the facility determined they were unable to meet the resident's needs and sent an immediate discharge notice to the hospital on [DATE]. The facility identified the psychiatric hospital was the discharge location and did not plan to readmit the resident until after a decision was made following a hearing on 01/07/26. The facility did not amend the immediate discharge notice with an appropriate discharge location. The facility's census was 114. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #2), in a review of 14 sampled residents, from abuse. Resident #1, who had a diagnosis of intermittent explosive disorder (a mental health condition marked by frequent impulsive anger outbursts or aggression) and had a history of assault, approached Resident #2 and forcefully slammed Resident #2's head against the vending machine and struck Resident #2 multiple times in the face with a closed fist. Resident #2's sustained lacerations to the right eyebrow and upper lip that required sutures. The facility census was 113. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity when residents on the secured unit only had plastic forks and spoons provided to use for meal service. The facility provided no knives for resident use. Residents reported having to use their hands to eat meat because the meat could not be cut with a plastic fork or spoon. Fifty-seven residents resided on the secured unit. The facility census was 113. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from obtaining illegal substances when staff failed to follow their policy to search and inventory one resident's (Resident #3's) personal belongings upon admission and failed to remove items that were not allowed in the facility. Resident #3 reported he/she brought a dab pen (a portable device that contains cannabis/marijuana concentrate), 20 tablets of Adderall (a prescription medication used to treat attention deficit hyperactivity disorder and narcolepsy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff documented the rationale for use of as needed (PRN) antipsychotic medications to ensure adequate indication for use as directed in facility policy for one resident (Resident #1), in a review of 14 sampled residents. The facility's census was 113. Review of the facility's policy for PRN Medication Use, last reviewed on 05/18/24, showed the following:-PRN medications referred to a medication that is taken as needed for a specific situation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff notified one resident's (Resident #8) physician and nurse practitioner who worked in collaboration with the physician, and the resident's representative when the resident refused an ordered diagnostic procedure, experienced weight loss and had low blood pressure readings, in a review of seven sampled residents and two closed records .The facility census was 115. Review of the facility policy titled, Notification of Changes Policy, dated 5/14/24 showed the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consult's the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and serve double portions or a double entree at meals for five residents (Residents #2, #3, #4, #7, and #8), out of review of five residents who had physician's orders for double portions/entree. The facility census was 113. 1. Review of the Diet Spreadsheet menu for the lunch meal on 4/1/25 showed staff were to serve the following items to residents on a regular diet: -A 6-ounce serving of sweet and sour chicken; -A 4-ounce serving of steamed rice; -A 4-ounce serving of sauteed peppers and onions. Review of the Diet Type Report, dated 4/1/25, showed five residents (Residents #2, #3, #4, #7, and #8) were to receive double entrees with all meals or double portions with each meal. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision/oversight following an altercation involving two residents (Resident #1 and #3), in a review of seven sampled residents. While Residents #1 and #3 were on one-on-one supervision following the altercation, staff failed to adequately separate the residents and intervene to ensure the second altercation, involving Resident #1 and #2, did not occur. The facility census was 117. Review of the facility's Behavioral Emergency Policy, last revised 6/26/24, showed the following: -All staff should recognize when the resident has become or can become a danger to themselves or someone else. De-escalation techniques should be utilized as first resort; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one resident (Resident #1), in a sample of seven residents, from physical abuse by another resident, (Resident #3), who had a history of aggressive behaviors. Staff failed to separate the residents and sufficiently monitor Resident #3 after he/she had initially verbally assaulted Resident #1. Resident #3 was able to return to the dining area and physically assault Resident #1. Resident #1 received scratches and had a large clump of hair pulled from his/her scalp. The facility census was 117. Review of the facility policy, Resident's Rights, dated (revised) 07/05/23, showed the facility must protect and promote rights of each resident, including freedom from verbal, sexual, mental and physical abuse, corporal punishment and involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse involving two residents (Resident #1 and Resident #3), in a sample of seven residents, to the state agency (SA) as required. The facility census was 117. Review of the facility policy, Abuse and Neglect, dated (revised 06/12/24), showed