Every finding on record at Adair Village

Based on observation, interview and record review the facility failed to implement interventions to promote optimal food intake for one resident who the facility identified at risk for weight loss (Resident #2). The resident experienced a severe weight loss of 21.7 pounds or 15.78 % body weight in three months. The facility failed to follow their policy to fully inform the physician, involve the Dietary Manager (DM), and notify the consultant Registered Dietitian (RD) for an assessment related to the weight loss, failed to assess or identify reasons for the weight loss or develop and implement interventions to prevent further weight loss including the provision of assistance and encouragement during meals. The facility census was 57.Review of the facility's policy titled Weight Assessment and Intervention dated 2001, showed the following:-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation;-If the weight is verified, nursing will notify the Dietician;-Unless notified of significant weight change the Dietician will review the unit weight record monthly to follow individual weight trends over time; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss= (usual weight- actual weight)/(usual/weight) x 100]: One month 5% weight loss is significant; greater than 5% is severe;-If the weight change is desirable, this is documented;-Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant'' weight change has been met. The evaluation includes:-The resident's target weight range (including rationale if different from ideal body weight);-The resident's calorie, protein, and other nutrient needs compared with the resident's current intake;-The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (eating disorder), weight loss or increasing the risk of weight loss;-Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate;-Individualized care plans shall address: The identified causes of weight loss, goals and benchmarks for improvement, time frames and parameters for monitoring and reassessment; -Interventions for undesirable weight loss are based on careful consideration of the following:-Resident choice and preferences;-Nutrition and hydration needs of the resident;-Functional factors that may inhibit independent eating;-Environmental factors that may inhibit appetite or desire to participate in meals;-The use of supplementation and/or feeding tubes (a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications). Review of Resident #2's medical record showed: -An admission date of 02/11/2025;-Diagnoses included heart disease, kidney disease, dementia, diabetes, high blood pressure and neurologic neglect syndrome (a disabling, often post stroke condition where patients disregard one side of their body or environment. It results from damage of one brain hemisphere. Key signs include eating from only half a plate). Review of the care plan last reviewed on 11/24/2025 showed the following:-Resident was at risk for weight loss related to poor appetite;-Continue 30 milliliter (ml) of TwoCal (supplement drink) three times a day (TID) with medications;-Continue weekly weights for four more weeks;-Determine resident's ability to chew and swallow;-Educate resident/representative regarding nutritional needs and requirements;-Modify diet as appropriate according to resident's food tolerances and preferences;-Regular diet, regular thin liquids;-The resident had unplanned and unexpected weight loss;-Administer medication as directed to manage pain so resident can focus on meals;-Alert RD if consumption was poor for more than 48 hours;-If weight decline persists, contact physician and dietician immediately;-Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss;-Serve food in small bowls;-Staff to encourage the resident to return to dining room if he/she leaves before finishing meal;-The resident was at risk for visual impairment. The family reports poor vision. Review of the resident's Weight and Vital Signs records, showed staff documented the following:-On 10/01/2025, the resident weighed 137.5 pounds (pounds); -On 11/04/2025, the resident weighed 131 pounds;-On 01/13/2026, the resident weighed 117 pounds which was a 14.91% loss in three months;-On 01/21/2026, the resident weighed 115.8 pounds which was a 15.78% loss in three months.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 11/20/25, showed the following:-Severe cognitive impairment;-Required assistance with bed mobility, transfers, dressing, toileting hygiene and bathing.-The resident required supervision and set up assistance for eating;-The resident was 61 inches tall, weighed 129 pounds and had an unplanned weight loss;-Nutritional approaches included a mechanically altered diet (require change in texture of food or liquids) -Staff failed to identify this weight loss as a significant weight loss in one month. Review of the RD consultant's summary and recommendations, dated 01/09/26, showed the following:-Progress note/weight loss: Weight 121 pounds, Height 61 inches, Body Max Index (BMI, a screening tool that uses height and weight to estimate if an adult is at a healthy weight): 22.9. Loss of 10 pounds (7.6%) x 60 days. Severe weight loss;-Diet was downgraded to mechanical soft (foods are ground, minced, chopped or blended to require minimal chewing) with 30 ml Two Cal TID. History of swelling to the bilateral lower extremities.-RD recommendation included weekly weights, increase Two Cal to 60 ml three times a day and encourage intake and assist as needed. Review of the resident's January 2026 physician orders sheet (POS) showed the following:-On 9/16/2025 an order for a regular diet, mechanical soft texture, regular/thin consistency;-On 10/01/2025 an order for the resident's vitals and weight to be taken monthly;-There was no update to the POS regarding the RD's recommendation on 01/09/2026 for Two Cal supplement to be increased to 60 ml. Review of the resident's January 2026 Medication Administration Record (MAR), showed the following:-TwoCal 30 ml, start date 11/19/25;-The resident refused three times in January;-The MAR did not show the RD's 01/09/26 recommendation to increase the Two Cal to 60 ml. Review of the resident's progress notes showed no Dietary Manager notes.Review of the resident's diet card showed staff did not include any food likes or dislikes or any preferences. Observation and interview on 01/21/26 at 11:28 A.M., showed the staff weighed the resident and documented a weight of 115.8 pounds. When asked if the resident was ready for lunch the resident said his/her favorite food was any flavor of ice cream, but he/she didn't get ice cream very often. The menu showed lunch was pork roast, spinach, mashed potatoes and a dessert (peaches).Observation and interview on 01/21/26 at 11:37 A.M., showed the resident sat at a table in the dining room and said he/she would eat anything. He/She was hungry.Observation of lunch on 01/21/26, showed: -At 11:39 A.M., staff brought a cup of coffee to the resident. The resident drank it;-At 11:44 A.M., staff passed the resident his/her meal tray. The resident was served regular textured food on a regular plate. Staff did not serve the resident's food in bowls. The resident attempted to eat using a fork. The resident was only able to get very small amounts of spinach on the end of the fork. The resident spilled spinach on his/her lap and attempted to take very small bites of the mashed potatoes;-The resident appeared to be frustrated;-At 11:55 A.M., the resident pushed his/her chair back, stood up and walked out of the dining room;-At 11:58 A.M., the resident re-entered the dining room with the Administrator. The Administrator asked the resident if he/she had eaten his/her lunch. Staff spoke up and said the resident had eaten some of his/her lunch meal. The resident sat back down at the dining room table and pushed his/her plate away from him/her. Staff approached and placed peaches in front of resident. The resident took a few small bites of spinach and mashed potatoes and ate two to three small peaches. The resident tried to eat with the fork, but food fell off the fork. The resident was not able to get a lot of food into his/her mouth. The resident pushed the plate away;-No staff approached or encouraged the resident during the meal;-At 12:09 P.M., the resident said he/she was done. The resident ate less than 10% of the meal;-At 12:10 P.M., the staff cleared off the table and the resident's plate. Staff did not document the meal intake or percentage of meal eaten;-At 12:11 P.M., the resident left the dining room.Observations during the survey investigation showed no staff administering the Two Cal 30 ml or 60 ml to the resident. During an interview on 01/22/26 at 1:40 P.M., Certified Medication Technician (CMT) H said he/she worked the 6:00 A.M., to 6:00 P.M., shift. The resident could feed himself/herself and was mostly independent with eating meals. Staff cut up meats and set-up the resident's plate. Staff did not need to sit with the resident during meals. If the resident did not eat one or two meals, then staff needed to sit with resident and encourage eating. Staff usually took the resident to the dining room too early. The resident did not like sitting very long and would get up and leave the dining room. The resident received a supplement for weight loss with breakfast, lunch and dinner, and preferred the chocolate flavor. The resident liked sweets and coffee. If a recommendation was made by the RD, it should have been added to the POS as soon as possible and followed. CMT H said he/she gave the resident his/her Two Cal supplement during the church activity that started at 10:00 A.M. CMT H was not aware the Two Cal supplement had been increased. It was not on the POS or on the MAR. During an interview on 01/22/26 at 2:05 P.M., Certified Nurse Aide (CNA) I said the resident was not alert or oriented. He/she needed to be taken back and forth to the dining room. The resident would go into the dining room and was up and down especially if the meal had not been served yet. Staff encouraged the resident to go back to the dining room to eat. The resident was able to feed himself/herself. CNA I was not sure if the resident had any weight loss. Staff do not sit with the resident. CNA I was not sure if he/she would allow staff to help. The resident