the following: -It is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources or misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulation within prescribed time frames; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate an allegation of verbal and physical resident to resident abuse involving two residents (Resident #1 and #3) in a sample of seven residents reviewed. The facility census was 117. Review of the facility policy, Abuse and Neglect, dated (revised 06/12/24), showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 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; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 15 sampled residents, remained free from abuse when Licensed Practical Nurse (LPN) A engaged in text communication of a sexual nature in response to one resident's (Resident #1's), requests on social media for a sexual relationship with LPN A. The resident had diagnoses of physical and mental health disorders, resided on a secured unit for residents with behaviors, and was under guardianship. The facility census was 113. On 8/7/24 at 5:15 P.M., the administrator was notified of the past noncompliance which occurred on 7/14/24. On 8/1/24, the administrator became aware of the violation of abuse, regarding sexual text messages to Resident #1 by LPN A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to having sexual relations and failed to protect one resident (Resident #47) from sexual abuse by a resident (Resident #115). Resident #47 reported feeling worthless, having a flashback, and fear of contracting STDs (Sexual Transmitted Diseases). A sample of fourteen residents was selected for review. The facility census was 115. Review of the facility's Sexual Activity/Abuse and Neglect Policy, last reviewed 4/18/22, showed the following: -The purpose of this policy is to ensure the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety and sanitation. Staff failed to ensure opened food items were sealed and ensure food items in damaged containers were segregated from food items in active use. Staff failed to ensure resident food items, located in a unit refrigerator outside of the kitchen, were stored under sanitary conditions. Staff failed to ensure trash cans in the kitchen were covered when not in use. Staff failed to ensure ice and water dispensing machines were clean and ensure an air gap was present at each ice machine drain to prevent potential backflow of liquids back into the units. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five residents (Resident #61, #100, #31, #67 and #91) in a review of 34 sampled residents, and two additional residents (Resident #27 and #40), were treated in a manner to maintain dignity and respect, or honor the right to make choices. The facility census was 116. Review of the facility's policy, Dignity and Respect, revised on 06/29/23, showed the following: -The purpose of the policy is to ensure that every resident is treated with dignity and respect; -Every resident has a right to be treated with dignity and respect; -All staff will speak to and treat all residents with dignity and respect; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to retain and use personal possessions, including instant coffee, when the facility kept residents' instant coffee locked up in the medication room and controlled the times the residents could access their coffee. This affected three residents (Residents #31, #91 and #106), in a review of 34 sampled residents, and four additional residents (Residents #50, #56, #60, and #75). The facility held coffee for eight residents. The facility census was 116. Review of the facility's policy, Resident's Rights, revised on 07/05/23, showed the following: -The purpose of the policy is to ensure that resident rights are protected; -Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for one resident (Resident #81) in a review of 34 sampled residents, when staff did not ensure the resident had an appropriate and comfortable alternative chair to sit in when the resident would request to get out of bed. The facility also failed to provide adequate seating in the Station 2 common/dining area. This affected all residents residing in Station 2. The facility census was 116. Review of the facility policy, Resident Rights, revised 07/25/2023 showed the following: -The resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences; -The resident has a right to be free from chemical or physical restraints. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly and follow up with a response to residents' concerns that were voiced in resident council meetings. The facility also failed to have monthly resident council meetings. The facility census was 116. Review of the resident council meeting minutes, dated 12/2023, showed the following: -Station one: -No old business listed; -New business concerns: one resident needing clothes out of storage, laundry shrinking clothes, missing nightgown and socks; -Request for dietary to serve frozen fruit; -There was no documentation of the concerns being communicated to the staff for resolutions; -No documentation of a resolution related to the concerns; -Station two: -Old business: unclear as to what this was referring to, just listed a few resident names and winter coat; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a clean, sanitary and orderly environment. The facility census was 116. Review of the facility policy, Clean Check Training System, dated 2015, showed the following: -Routine cleaning of an occupied room included: - Remove trash and dispose of sharps; -Clean and disinfect high touch surfaces; -Spot clean walls and glass; -Clean resident restroom; -Hard floor care; -Additional periodic common area cleaning task; -Additional surface disinfection; -Windows; -Floor burnishing. 