did not like sandwiches. The resident's family brought in cookies and other snacks. During an interview on 01/23/26 at 9:42 A.M., Registered Nurse (RN) A said he/she started working there in December 2025. He/she was an RN supervisor. When there was a resident with wight loss the nurse should notify the physician and family. The DM would contact the RD and supplements may be implemented. The resident was alert to self, walked independently and needed some help from staff with activities of daily living. The resident could eat independently. RN A was not aware of any significant weight loss. RN A was not sure how frequently the resident needed to be weighed. Staff did not document any meal intakes. If the RD made any recommendations for residents the DM passed it onto nursing who contacted the physician and family and put in an order on the POS. When staff brought the resident a plate, they should tell him/her what's on the plate. Staff should sit with the resident, who could be easily redirected. Staff should try to keep resident from going to the dining room too soon and closer to meal serve-out. Finger foods may have been a good intervention. All staff should know if a resident was at risk for weight loss or had any kind of weight loss. During an interview on 01/21/26 at 2:10 P.M., and on 01/23/26 at 10:06 A.M., the DM said she had worked for the facility for six years and had been the DM for four years. She did not document any notes unless something significant happened. She added her part in the MDS on a quarterly basis. Dietary cards showed a resident's likes and dislikes and any preferred foods. The resident was alert with dementia and became confused easily. Staff did not document meal or fluid intake for any meals. Staff should document meal intake on any resident at risk for weight loss or had significant weight loss, including the resident. The DM, Social Services, MDS Coordinator, Administrator, DON and Assistant Director of Nursing (ADON) had weekly weight meetings. The resident had been discussed at the meetings, and they had considered giving the resident finger foods, but it was never started. and the resident was discussed. Staff have been watching the resident's weight for quite some time. The e RD saw residents monthly, made recommendations and noted any concerns. When the RD made a recommendation, she took it to the Director of Nursing (DON) to let her know so the physician could add the recommendation to the POS. Residents with weight loss were weighed weekly and observed. The DM said she took the most recent recommendation from the RD who saw the on 01/09/26, and noted the TwoCal should be increased from 30 ml to 60 ml and given TID with medication pass. The recommendation from the RD on 01/09/26 should have been added to the POS and should have been given as ordered. She did not know the recommendation to increase TwoCal was never implemented or added to the POS. Staff should have sat with the resident during meals and assisted the resident. Staff had not been doing this. Staff should have only encouraged the resident to eat meals should have never told the resident he/she didn't have to eat. The DM and other staff watched what the resident ate during meals but did not document intake and have no record of meal intake. The resident liked Oreo cookies and most sweets. During an interview on 01/23/26 at 11:06 A.M., the RD said she was in the facility once a month and as needed. She reviewed new admissions, weight concerns and made any recommendations that were needed. She did not participate in the weekly weight meeting. When she made any recommendation she sent it to the DM, DON and the Administrator. She expects the recommendations to be reviewed, physician notified and if the physician agreed, to get an order and add it to the POS. When a resident had weight loss it was a good practice to document and track meal intake. The resident had had a weight loss, and she had recommended the resident be given food in bowls. They had discussed the resident having some vision issues. She was not sure if the staff told her they stopped using the bowls. She had not seen staff consistently sit with the resident. The resident may need to be moved to a different table. During an interview on 01/23/26 at 12:07 P.M., the Administrator, DON and the ADON the resident was alert to self, but not oriented. The resident could be easily redirected. Staff assisted the resident with what he/she would let them do. They were aware the resident had had weight loss. The DON said it started within the last two to three months. They have weekly weight meetings, and the resident had been identified for weight loss and interventions had been put in place. The resident was placed on TwoCal 30 ml and then recently the dose was increased to 60 ml. The TwoCal should be given during medication pass and should be given three times a day. All staff should know if a resident had a weight loss. The RD's recommendation should have been put in place that day. Nursing should have contacted the physician and added an order to the POS. The physician should have been notified of any change in condition to include a resident with weight loss. Staff should have been sitting with the resident to assist and encourage meal intake. Staff did not document meal intake. Food preference should have been on the meal card. The Administrator and DON were not aware the resident's weight loss was that significant.During an interview on 01/23/26 at 10:39 A.M., the Medical Director said he had been in the position for the last four to five months. He was the resident's facility doctor. He was in the facility twice a week. If a resident had a change in condition, including weight loss, he wanted to be notified. The resident was alert to self, pleasantly confused but could make most of his/her needs known to staff. The resident could feed himself/herself and required staff to assist with most other self-care activities. He was not aware of any weight concerns or weight loss related to the resident. Staff had not notified him of any weight loss or a 20-pound weight loss in three months. He would have documented this in his monthly progress notes and added interventions. He needed to be involved in the weekly weight meetings from now on. When the RD made a recommendation, he should be notified so it could be added to the POS. He was never notified of any of the RDs recommendations. Staff should have documented meal intake, and the resident should be moved to the assist table to ensure he/she was eating. The resident should have a Magic Cup (ice cream like supplement). All staff had to do was tell him. If he didn't know, he could not order any interventions. He could be easily reached, 24 hours a day.

Based on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration and follow the manufacturer's instructions for administration for three residents during five different observations (Residents #8, #44 and #4). The facility census was 57. Review of the facility policy titled Adverse Consequences and Medication Errors, dated June 2025, showed the following:-The interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects;-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services;-Examples of medication error includes failure to follow manufacturer's instructions and/or accepted professional standards, such as crushing a medication on the do not crush list without an order;-Medication errors are managed according to facility policy. Review of the facility policy titled Insulin Administration dated March 2025, showed the following:-To provide guidelines for the safe administration of insulin;-The nursing staff have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use;-Insulin therapy is individualized based on prognosis, treatment goals, and blood glucose levels;-Insulin may be premixed in an insulin pen or syringe;-Injectable insulin comes in concentrations of 100 units per milliliter (ml) of liquid. Review of the facility undated policy, titled Insulin Pens, showed the following:-Similar to vials of insulin, insulin pens do not require constant refrigeration once they have been opened; -Each time you use the pen: -Remove the pen cap and clean the top with alcohol; -Attach the needle to the pen. Use a new needle each time; -Prime the pen and then dial up the correct dose; -Double-check the dose before you inject; -Remove the cap and choose a clean site to inject; -Push the button to inject the insulin and wait five to 10 seconds to be sure allof the insulin has been absorbed; -Remove the needle and dispose of it properly. Review of the manufacturer's Instructions for Use for Humalog Kwikpen (brand name for insulin lispro a fast-acting insulin to help prevent and treat high blood sugar from meals), dated July 2023, showed the following:-Prime the pen before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If you do not prime before each injection, you may get too much or too little insulin. -To prime your pen, turn the dose knob to select two units;-Hold the pen with the needle pointing up;-Tap the cartridge holder gently to collect air bubbles at the top;-Continue holding the pen with needle pointing up;-Push the dose knob in until it stops, and 0 is seen in the dose window;-Hold the dose knob in and count to five slowly;-You should see insulin at the tip of the needle;-Humalog is injected under the skin (subcutaneously) of the stomach area, buttocks, upper legs or upper arms;-Wipe the skin with an alcohol swab and let the skin dry before injecting the dose;-Insert the needle into skin;-Push the dose knob all the way in;-Continue to hold the dose knob in and slowly count to five before removing the needle. 1. Review of Resident #8's face sheet (brief information sheet about the resident) showed the following: -admitted on [DATE];-Diagnoses included: Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) without complications and metabolic encephalopathy (a disease that affects the function or structure of your brain). Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/17/25, showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 11/17/25, showed the following:-Resident had diagnosis of diabetes mellitus;-Staff should administer diabetes medication as ordered by the physician;-Staff should monitor and document signs and symptoms of side effects and effectiveness. Review of the resident's physician's orders showed the following:-An order dated 11/18/26, Humalog Kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin lispro), inject as per sliding scale: if blood sugar 160 to199 give 2 units, if 200 to 249 give 4 units, if 250 to 299 give 6 units, if 300 to 349 give 8 units, if 350 to 399 give 10 units, if over 400 notify the physician, subcutaneously before meals for diabetes mellitus. Observation on 01/21/26 at 11:35 A.M., showed the following: -Licensed Practical Nurse (LPN) G prepared supplies and obtained a blood sample; -Blood glucose was 216; -He/She wiped the resident's left lower abdomen and administered the insulin;-He/She did not hold the needle in the skin for any length of time after pushing the plunger; -The nurse did not prime the pen;-The nurse did not hold the insulin pen in the skin for at least five seconds.Observation on 01/22/26 at 11:32 A.M., showed LPN E entered the resident's room with an insulin pen. He/She turned the dial to two units and administered the insulin. LPN E did not prime the insulin. 2. Review of Resident #44's face sheet showed the following: -admitted [DATE];-Diagnoses included: cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), type 2 diabetes mellitus without complications. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/18/25, showed the following:-Resident had diabetes mellitus;-Staff should administer diabetes medications as ordered by the physician;-Staff should monitor and document and side effects and effectiveness. Review of the resident's physician's orders showed the following:-An order dated 09/06/25, insulin lispro subcutaneous solution pen-injector 100 unit/ml (insulin lispro), inject 10 units subcutaneously before meals for diabetes mellitus. Observation on 01/21/26 at 4:15 P.M., showed the following: -LPN G prepared supplies and verified the physician's order;-The nurse turned the insulin pen dial to 10 units;-He/She wiped the resident's left upper arm and administered the insulin;-He/She did not hold the needle in the skin for any length of time after pushing the plunger; -The nurse did not prime the pen;-The nurse did not hold the insulin pen in the skin for at least five seconds.Observation on 01/22/26 at 11:25 A.M., showed LPN E entered the resident room with an insulin pen. He/She turned the dial to 10 units and administered the insulin. LPN E did not prime the pen. 3. Review of Resident #4's face sheet, showed the following: -admitted on [DATE];-Diagnoses included: stroke, type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), chronic kidney disease stage 3 (CKD, mild to moderate kidney damage). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses that included diabetes mellitus (high blood glucose);-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/17/25, showed the following:-Resident had diabetes mellitus;-Staff should administer diabetes medications as ordered by the physician;-Staff should monitor and document side effects and effectiveness;-Staff should obtain fasting blood sugar as ordered by the physician. Review of the resident's physician's orders showed an order dated 10/14/25, insulin lispro subcutaneous solution pen injector 100 unit/ml (insulin lispro), inject 8 units subcutaneously in the evening for diabetes mellitus. Observation on 01/21/26 at 4:40 P.M., showed the following:-LPN G obtained the resident's insulin lispro pen from the medication cart; -He/She then turned the insulin pen dial to 8 units; -LPN G administered the insulin to the resident's left lower abdomen; -LPN G did not hold the pen in the skin for any length of time;-He/She did not prime the pen. 4. During an interview on 01/22/26 at 11:35 A.M., LPN E said when administering insulin using insulin pens, he/she first double checked the order. He/She turned the pen dial to the ordered units and administered it to the resident. Generally, he/she only primed the pens when first opened. LPN E does not prime every time because he/she could see if there was air in the pen. All of the insulin would be administered because there wouldn't be air in the pen. During an interview on 01/22/26 at 12:10 P.M., Registered Nurse A said when administering insulin with an insulin pen he/she turned the dial to two units to prime every time to get insulin into the needle. If the pen was not primed it was possible the correct dose would not be given. After pushing the plunger all the way down staff should hold the pen in the skin for about six seconds. During an interview on 01/22/26 at 1:25 P.M., LPN B said when he/she administered insulin with an insulin pen he/she first checks the orders for correct dose. Then he/she primed the pen with two units and then turned the dial to the ordered dose. The pen should be held for several seconds after administration to ensure the full dose was administered. Insulin pens were primed with every use to ensure no air in the needle and administration of the correct dose. 5. During an interview on 01/22/26 at 1:45 P.M., the Assistant Director of Nursing said nursing staff should prime the insulin pens to take air out of the needle. This should be done every time, not just with new pens. If the pen was not primed the resident might not get the whole dose of insulin. 6. During an interview on 01/22/26 at 2:00 P.M., the Director of Nursing said staff should turn the dial to one or two units to prime the needle, and should be done every time. Once primed staff should turn to the ordered dose and administer. After the plunger was pushed in, staff should hold at least three seconds. If the pen was not primed and the plunger not held, the resident may not get the full dose. 7. During an interview on 01/23/26 at 1:15 P.M., the Administrator said staff should follow physician orders and manufacturer instructions for insulin pens. Staff should have primed the pens every time.

Based on observation, interview and record review the facility failed to ensure residents were free of medication errors greater than 5% when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration and failed to follow manufacturer's administration instructions for three residents (Resident #8, #44, #4). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 57. Review of the facility policy titled Administering Medications, dated April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-Medications are administered in accordance with prescriber orders, including any required time frames. Review of the facility policy titled Insulin Administration dated March 2025, showed the following:-To provide guidelines for the safe administration of insulin;-The nursing staff have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use;-Insulin therapy is individualized based on prognosis, treatment goals, and blood glucose levels. Review of the facility undated policy, titled Insulin Pens, showed the following:-Similar to vials of insulin, insulin pens do not require constant refrigeration once they have been opened; -Each time you use the pen: -Remove the pen cap and clean the top with alcohol; -Attach the needle to the pen. Use a new needle each time; -Prime the pen and then dial up the correct dose; -Double-check the dose before you inject; -Remove the cap and choose a clean site to inject; -Push the button to inject the insulin and wait five to 10 seconds to be sure allof the insulin has been absorbed; -Remove the needle and dispose of it properly. Review of the manufacturer's Instructions for Use for Humalog Kwikpen (brand name for insulin lispro a fast-acting insulin to help prevent and treat high blood sugar from meals), dated July 2023, showed the following:-Prime the pen before each injection;-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If you do not prime before each injection, you may get too much or too little insulin.-To prime your pen, turn the dose knob to select two units;-Hold the pen with the needle pointing up;-Tap the cartridge holder gently to collect air bubbles at the top;-Continue holding the pen with needle pointing up;-Push the dose knob in until it stops, and 0 is seen in the dose window;-Hold the dose knob in and count to five slowly;-You should see insulin at the tip of the needle;-Humalog is injected under the skin (subcutaneously) of the stomach area, buttocks, upper legs or upper arms;-Wipe the skin with an alcohol swab and let the skin dry before injecting the dose;-Insert the needle into skin;-Push the dose knob all the way in;-Continue to hold the dose knob in and slowly count to five before removing the needle. 1. Review of Resident #8's face sheet (brief information sheet about the resident) showed the following: -admitted on [DATE];-Diagnoses included: Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) without complications and metabolic encephalopathy (a disease that affects the function or structure of your brain). Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/17/25, showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 11/17/25, showed the following:-Resident had diagnosis of diabetes mellitus;-Staff should administer diabetes medication as ordered by the physician;-Staff should monitor and document signs and symptoms of side effects and effectiveness. Review of the resident's physician's orders showed the following:-An order dated 11/18/26, Humalog Kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin lispro), inject as per sliding scale: if blood sugar 160 to199 give 2 units, if 200 to 249 give 4 units, if 250 to 299 give 6 units, if 300 to 349 give 8 units, if 350 to 399 give 10 units, if over 400 notify the physician, subcutaneously before meals for diabetes mellitus. Observation on 01/21/26 at 11:35 A.M., showed the following:-Licensed Practical Nurse (LPN) G prepared supplies and obtained a blood sample; -Blood glucose was 216;-He/She wiped the resident's left lower abdomen and administered the insulin;-He/She did not hold the needle in the skin for any length of time after pushing the plunger; -The nurse did not prime the pen;-The nurse did not hold the insulin pen in the skin for at least five seconds. 2. Review of Resident #44's face sheet showed the following: -admitted [DATE];-Diagnoses included: cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), type 2 diabetes mellitus without complications. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses included diabetes mellitus;-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/18/25, showed the following:-Resident had diabetes mellitus;-Staff should administer diabetes medications as ordered by the physician;-Staff should monitor and document and side effects and effectiveness. Review of the resident's physician's orders showed the following:-An order dated 09/06/25, insulin lispro subcutaneous solution pen-injector 100 unit/ml (insulin lispro), inject 10 units subcutaneously before meals for diabetes mellitus. Observation on 01/21/26 at 4:15 P.M., showed the following: -LPN G prepared supplies and verified the physician's order;-The nurse turned the insulin pen dial to 10 units;-He/She wiped the resident's left upper arm and administered the insulin;-He/She did not hold the needle in the skin for any length of time after pushing the plunger; -The nurse did not prime the pen;-The nurse did not hold the insulin pen in the skin for at least five seconds. 3. Review of Resident #4's face sheet, showed the following: -admitted on [DATE];-Diagnoses included: stroke, type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), chronic kidney disease stage 3 (CKD, mild to moderate kidney damage). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses that included diabetes mellitus (high blood glucose);-Medications received the last seven days included insulin. Review of the resident's care plan, reviewed 12/17/25, showed the following:-Resident had diabetes mellitus;-Staff should administer diabetes medications as ordered by the physician;-Staff should monitor and document side effects and effectiveness;-Staff should obtain fasting blood sugar as ordered by the physician. Review of the resident's physician's orders showed an order dated 10/14/25, insulin lispro subcutaneous solution pen injector 100 unit/ml (insulin lispro), inject 8 units subcutaneously in the evening for diabetes mellitus. Observation on 01/21/26 at 4:40 P.M., showed the following:-LPN G obtained the resident's insulin lispro pen from the medication cart; -He/She then turned the insulin pen dial to 8 units; -LPN G administered the insulin to the resident's left lower abdomen; -LPN G did not hold the pen in the skin for any length of time;-He/She did not prime the pen. 4. During an interview on 01/22/26 at 11:35 A.M., LPN E said when administering insulin using insulin pens, he/she first double checked the order. He/She turned the pen dial to the ordered units and administered it to the resident. Generally, he/she only primed the pens when first opened. LPN E does not prime every time because he/she could see if there was air in the pen. All of the insulin would be administered because there wouldn't be air in the pen. During an interview on 01/22/26 at 12:10 P.M., Registered Nurse A said when administering insulin with an insulin pen he/she turned the dial to two units to prime every time to get insulin into the needle. If the pen was not primed it was possible the correct dose would not be given. After pushing the plunger all the way down staff should hold the pen in the skin for about six seconds. During an interview on 01/22/26 at 1:25 P.M., LPN B said when he/she administered insulin with an insulin pen he/she first checks the orders for correct dose. Then he/she primed the pen with two units and then turned the dial to the ordered dose. The pen should be held for several seconds after administration to ensure the full dose was administered. Insulin pens were primed with every use to ensure no air in the needle and administration of the correct dose. 5. During an interview on 01/22/26 at 1:45 P.M., the Assistant Director of Nursing said nursing staff should prime the insulin pens to take air out of the needle. This should be done every time, not just with new pens. If the pen was not primed the resident might not get the whole dose of insulin. 6. During an interview on 01/22/26 at 2:00 P.M., the Director of Nursing said staff should turn the dial to one or two units to prime the needle, and should be done every time. Once primed staff should turn to the ordered dose and administer. After the plunger was pushed in, staff should hold at least three seconds. If the pen was not primed and the plunger not held, the resident may not get the full dose. 7. During an interview on 01/23/26 at 1:15 P.M., the Administrator said staff should follow physician orders and manufacturer instructions for insulin pens. Staff should have primed the pens every time.

Based on interview and record review, the facility failed to ensure each resident or resident's representative received written notice of transfer and/or discharge when the facility failed to have a process in place to routinely provide transfer letters and notice of bed hold for three sampled residents (Resident #57, #25, #7) transferred to the hospital. The facility census was 57. Review of the facility policy, dated March 2025, titled Transfer or Discharge Notices, showed the following:-Residents or resident representatives are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand;-When a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the resident's return is generally expected;-Notice of transfer is provided to the resident and representative as soon as practicable before the transfer;-Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer;-Notices are provided in a form and manner the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments;-Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge;-The resident and representative are notified in writing of the following information:-The specific reason for the transfer or discharge, including:-The effective date of the transfer or discharge;-The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ;-An explanation of the resident's rights to appeal the transfer or discharge to the state, including:-The name, address, email, and telephone number of the entity which receives such appeal hearing requests;-Information about how to obtain an appeal form; and-How to get assistance in completing and submitting the appeal hearing request;-The name, address, and telephone number of the Office of the State Long-term Care Ombudsman (statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected);-The Notice of Facility Bed-Hold and policies;-The name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); and-The name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies). Review of the facility policy, dated October 2022, titled Bed-Holds and Returns, showed the following:-Residents and/or representatives are informed in writing of the facility and state bed-hold policies;-All residents and/or representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absences, hospitalization or therapeutic leave; -Residents, regardless of payer source, are provided written notice about these policies at least twice: notice 1 - well in advance of any transfer, such as admission packet, notice 2 - at the time of transfer if the transfer was an emergency within 24 hours;-Multiple attempts to provide the representative with notice 2 should be documented in cases where staff were unable to reach and notify the representative timely. 1. Review of Resident #57's face sheet showed the following: -admitted on [DATE];-Diagnoses included chronic obstructive pulmonary disease (COPD - common lung disease causing restricted airflow and breathing problems) with acute exacerbation (rapid onset of worsening disease), and encephalopathy (group of conditions that cause brain dysfunction). Review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff) list in the medical record showed the following:-admitted on [DATE];-discharged with return anticipated on 11/15/25. Review of the resident's nurse progress notes showed staff documented the following:-On 11/15/25 at 8:15 A.M., during breakfast time the Certified Nursing Aide (CNA) alerted the nurse to come and check out the resident as he/she was weak. The resident was on the toilet slumped over and slow to respond but was able to respond and come to. His/her vitals were blood pressure (BP) of 105/72 (normal 120/80), pulse 89 (normal 60 to 100), he/she was able to be reoriented and was alert and oriented times three. The charge nurse came to evaluate the resident as well, and the resident said he/she was ok. At 9:15 A.M., the resident was weak again and assessed; he/she was shaking and very drowsy. He/she was alert and oriented times two but was able to be reoriented to time, but at first he/she said it was 1965. The resident's vital signs were BP 160/85 and pulse 75, oxygen saturation was 93% on 1.5 Liters of oxygen. The charge nurse and physician were alerted, but the resident refused to go to the hospital. He/she stated I'm fine; -On 11/16/25, at 12:36 P.M., the resident was admitted to the hospital. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 11/15/25. 2. Review of Resident #25's face sheet showed the following: -admitted on [DATE];-Diagnoses included acute and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (insufficient oxygen at the tissue level), COPD, and hypokalemia (low potassium level in bloodstream). Review of the resident's nurse progress notes showed staff documented the following:-On 11/8/25 at 2:43 P.M., the resident had been de-satting (oxygen levels are dropping) that day, dropping down to low 80's (normal 90 to 100%) while on oxygen, at rest. Confusion observed and resident at times not making sense with sentences. Family here to visit and states they are worried resident may have pneumonia (infection in lungs) due to symptoms. Lungs are diminished throughout with crackles heard to upper lobes. Physician notified and agreed the resident should be assessed at the emergency room. Emergency Medical Services (EMS) arrived at 2:35 P.M. and departed at 2:40 P.M. The Administrator and DON were notified and made aware;-On 11/8/25 at 6:43 P.M., staff received a call from the resident's family that the resident was being admitted to the hospital for pneumonia;-On 11/11/25, at 12:21 P.M., the resident readmitted from hospitalization for pneumonia; acute on chronic respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide in bloodstream). Resident is alert and oriented times three. Review of the resident's MDS list in the medical record showed the following:-admitted on [DATE];-discharged with return anticipated on 11/8/25;-re-admission on [DATE]. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 11/08/25. 3. Review of Resident #7's face sheet showed the following: -admitted on [DATE];-Diagnoses included COPD, pneumonia, severe sepsis (infection causing organ damage) with septic shock (critical condition brought on by the sudden drop in blood flow through the body), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, resulting from disease of the brain). Review of the resident's MDS list in the medical record showed the following:-admitted on [DATE];-discharged with return anticipated on 12/31/25;-re-admitted on [DATE]. Review of the resident's nurse progress notes showed staff documented the following:-On 12/31/25 at 1:23 P.M., the resident complained of not feeling well, resident shaking and light-headed, resident BP 196/100; pulse was 113 but was not stable, oxygen saturation 87% on 3 liters of oxygen via nasal canula. Staff contacted the physician who suggested staff send the resident to the emergency room, the resident agreed and family was notified;-On 01/07/26, at 11:30 A.M., the resident arrived back to facility at 10:55 A.M. via facility transport with a manual wheelchair and oxygen at 2 liters via nasal cannula. The resident had a peripherally inserted central catheter line (PICC - thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart, used when intravenous (IV) treatment is required over a long period) to right upper arm and will receive IV antibiotics (medicine to fight bacterial infection). Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or the resident's representative pertaining to a hospital transfer on 12/31/25. 4. During an interview on 01/22/26 at 12:00 P.M., the Social Service Director said when a resident was sent to the hospital, the nursing staff sends a bed hold with the resident or calls the family. He/she did not mail any information to the family regarding the transfer. He/she talked about the transfer with family by phone call. He/she sent the Ombudsman a monthly list of resident transfers and discharges. He/she had copies of the notices to Ombudsman that showed Resident #57's hospital transfer on 11/15/25, Resident #25's transfer on 11/08/25, and Resident #7's transfer on 12/31/25. During an interview on 01/22/26 at 12:10 P.M., RN A said when sending a resident to the hospital, the nursing staff should send a copy of the resident's face sheet, medication list, and copy of their code status. The nurse should call the doctor and the family. The nurse keeps a copy of the bed hold at the facility and sends a copy with the resident. He/she was not aware of any information or hospital transfer letter to the resident or family. During an interview on 01/22/26 at 12:30 P.M., the MDS Coordinator said he/she did not send any hospital discharge or transfer letter to residents or families. He/she said Social Services sends any letters. During an interview on 01/22/26 at 1:25 P.M., LPN B said when a resident was sent to the hospital, he/she sends a copy of the face sheet, the medication list, code status, and labs if applicable. He/she would talk to the family and tell them of bed hold by phone. He/she was not aware of any written information provided to the resident or family regarding the transfer. During an interview on 01/22/26 at 1:45 P.M., the ADON said with a hospital transfer, staff are to send a copy of the resident's face sheet, orders, vital signs, and code status. Staff are to call the resident's family regarding the transfer and discuss bed hold information by phone. He/She was not aware of any letter sent to family. During an interview on 01/22/26 at 2:00 P.M., the DON said when a resident was sent to the hospital, the nursing staff should notify the responsible party or family of the resident transfer. She was just told that the bed hold and transfer notification should be sent by mail to the family. She was not aware of sending a written notification of transfer. During an interview on 01/23/26 at 12:15 P.M., Administrator said when a resident was sent to the hospital, the nursing staff should complete the bed hold form, give it to the resident, and should notify the responsible party by telephone. She was not aware of the requirement for a written notice of transfer to the hospital.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #3 and #5) who remained in the facility. The facility census was 57.Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following information:-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters.-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have.-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. 1. Record review of Resident #3's Skilled Nursing Facility Beneficiary Protection Notification Review, completed by staff on 01/22/26, showed the following information:-Med A Skilled Services start date was 12/22/25;-Last covered date was 01/20/26;-The facility/provider initiated the discharge from Medicare Part A Services when the benefit days were not exhausted;-A SNFABN - form CMS-10055 was not provided, and the social service designee (SSD) hand wrote on the form, unaware an ABN was needed as well;-A Notice of Medicare Non-Coverage (NOMNC - form CMS-10123) was provided 01/19/26 by phone to a family representative with a verbal acknowledgement;-Facility staff did not provide the resident or his/her legal representative the SNFABN - form CMS-10055 or alternative denial letter;-The resident remained in the facility after Medicare Part A services ended. 2. Record review of Resident #5's Skilled Nursing Facility Beneficiary Protection Notification Review completed by staff on 01/22/26, showed the following information:-Med A Skilled Services start date was 10/31/25;-Last covered date was 12/11/25;-The facility/provider initiated the discharge from Medicare Part A Services when the benefit days were not exhausted;-A SNFABN - form CMS-10055 was not provided, and the SSD hand wrote on the form, unaware an ABN was needed as well;-A NOMNC - form CMS-10123 was provided 12/08/25 by phone to family member with a verbal acknowledgement;-Facility staff did not provide the resident or his/her legal representative the SNFABN - form CMS-10055 or alternative denial letter. -The resident remained in the facility after Medicare Part A services ended. During an interview on 01/22/26 at 4:50 P.M., the SSD said she has worked for the facility since October 2024. She did not know until today that she should have completed a SNFABN - form CMS-10055 for residents who had therapy. During an interview on 01/23/26 at 12:06 P.M., the administrator said the SSD was responsible for providing residents or legal representatives with the SNFABN - form CMS-10055 or alternative denial letter and NOMNC form. The administrator said she and the SSD did not know the requirement for providing the SNFABN - form CMS-10055 or alternative denial letter for residents remaining in the facility.

Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO, microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during personal cares for a resident who had a catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) and failed to complete proper hand hygiene during personal cares for one resident (Resident #9). The census was 57.Review of the facility provided policy titled Enhanced Barrier Precautions, dated March 2024, showed the following:-Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care;-All staff receive training on EBP upon hire and annually and are expected to comply with all designated precautions;-EBP will be initiated for residents with wounds, indwelling or implanted medical devices (urinary catheters);-High contact resident activities include dressing, bathing, transferring, providing hygiene, changing liens, changing briefs or assisting with toileting. Review of the facility provided policy titled Nursing Services Policy and Procedure Manual for Long Term Care Infection Prevention and Control, dated March 2025, showed the following:-Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases;-Hand hygiene refers to washing hands with soap (anti-microbial or non anti-microbial) or the use of alcohol-based hand rub (ABHR);-Hand hygiene is performed before and after contact with a resident, before preforming an aseptic (clean) task, before moving from work on a soiled body site to a clean body site on the same resident, after contact with the resident's room, and after removing gloves. Review of resident #9's face sheet (brief information sheet about the resident), showed the following: -admission date of 3/1/22;-Diagnosis of chronic kidney disease (gradual loss of kidney function), Alzheimer's disease, atherosclerotic heart disease (caused by buildup of plaque in the artery walls). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 10/21/25, showed the following: -Severely impaired cognitive skills;-Rarely is able to make self understood;-Dependent on staff for all care. Review of the resident's care plan dated 7/28/25, showed the resident was at risk for infection due to his/her catheter and staff should use enhanced barrier precautions.Review of the resident's physician orders dated 1/22/26, showed the resident had a current order for enhanced barrier precautions due to catheter. Observation of resident care on 1/22/26, at 10:35 A.M., showed the following:-Certified Nurse Aid (CNA) C and CNA D donned gloves (they were not observed washing hands but stated they did) and entered the resident's room, they did not don gowns;-CNA C closed the door while CNA D pulled the curtain to provide privacy for the resident;-CNA C removed the covers from the resident and both CNAs removed the resident's pants and incontinence brief;-The CNAs did not provide catheter care at that time. They assisted the resident to roll to his/her side and placed and new brief and Hoyer lift (mechanical lift) pad under the resident;-CNA C and D then fastened the new brief and pulled up the resident's pants;-CNA D grabbed the resident's catheter bag and placed it in the resident's lap while CNA C began fastening the Hoyer lift pad to the lift;-The resident was lifted over the bed and then placed in his/her wheelchair. The Hoyer lift straps where removed;-CNA D then picked up and placed the catheter bag in the dignity bag attached to the wheel chair;-CNA D picked up the resident's hairbrush and began brushing the resident's hair while CNA C gathered trash and made the resident's bed;-CNA D left the room with the resident and was not observed removing his/her gloves or washing his/her hands; -CNA C removed his/her gloves and washed his/her hands. During an interview on 1/22/26 at 10:45 A.M., CNA C said the following:-He/She was not sure what EBP stands for but he/she knew it meant to wear gowns and gloves;-He/She forgot to wear a gown while caring for the resident;-Hand washing should occur before and after touching a resident and every time gloves were changed. During an interview on 1/22/26 at 10:55 A.M., CNA D said the following:-EBP meant he/she needed to wear a gown and gloves while caring for the resident;-Residents with catheters and wounds were on EBP;-He/She forgot to wear a gown while caring for the resident;-He/she washed his/her hands before and after contact with a resident and when entering and exiting a room;-He/she washed his/her hands after taking the to the dining room because they were running late for lunch. During an interview on 1/22/26 at 11:35 A.M., Registered Nurse (RN) A said the following:-EBP was important for infection prevention in residents with indwelling devices and wounds;-Staff should wear a gown and gloves while caring for residents on EBP;-Staff should wash hands before and after any contact with a resident;-Staff should wash hands and change gloves after touching a catheter bag. During an interview on 1/22/26 at 11:55 A.M., Licensed Practical Nurse (LPN) E said the following:-EBP was for resident's with catheters and used along with contact precautions;-The Assistant Director of Nursing (ADON) was in charge of the infection control program, and did staff education on infection control; -Staff should follow EBP;-Staff should wash their hands before and after contact with a resident and during care when going from a dirty to clean area. During an interview on 1/22/26 at 1:27 P.M., the ADON said the following:-EBP was important for infection control and prevention;-He/She expected all staff to wear a gown and gloves while caring for residents on EBP;-Residents on EBP had signs on their doors that instructed staff to wear gowns;-He/She expected all staff to wash hands before and after contact with residents and when going from clean to dirty areas on a resident. Durin an interview on 1/22/26 at 2:05 P.M., the Director of Nursing (DON) said the following:-EBP was for any resident with indwelling devices such as a catheter;-EBP was important to protect compromised residents and prevent infection;-EBP included gowns and gloves;-He/She expected staff to change gloves and hand wash before and after resident contact and when going from clean to dirty while working with a resident. During an interview on 1/23/26 at 12:07 P.M., the Administrator said the following:-He/She expected staff to follow all EBP precautions;-He/She expected staff to wash their hands while caring for residents. -

Based on interview and record review, the facility failed to provide sufficient medical documentation to support a new mental health diagnosis of schizophrenia for one resident (Resident #4). The facility census was 57. Review of the facility policy titled Psychotropic Medication Use, dated February 2025, showed the following: -Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or representative and includes determining adequate indication for use, establishing appropriate dose, adequate monitoring of efficacy and adverse consequences, and determining appropriateness of gradual dose reductions;-When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's physical, behavioral, mental, and psychosocial status, comorbid conditions, expressions or indications of distress, changes in functional status, resident complaints, behaviors and symptoms and the state PASARR (preadmission screening and resident review) evaluation;-Circumstances that warrant an evaluation of the resident's underlying medical condition and medication use include admission or readmission, new or worsening change in condition, or an irregularity identified during the drug regimen review;-A diagnosis alone does not necessarily warrant the use of psychotropic medication; if psychiatric diagnosis is part of the rationale for the use of psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis based on the current diagnostic and statistical manual of mental disorders. Review of Resident #4's face sheet (brief information sheet about the resident), showed the following: -admit date of 6/1/23;-admission diagnosis of cerebral infarction due to unspecified occlusion (a critical condition where reduced blood flow causes tissue death in the brain);-Diagnosis of bipolar disorder (chronic mental health condition characterized by extreme mood swings alternating between high energy manic and deeply depressive states);-Diagnosis of schizophrenia (a chronic severe mental health condition causing a disconnect with reality through hallucinations, delusions, and disordered thinking), added on 10/30/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 12/05/25, showed the following:-Cognitively impaired;-Utilizes wheelchair for mobility;-Incontinent of bowel and bladder. Review of the resident's care plan, dated 12/17/25, showed the following: -Requires a level two PASRR that is updated as needed;-Uses psychotropic medication, antianxiety, and anti-depressant medication; -Has periods of verbally aggressive behavior. Review of the resident's physician progress note, dated 9/7/25, showed no psychiatric evaluation or documentation to support a new diagnosis of schizophrenia.Review of the resident' physician progress note, dated 10/5/25, showed no psychiatric evaluation or documentation to support a new diagnosis of schizophrenia.Review of the resident's nurse's notes documentation, from 9/21/25 to 10/21/25, showed no documentation by nursing staff of symptoms to support schizophrenia diagnosis. Review of a pharmacy recommendation fax to the physician, dated 10/30/25, showed the following: -The facility requested the physician choose a diagnosis of Huntington's disease (an inherited disorder that causes the progressive breakdown of nerve cells in the brain), schizophrenia, or Turret's syndrome (a nervous system disorder characterized by involuntary, repetitive movements and sounds known as tics) as the indication for resident use of Seroquel (an antipsychotic medication); -The facility indicated the resident is currently on Seroquel but for another diagnosis and would like the physician to use a preferred diagnosis or change the medication order;-The physician response section indicated the physician chose a diagnosis of schizophrenia; the section was not signed. Review of the resident's physician progress note, dated 11/2/25, showed no psychiatric evaluation or documentation to support a new diagnosis of schizophrenia. Review of the resident's nurse's notes documentation, from 10/21/25 to 11/21/25, showed no documentation of symptoms to support a schizophrenia diagnosis and no documentation of the added diagnosis of schizophrenia. Review of the resident's current active physician orders summary showed an order for Quetiapine Fumarate Oral Tablet 50 MG (Seroquel), give one tablet by mouth at bedtime related to schizophrenia. During an interview on 1/22/2025 at 11:35 A.M., Registered Nurse (RN) A said the following:-Nursing staff document on resident symptoms and behaviors in the nurses notes every shift;-Any change in behavior or symptoms are reported to the Director of nursing (DON) or Assistant director of nursing (ADON);-The MDS coordinator handles all PASRR issues. During an interview on 1/22/2025 at 11:55 A.M., Licensed Practical Nurse (LPN) E said the following:-Nursing staff chart in the nurses' notes behaviors, symptoms, and changes in condition for every resident, every shift;-PASRR level one and level two for mental health disorders is monitored by the MDS coordinator. During an interview on 1/22/2025 at 1:27 P.M., the ADON said PASRR level one and level two recommendations and mental health diagnosis is handled by the MDS coordinator. During an interview on 1/22/2025 at 1:35 P.M., the MDS coordinator said the following:-He/she ensures a PASRR screen is completed on all residents admitted to the facility;-He/she reviews all diagnoses that would trigger a level two assessment for a resident;-He/she does not know if a new diagnosis for schizophrenia would trigger a review of a previous level two assessment on its own, but it could;-The physician can add new diagnoses based on pharmacy recommendations;-He/she believes Resident #4's diagnosis of schizophrenia was based on a pharmacy recommendation;-He/she would contact the central office medical review unit (COMRU) if a significant change had happened with a resident that triggers a level two screening. During an interview on 1/22/2026 at 3:40 P.M., the resident's physician said the following:-He/she is very familiar with the resident and has been treating the resident for over two years;-Seroquel is necessary for the management of the resident's mood and behavior and he/she does not want any changes made to the resident's current medication as it is clinically contraindicated;-He/she did not recall the added diagnosis of schizophrenia by the facility but would not argue with it as the resident has many schizophrenia-like symptoms. During an interview on 1/22/26 at 2:05 P.M., and on 1/23/26 at 11:54 P.M., the DON said the following:-The facility does not have an in-house psychiatrist team, but they do utilize outpatient services when needed;-All residents with concerns related to psychiatric medication are discussed by the interdisciplinary team;-Resident #4 has schizophrenic tendencies; -Behaviors and symptoms are charted in the nurses' notes; charting is done by exception;-He/she reviews pharmacy recommendations and gives those to the physician for approval; -Documentation of a new mental health diagnosis should include a rationale, physician notification, and documentation of behaviors and symptoms. During an interview on 1/23/2026 at 11:54 A.M., the Administrator said he/she expects staff to document on residents with a new mental health diagnosis.