1. Observation on 03/06/24, at 9:29 P.M., showed the door frame going into the shower room/bathroom on 200 hall was marred and had missing paint in multiple places. Observation on 03/06/24, at 9:24 P.M., in occupied resident room [ROOM NUMBER] showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents knew how to file a grievance, where grievance forms were located or how to complete a grievance form. Residents said they felt there concerns were not heard or addressed. The facility census was 116. Review of the facility policy, Resident Rights, dated 7/5/23, showed the following: -The resident has the right to: 1. Voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; 2. Prompt efforts by the facility to resolve grievances the resident may have including those with respect to the behavior of other residents; -The resident has a right to voice grievances and recommend changes to policies and services to facility staff or outside representatives of his/her choice; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required pre-employment screenings for four of eight sampled employees hired since the previous survey. The facility failed to request a criminal background check (CBC) for two employees, check the Employee Disqualification List (EDL) for three employees, and check the Nurse Aide (NA) Registry for three employees, prior to hire as directed by facility policy. The facility census was 116. Review of the facility policy, Screening - Applicant, Employee, Volunteer and Vendor, revised 06/29/23, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff prepared and safely administered medications to five residents (Resident #67, #6, #102, #60 and #108) when Certified Medication Technician (CMT) I prepared the resident's medications and Certified Nurse Aide (CNA)/CMT/Team Lead G administered the medications. The facility failed to obtain a physician order for Resident #60 to self-administer his/her own eye drops. The facility failed to complete accuchecks (a test to check sugar levels in the blood) as ordered for one resident (resident #81), in a review of 34 sampled residents, and failed to obtain a urinalysis when ordered for one resident (Resident #12). The facility failed to document the narcotic counts were completed by two staff. The facility census was 116. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident for five residents (Resident #25, #48, #110, #116 and #96) out of 34 sampled residents. The facility census was 116. Review of the facility's Activities Policy, revised on 07/19/23, showed the following: -Purpose: the purpose of this policy is to ensure that all residents in the facility are provided on ongoing program of activities designed to meet, in accordance with comprehensive assessments, their interests and there physical, mental and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure systems were put in place for one resident to ensure the resident's safety, (Resident #102), after the resident expressed suicidal ideations and said he/she would self-harm by placing a bag over his/her head, and failed to ensure staff placed one resident's (Resident #48's), feet on wheelchair foot pedals to prevent accidents or injuries of 34 sampled residents. The facility failed to ensure effective interventions were implemented to ensure one resident (Resident #21), of 20 additional residents, was not transported in his/her rollator walker, when another resident routinely pushed Resident #21 backwards in the walker to his/her room. The facility census was 116. Review of the facility policy, Intensive Monitoring/Visual Checks,revised 6/30/23, showed the following: -PURPOSE: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer sufficient fluids to maintain proper hydration and health when staff failed to pass and offer water to three sampled residents (Resident #48, #96 and #110) out of 34 sampled residents. The facility census was 116. Review of the facility policy for Hydration dated 6/29/23 showed: -The purpose of this policy is to ensure that a hydration program is in place in each facility, to monitor hydration of residents and to define clinical symptoms of dehydration. The policy will also address assessment of residents at risk for dehydration and put a plan in place to identify nursing interventions including an interdisciplinary team approach in addressing the resident who is at increased risk for dehydration or the resident that requires special assistance or special monitoring of fluid intake; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two nurse aids (NA BB and NA U) of three staff reviewed, completed a certified nurse aid (CNA) training program within four months of their employment in the facility. The facility census was 116. Review of an electronic mail communication on 03/22/24 at 9:52 A.M., the Director of Nursing said the facility did not have a specific policy on Nursing Assistant and Certified Nursing Assistant training program. 1. Review of the facility provided list of employees hired since last annual survey showed the following: -NA BB's date of hire was 02/09/23; -NA U's date of hire was 06/02/23. 