Based on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission for one resident (Residents #60). The facility census was 57. Review of the facility's policy titled Baseline Care Plans, dated March 2022, showed the following:-A baseline plan of care (gives initial instructions on necessary care until a comprehensive care plan (extremely detailed note that provides information on a patient's past medical history AND current medical history) is established) to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission;-The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:-Initial goals based on admission orders and discussion with the resident and representative;-Physician orders;-Dietary orders;-Therapy services;-Social services;The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan;-The baseline care plan is updated to meet the resident's needs until the comprehensive care plan is developed;-The resident and/or representative are provided with a written summary of the baseline care plan that includes, but is not limited to the following:-The stated goals and objectives of the resident's;-A summary of the resident's medications and dietary instructions;-Any service and treatments to be administered by the facility and personnel acting on behalf of the facility;-Any updated information based on the details of the comprehensive care plan as necessary. Review of Resident #60's face sheet (brief information sheet about the resident) showed the following:-admission date of 01/15/26;-Diagnoses included end stage renal disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids) and dependence on renal dialysis. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/15/26, showed the resident admitted to facility. Review of the resident's baseline care plan, dated 01/19/26, showed the following:-Not completed until 4 days after admission;-Resident on dialysis Monday, Wednesday, and Friday;-Resident can communicate easily with staff;-Resident required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, and transfers;-Resident required partial to moderate assistance with showering;-Resident used a walker;-Resident was cognitively intact. Review of the resident's 48-hour care plan, used in conjunction with the Initial Care Plan and completed within 48 hours of admission, dated 01/20/26, showed the following:-Admitting diagnosis of renal disease;-Participation in treatment for long term care placement;-Dated five days after admission. Review of resident's comprehensive care plan, dated 01/20/26, showed the following:-Resident needs hemodialysis (life-saving medical procedure that filters waste products, toxins, and excess fluids from the blood using an external machine) related to renal failure every Monday, Wednesday and Friday;-Resident will have no signs or symptoms of complications from dialysis through the review date;-Staff should not draw blood or take blood pressure in arm with graft;-Staff should encourage resident to go for the scheduled dialysis appointments;-Staff should monitor labs and report to doctor as needed;-Staff should monitor, document, and report as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of the resident's medical record in the nursing progress notes showed staff documented the following:-On 01/15/26 at 2:10 P.M., admission summary: Resident arrived by private car and ambulated to room on own. Resident up per self with no assistance, shuffled gait. Resident legally blind, full code. Resident attends dialysis clinic on Monday, Wednesday, and Friday at 5:15 A.M. Resident is on a regular diet and no complaints of pain. No swelling in extremities. Lung sounds clear, bowel sounds active. No concerns voiced or observed at this time. Resident pleasant during assessment. Resident takes medications whole. The resident would like to adhere to a renal diet even though we do not offer special diets;-Dialysis communication forms dated 01/16/26 and 01/19/26 were scanned into the medical record. Review of the resident's Physician Order Sheet (POS), current as of 01/20/26, showed staff did not document an order for dialysis and staff did not have an order regarding assessment of the resident's dialysis site. During an interview on 01/22/26 at 11:50 A.M., the Social Service Director said nursing staff and the MDS Coordinator were responsible for the baseline care plans. During an interview on 01/22/26 at 12:10 P.M., Registered Nurse (RN) A said when a resident was admitted the baseline care plan should be completed within 24 to 48 hours of admission. He/she would not expect the care plan to be started four or five days after admission. He/she said normally, the MDS Coordinator completed the care plans, but the nursing staff can add to the care plans as necessary. During an interview on 01/22/26 at 12:30 P.M., the MDS Coordinator said usually the nursing staff started the baseline care plan for new admissions. The baseline care plan should be done within 48 hours of admission. During an interview on 01/22/26 at 1:25 P.M., Licensed Practical Nurse (LPN) B said baseline care plans should be done right away with the initial resident admission. The baseline care plan should not be started four days after admission. During an interview on 01/22/26 at 1:45 P.M., the Assistant Director of Nurses (ADON) said baseline care plans should be started within 24 hours of admission. It should not be four days before the care plan is started. During an interview on 01/22/26 at 2:00 P.M., the Director of Nurses (DON) said baseline care plans should be done within 24 to 48 hours of resident admission. The baseline care plan should not be started four days after admission. During an interview on 01/23/26 at 12:15 P.M., the Administrator said baseline care plans should done within 24 hours of admission. She would not expect the care plan to be started four days after admission.

Based on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to obtain an order for dialysis and routine assessment and monitoring of the dialysis site for one resident who received dialysis (Resident #60). The facility census was 57. The facility did not provide a policy related to dialysis. Review of the facility's undated form titled Dialysis Communication Record, showed the following:-Vital Signs: blood pressure, pulse, respiration, temperature, weight;-Vital signs completed prior to dialysis as ordered by physician, Yes or No;-Shunt site (a surgically created connection between an artery and a vein);-Nurse Signature;-Time left for dialysis. Review of Resident #60's face sheet (brief information sheet about the resident) showed the following:-admission date: 01/15/26;-Diagnoses included end stage renal disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 01/15/26, showed the resident admitted to facility. Review of the resident's medical record, showed the following:-On 01/15/26, at 2:10 P.M., progress note admission summary: Resident arrived by private car and ambulated to room on own. Resident up per self with no assistance, shuffle gait. Resident legally blind, full code. Attended Dialysis Clinic on Monday, Wednesday, and Friday at 5:15 A.M. Resident on regular diet, no complaints of pain. No swelling in extremities. Lung sounds clear, bowel sounds active. No concerns voiced or observed at this time. Resident pleasant during assessment. Resident takes medication whole. The resident would like to adhere to renal diet even though we do not offer special diets;-Dialysis communication forms dated 01/16/26 and 01/19/26 were scanned into the medical record. Review of the resident's baseline care plan, dated 01/19/26, showed the following:-Resident on dialysis Monday, Wednesday, Friday;-Resident can communicate easily with staff;-Resident required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, transfers;-Resident required partial to moderate assistance with showering;-Resident used a walker;-Resident was cognitively intact. Review of the resident's 48-hour care plan, used in conjunction with the Initial Care Plan and completed within 48 hours of admission, dated 01/20/26, showed the following:-Admitting diagnosis of renal disease;-Participation in treatment for long term care placement. Review of resident's comprehensive care plan, dated 01/20/26, showed the following:-Resident needed hemodialysis (dialysis) related to renal failure every Monday, Wednesday and Friday;-Resident will have no signs or symptoms of complications from hemodialysis through the review date;-Staff should not draw blood or take blood pressure in arm with graft (shunt site);-Staff should encourage resident to go for the scheduled dialysis appointments;-Staff should monitor labs and report to doctor as needed;-Staff should monitor, document, report as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds;-No information in care plan related to time of dialysis or which arm was affected. Review of the resident's physician order sheet, current as of 01/20/26, showed staff did not document an order for dialysis and did not have an order regarding assessment of the resident's dialysis site. Observation and interview on 01/19/26 at 3:30 P.M., showed the resident was in his/her room. The resident said he/she left the facility at about 5:00 A.M. for dialysis and did not receive breakfast until after returning from dialysis. During an interview on 01/22/26 at 9:18 A.M., the Regional Nurse Consultant said there was not a specific policy related to dialysis. During an interview on 01/22/26 at 12:10 P.M., Registered Nurse A said any resident that was on dialysis should have an order for when and where the resident went for dialysis. The resident had a new order for checking the bruit (audible, rushing, or whooshing sound heard through a stethoscope over an artery ) and thrill (palpable, physical vibration felt on the skin directly over a site of severe turbulent blood flow, such as a fistula (shunt) but did not know if there was an order for when and where the resident went for dialysis. The resident went super early so staff held a breakfast tray for the resident. During an interview on 01/22/26 at 1:25 P.M., Licensed Practical Nurse (LPN) B said there should have been an order for residents that were on dialysis. They had not had a dialysis resident for a while. There was a newer resident who was now on dialysis. LPN B did not know if there was an order or information in the care plan. During an interview on 01/22/26 at 1:45 P.M., the Assistant Director of Nursing said there should have been an order for dialysis. He/She said the order should include to check the shunt site for dialysis. He/She did not know if the resident had an order for dialysis. During an interview on 01/22/26 at 2:00 P.M., the Director of Nursing said there probably should have been an order for dialysis. The facility received the dialysis information from the resident's guardian on admission. During an interview on 01/23/26, at 12:15 P.M., the Administrator said residents who received dialysis should have physician orders. The information should also be on the care plan.