2. Review of NA B's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four residents (Residents #28, #48, #95 and #96), who were prescribed psychotropic medications, in a review of 34 sampled residents, received a gradual dose reduction (GDR), unless clinically contraindicated. The facility census was 116. Review of the facility's Medication Administration and Monitoring Policy, revised 09/20/23, showed the following: -The purpose is to ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications; -The facility will confer the pharmacist consultant and utilize drug reference guideline sources to ensure that residents receive medications safely without negative outcomes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard an opened insulin pen after 28 days of use for one resident (Resident #67), in a review of four sampled residents with insulin pens. The facility failed to dispose of house stock influenza vaccine after it had expired. The facility census was 116. Review of the facility's Monthly Inspections - Medications Policy, revised 07/05/22, showed the following: -The purpose of this policy is to ensure that the facility is monitoring the labeling and storage of all medications within the facility on a routine monthly basis; -The facility will utilize a pharmacy consultant to review the facility's storage of medications, that will include inspections of the medication carts and medication rooms; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the nutritional needs of the residents and failed to ensure staff served the correct portion sizes to residents as meals. The facility census was 116. Review of the facility's Dietary Food Preparation, revised 07/05/23, showed the following: -Standardized recipes will be used for all products prepared; -Uniform portions shall be established for each diet served to all residents; -Provide proper equipment for portioning out the correct quantity of food for the residents; -Instruct all dietary employees in the procedures of standardized portions; -Recipes and menus will have appropriated portions noted; -The dietary manager will monitor for the cooks and their use of portion control utensils on tray line. Review of the facility policy, Dietary Menu Planning and Nourishment, revised 7/5/23, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with palatable meals served at appetizing temperatures or a variety snacks for 10 residents (Resident #67, #91, #57, #61, #100, #33, #70, #81, #97 and #106) in a review of 34 sampled residents and four additional residents (Resident #4, #27, #116 and #24) . The facility census was 116. Review of the facility's Dietary Menu Planning and Nourishment Policy, revised 07/05/23, showed the following: -Menu planning is there responsibility of Health Technologies and meet the requirements of the Department of Health and Senior Services; -The menus are three meal plus a snack; -Nourishments will be provided to offer therapeutic nutritional support; A physician's order will be required; [...]

Inspectors wrote10. Review of Resident #5's progress notes, dated 3/04/24 at 6:02 A.M., showed the resident tested positive for COVID-19 and was compliant with isolation. Review of the resident's care plan, dated 3/04/24, showed the following: -The resident tested positive for COVID-19; -Educate staff, residents, family and visitors of COVID-19 signs and symptoms and precautions to follow; -Follow facility protocol for COVID-19 screening and precautions. Observation on 3/05/24 at 3:25 P.M., showed the following: -There was a plastic barrier duct taped top to the resident's door with a red zipper down the middle facing the hallway; -There was no personal protective equipment outside of the resident's door; -There was no hand sanitizer outside of the resident's door; -There was no trash receptacle outside of the resident's door; -The resident sat on a recliner inside of his/her room; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or responsible parties when three residents (Residents #19, #55 and #106), in a review of 34 residents, had a change in condition. The facility census was 116. Review of the facility's Notifying Clinicians Policy, revised 08/23/22, showed the following: -The purpose of the policy is to outline indications of when to notify the physician; -The physician is to be called on, but not limited to: a. Medical emergency: excessive nausea/vomiting/diarrhea, falls, incidents/injuries, hypo/hypertensive episodes (low/high blood pressure), hypo/hyperglycemic episodes (low/high blood sugar), desaturation (drop of oxygen level)/respiratory distress, any changes in lung sounds/positive results in rapid Covid tests, change in condition; b. Behavioral emergencies; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one resident (Resident #46 ), out of 34 sampled residents, remained free from misappropriation of property, when a facility employee took $450.00 of Resident #46's money when the resident offered to assist the employee with unpaid bills. The facility census was 116. The administrator was notified on 3/12/24 at 10:00 A.M., of the Past Non-compliance which occurred on 3/2/24. On 3/2/24, the administrator became aware of the violation of misappropriation of resident money. The facility began the investigation and terminated the employee on 3/2/24 for taking money from Resident #46. The resident received $450.00, full reimbursement of his/her funds. Staff were inserviced regarding the facility policy for misappropriation and facility expectation. The D grid deficiency was removed and corrected on 3/2/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a decline in limited range of motions or development/worsening of contractures (shortening and hardening of the muscles, tendons, and other tissues, often causing deformity and rigidity of joints) for one resident (Resident #28), in a review of 34 sampled residents. The facility census was 116. The restorative nursing policy was requested and not provided. Review of the facility policy, Physician's Orders for Therapy, revised on 06/29/23, showed the following: -Nursing to therapy communication forms will be initiated by a licensed Registered Nurse (RN); -All admissions, re-admissions and changes in functional status, that require therapeutic intervention will be screened for therapy services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to asses residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, and failed to obtain informed consent with risks prior to installing and using a bed rail for two residents (Residents #32 and #35), who had assist bars attached to their bed, in a review of 34 sampled residents. The facility census was 116. Review of the facility Bed Siderails policy, reviewed 6/29/23, showed the following: -To ensure all bed side rails in use have been evaluated for safety; -All residents using any size side rail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly, and as needed if there is a significant change in the resident's condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately administer insulin (a hormone used to treat diabetes) to one resident (Resident #76) and one additional resident (Resident#75), of four sampled residents who received insulin injections, when Licensed Practical Nurse (LPN) Y did not prime (remove air bubbles) the insulin pens prior to administration and did not hold the needle in the skin for six seconds after administration as directed by the manufacturer of the medication. The census was 116. Review of the facility's Blood Glucose Monitoring and Insulin Administration Policy, dated 06/29/23, showed it did not address the specific procedure to follow when administering insulin via an insulin pen and only addressed insulin administration via vial and syringe. Review of the manufacturer's information for Novolog insulin FlexPen showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Residents #48), in a review of 34 sampled residents, received dental services and failed to follow up with recommendations for further dental intervention. The facility census was 164. The facility did not provide a policy for dental services. 1. Review of Resident #48's care plan dated 8/14/20 showed no care plan to address dental care or dental issues. Review of the resident's nurses notes dated 11/21/2023 at 3:23 P.M., showed the resident was seen by a local dental clinic. There are multiple areas of decay, non restorable teeth. A referral will be sent to an oral surgeon, the resident needs extraction of all remaining teeth. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/19/24 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumoccal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for one resident (Resident #61), who gave consent to receive the vaccine upon his/her admission to the facility, in a review of 34 sampled residents. The facility census was 116. Review of the facility policy for Influenza and Pneumococcal Immunizations, revised 3/18/22, showed the resident or their legal representative will be told the pneumococcal immunization will be offered upon admission and a second pneumococcal immunization may be recommended after five years from the first immunization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete entrapment assessments for two residents who had side rails attached to their bed (Residents #32 and #35), in a sample of 34 residents, to ensure the environment remained safe and free of accident hazards. The facility census was 116. Review of the facility Bed Siderails policy, reviewed 6/29/23, showed the following: -To ensure all bed side rails in use have been evaluated for safety; -All residents using any size siderail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly, and as needed if there is a significant change in the resident's condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to all residents, family members and legal representatives. The facility census was 116. Review of the facility policy Resident Rights, dated 7/5/23, showed the resident has the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility in a place readily accessible to residents and the facility must post a notice of their availability. 1. During the resident council meeting on 3/6/24 at 1:00 P.M., the residents said they were not aware they could see the results of the annual inspections/surveys or any complaint investigations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #13) with a mental health disorder, in a review of 13 sampled residents, received individualized treatment and services to meet his/her psychosocial needs. The resident had a history of alcohol use, impulsiveness, self-mutilation, and multiple suicide attempts. On 8/3/23, the resident cut himself/herself and swallowed batteries. Staff believed the resident's behavior was a result of staff confiscating contraband (chewing tobacco and cigarettes) after the resident returned to the facility after attending church. On 11/5/23, staff reported the resident was upset when staff confiscated chewing tobacco, cigarettes and two bottles of alcohol-based hand sanitizer upon the resident's return from attending church. The resident also presented with signs/symptoms of alcohol consumption. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and respect the rights of two residents (Resident #9 and #13), in a review of 13 sampled residents. The facility implemented a procedure that infringed on Resident #13's rights and required he/she sign out against medical advice when he/she left the facility to attend church. Resident #13 was his/her own responsible party. The staff locked the facility when the resident left for church services, searched the resident for alcohol upon his/her return, and threatened to involve law enforcement and deny readmission to the facility if the staff detected alcohol or if the resident appeared impaired. The facility then prohibited the resident from attending church services outside the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to comply with State law when the facility allowed the transportation coordinator and dietary/transportation staff A to transport residents without a current qualified Class E driver's license ( a license required to transport residents for compensation). The facility census was 111. Review of the Missouri Department of Revenue, Driver's License Classes, 12 CSR 10-24.200 (5), dated 7/31/23, showed the following: -Class E: The holder of a Class E license may drive all vehicles which may be driven by a holder of a Class F license and receive compensation in wages, salary, commission, or fare to transport persons or property; -As an owner or employee carrying passengers or property for hire; -Or occasionally operating the commercial motor vehicle of another person in the course of, or as an incident to, their employment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weights were monitored weekly after a significant weight loss was identified as directed in the facility policy, failed to provide interventions as ordered by the physician to prevent weight loss, failed to re-evaluate interventions to prevent weight loss for effectiveness, failed to monitor the meal and supplement consumption as directed in the facility policy, failed to update the resident's care plan to reflect the resident's current orders/interventions as directed in the facility policy, and failed to ensure dental needs were identified and actions taken to prevent further weight loss for one resident (Resident #21), who had a 14.5% significant weight loss, in a review of 31 sampled residents. The facility census was 108. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled, dated and covered; failed to ensure floors were clean and free of debris; failed to ensure the can opener blade was free of debris; failed to ensure staff wore hair restraints in the kitchen; and failed to ensure staff member's personal items and beverages were not stored in food preparation areas. The facility census was 108. Review of the undated facility policy, Personal Hygiene, showed the following: -These are the guidelines for personal hygiene to promote a safe and sanitary department; -Hair must be covered with a hairnet; -Beards or any excessive body hair that may be exposed must be covered. Review of the undated facility policy, Food Storage, showed the following: -Food items will be stored, thawed and prepared in accordance with good sanitary practice; -Procedure: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four residents (Residents #3, #4, #12,and #109), in a review of 31 sampled residents, and one additional resident (Resident #49), were treated in a manner to maintain dignity and respect. The facility census was 108. Review of the facility policy, Dignity and Respect, revised on 7/9/21, showed the following: -Every resident has a right to be treated with dignity and respect; -All staff will speak to and treat all residents with dignity and respect. 1. Review of Resident #3's care plan, revised 4/24/22, showed the following: -The resident has impaired cognitive function related to head injury; -He/She is able to adequately express wants and needs; -The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to the resident when the facility did not allow the residents to choose what time and how often they bathed, if they could attend activities, and when they could get up out of bed for four residents (Resident #60, #70, #96, and #110), in a review of 31 residents. The facility census was 108. Review of the facility policy, Resident Rights, revised on 4/29/21, showed the following: -Purpose: to ensure that resident rights are protected; -Residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote the rights of each resident; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and comfortable environment by failing to ensure residents' rooms and living spaces were clean and in good repair. The facility census was 108. Observations on 05/16/22 between 9:00 A.M. and 2:00 P.M. and on 05/17/22 between 8:30 A.M. and 11:00 A.M. showed the following: -In resident room [ROOM NUMBER], the bathroom wall was missing three 12-inch wall tiles, exposing raw sheet rock. The bathroom floor was stained with a brown sticky substance. The bathroom floor had cracks around all the tile next to the wall with dark brown substance in the cracks, areas of missing caulk on the floor, and bathroom ceiling was discolored. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin (medication used to treat diabetes) vials/pens for four residents (Residents #10, #48, #78, and #85) were dated when opened and/or discarded within the designated time frame after opening. The facility census was 108. Review of the facility's Medication Administration Policy, revised 9/17/21, showed all medications except for pre-packaged bubble cards or pre-packaged unit dose medications shall be dated by the Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Medication Technician (CMT)/Certified Medication Aide (CMA) when opened. This includes but is not limited to all liquid medications, nasal sprays, inhalers, insulins and all vials. Review of the Food and Drug Administration guidelines for Novolog (insulin), Levemir (insulin) and Lantus (insulin) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the menu by not preparing or serving all food items for lunch as directed by the spreadsheet menu on 5/16/22 and 5/17/22. The facility also failed to ensure residents on a pureed diet received proper portion sizes of protein on 5/16/22, and residents on a regular and mechanical soft diet received proper portion sizes of dessert for lunch on 5/16/22 and 5/17/22. The facility census was 108. Review of the undated facility policy, Diets Available in the Facility, showed the facility will provide each resident with a regular or therapeutic diet, as ordered by the physician, in order to ensure that each resident receives the diet prescribed by the physician. Review of the undated facility policy, Therapeutic Diets, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reasonable accommodation of needs for one resident (Resident #28), in a review of 31 sampled residents, by ensuring the resident had a shoes to wear when inside and outside the facility. The facility census was 108. Review of the facility policy, Resident Rights, revised on 4/29/21, showed the resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. Review of Resident #28's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/2/22, showed the following: -His/Her cognition was intact; -His/Her diagnoses included diabetes (elevated blood sugar levels); -He/She was independent with activities of daily living (ADLs); [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for one resident (Residents #3), in a review of 31 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 108. Review of the facility policy, Significant Change, revised 2/26/21, showed the following: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a stop date or document clinical justification for continued use of a psychotropic as needed (PRN) medications beyond 14 days for one resident (Resident #21), and failed to attempt a gradual dose reduction (GDR) on psychotropic medication or document a clinical justification to continue current dosage for one resident (Resident #106), in a review of 31 sampled residents. The facility census was 108. Review of the facility policy, PRN Antipsychotic and Psychotropic Medication, dated last revised 2/26/21, showed the following: -PRN psychotropic medication may be extended longer than 14 days with physician documentation explaining why the prescribing physician believes it to be appropriate to extend the time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food items were prepared and served at the proper consistency for residents, including Resident #106, had who physician's orders for a pureed therapeutic diet. The facility census was 108. Review of the undated facility policy, Therapeutic Diets, showed the following: -Therapeutic diets are prepared and served as prescribed by the attending physician; -Therapeutic diets are planned, prepared and served with supervision or consultation from a registered dietitian; -The dietitian and dietary manager must see that: Each food item, served separately in the regular diet, is pureed and served separately for the pureed diet according to the pureed recipes; each dietary staff member involved with serving must refer to and follow the therapeutic diet on the daily menu. [...]

Inspectors wroteBased on observation and interview, the facility failed to post survey results and plans of correction in locations within the facility accessible to all residents to view. The residents located on the locked/secured unit (identified as Unit 2) did not have access to the survey results. The facility census was 108. Review of the facility policy, Resident Rights, revised on 4/29/21, showed the resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility in a place readily accessible to resident and the facility must post a notice of their availability. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and the reason for the transfer for six residents (Residents #21, #27, #28, #33, #72, and #101 ), in a review of 31 sampled residents. The facility census was 108. 1. Review of Resident #101's face sheet showed the resident had a durable power of attorney (DPOA) who was responsible for making healthcare decisions. Review of the resident's progress notes showed he/she was transferred to the hospital for evaluation and treatment of a medical condition on 11/29/21, 4/14/22, and 5/10/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for six residents (Residents #21, #27, #28, #33, #72, and #101), in a review of 31 sampled residents. The facility census was 108. 1. Review of Resident #21's face sheet showed the resident had a legal guardian. Review of the resident's nurses notes, dated 2/10/22, showed he/she was transferred and admitted to the hospital for treatment of a medical condition on 2/10/22. Review of the resident's medical record showed no evidence the resident and/or resident representative was informed in writing of the facility's bed hold agreement at the time of transfer that included: [...]