Based on interviews and record review, the facility failed to keep residents free from accident hazards when staff failed to provide care with two staff as trained and care planned for one resident (Resident #1) resulting in a fall and fracture. The facility census was 43. Review of the facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include resident preferences for assistance, resident mobility (degree of dependency), resident's size, weight-bearing ability, cognitive status, whether the resident is usually cooperative with staff and the resident's goals for rehabilitation, including restoring or maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices; -Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents; -Safe lifting and movement of resident is part of an overall facility employee health and safety program which involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies, addresses reports of workplace injuries, provides training on safety, ergonomics and proper use of equipment and continually evaluates the effectiveness of workplace safety and injury-prevention strategies. 1. Review of the Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included cerebral infarction (stroke), obstructive sleep apnea, congestive heart failure (CHF - a long-term condition where the heart can't pump blood well enough to give the body a normal supply), high blood pressure, metabolic encephalopathy (group of conditions that cause brain dysfunction), and acute respiratory failure with hypoxia (low levels of oxygen in the body tissues). Review of the resident's care plan, last revised on 12/02/24, showed the following: -Resident was at risk for falls; -Staff to assist resident with ambulation and transfers, utilizing therapy recommendations; -Determine resident's ability to transfer; -Evaluate fall risk on admission and as needed; -Resident had an activities of daily living (ADL) self-care performance deficit and was totally dependent on staff for repositioning and turning in bed every two hours and as necessary; -Resident requires a mechanical lift with assistance of two staff for transfers; -Resident had altered cardiovascular status and received oxygen via nasal cannula as directed by physician; -Resident was on anticoagulant (medication that slows blood clotting) medication that therapy related to diagnosis of atrial fibrillation (irregular heart beat); -Administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 01/31/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for bed mobility, toileting, personal hygiene, transfers, showering and dressing for upper and lower body. Review of the facility's investigation summary, dated 02/17/25, showed the following: -An alert resident (Resident #1) turned on his/her call light for assistance to be cleaned up. Nurse Assistant (NA) C told the resident he/she had to go get some assistance as he/she was not supposed to provide care alone. The NA felt the resident implied he/she wanted to make him/her wait for care; -NA C retrieved the cleaning supplies and instructed the resident to turn towards him/her to provide care, and the resident turned the opposite direction, towards the wall and fell on the floor; -NA C was re-educated on providing care to the resident with the assistance of another nurse aide. NA C was given a corrective action for performing a nursing function he/she had been educated upon hire not to perform alone. Review of the resident's progress notes showed the following: -On 02/10/25, at 7:41 A.M., the nurse was called into the resident's room by the aide because the resident rolled out of bed while being changed at 12:20 A.M. The aide told the nurse the resident demanded to be changed and refused to wait for assistance for the aide. The resident lifted his/her hips and rolled toward the door after the aide had told the resident to roll toward him/her and the window. Nurse assessed resident from head to toe and found no injuries. Resident complaint of 8 out of 10 on pain scale in left arm and was unable to lift the arm. Staff contacted the physician and received orders to send the resident to the emergency room (ER) for an x-ray. Emergency medical services (EMS) was called at 12:45 A.M. The resident left the facility for the ER via ambulance at 1:02 A.M.; -On 02/10/25, at 8:17 A.M., nurse spoke with ER nurse at 2:39 A.M., confirming the resident had a fracture to the left humerus (upper arm bone) head. Resident returned to the facility at 3:07 A.M., wearing immobilizer to left arm and orders to follow up with orthopedic surgery at next available appointment. During an interview on 02/13/25, at 1:32 P.M., the resident said a staff member was changing his/her brief and got him/her too close to the edge of the bed, and he/she fell and broke his/her shoulder. There should have been two staff members assisting him/her. During an interview on 02/14/25, at 2:17 P.M., NA C said the following: -He/she was hired on 11/29/24 and had not started CNA classes; -The resident required two staff for transfers, and this information could be found on the back of the room door; -He/she was trained if a resident was a two staff assist for transfers then two staff are required for changing a brief; -He/she answered the resident's call light, and the resident wanted changed right then. He/she said assistance was required. The resident insisted for him/her to change the resident right then; -He/she began to change the resident with no assistance and the resident rolled the opposite way as directed and fell with his/her arm hitting the oxygen concentrator. During an interview on 02/18/25, at 1:46 P.M., NA D said the following: -Physical therapy developed a sheet that is on the back of the resident's doors showing if the residents are independent, one staff assist, or two staff assist; -If a resident required two staff for transfer, two staff should also be required to change the resident; -The resident required two staff for changing and for other cares; -He/she was given this information during report since the resident admitted ; -He/she has changed the resident alone a few times due to the resident's impatience. During an interview on 02/20/25, at 2:52 P.M., NA E said the following: -Residents have papers on the back of their doors indicating if they require one person or two person assist, and this information is also listed in the care plan book at the nurses' station; -If a resident required two staff for transfer, then two staff should also be required to change the resident; -The resident required two staff to assist with a mechanical lift and two staff to assist with changing; -He/she had changed the resident alone once or twice because the resident did not have the patience to wait for him/her to get assistance; -Staff should not change the resident without assistance because it was not safe. During an interview on 02/14/25, at 1:28 P.M., Certified Nurse Assistant (CNA) A said the following: -The resident required a mechanical transfer with two staff assisting; -The resident required two staff to change his/her brief and staff should not change him/her with only one staff; -Staff have walkies to call for assistance. During an interview on 02/14/25, at 1:54 P.M., CNA B said the following: -The resident was a two person assist for changing because he/she was unable to physically roll him/her without assistance; -The staff member assisting the resident with changing during the fall should have waited for help. During an interview on 02/21/25, at 10:52 A.M., Certified Medication Technician (CMT) F said the following: -The resident was a two staff assist with all cares, and he/she would not change the resident without assistance; -NA's should not change the resident without assistance, it is a safety concern. During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (D) said the following: -The resident required two staff for transfers and changing briefs, which was a nursing judgement prior to the fall based on his/her size and lack of mobility; -Aides are educated about resident requirements for transfers and changing. There are signs on the back of the resident's rooms, and if mechanical lift is checked staff should know two staff are required for changing and transferring; -NA's should not be changing the resident alone. During an interview on 02/21/25, at 11:53 A.M., Physical Therapist (PT) G said the following: -He/she assessed the resident upon admission, and the resident was totally dependent on staff, required mechanical transfers, and was wheelchair bound; -Therapy completed transfer sheets on all residents to assist staff with providing the appropriate care; -Two staff members should change the resident's brief for safety reasons. During an interview on 02/20/25, at 3:52 P.M., the resident's physician said the following: -The resident would not be a one staff assist due to his/her size and not always following directions; -It would not be safe to transfer the resident, or roll the resident in bed with one staff assist. During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing said the resident required a mechanical lift with assistance of two staff. During an interview on 02/21/25, at 4:10 P.M., the Regional Nurse Consultant said if a resident required two staff assist for cares, two staff should complete brief changing. During an interview on 02/21/25, at 4:47 P.M., the Administrator said the following: -Staff know how to transfer residents from the care plan and the transfer sheets on the door completed by therapy; -Mechanical lift and sit to stand requires two staff for assistance; -Staff are encouraged to provide care in pairs with the resident because he/she yells and was demanding; -The NA should have waited for assistance before changing the resident's brief due to his/her behaviors and for safety. MO00249332

Based on observation, interview, and record review, the facility failed to have a system in place to ensure nurses aides (NA) completed their training, competencies, and testing in a timely manner when two NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification within four months of hire and continued to work providing care to residents. The facility census was 43. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Nurse aides must undergo a state-approved training program; -A nurse aide is any individual providing nursing or nursing-related services to residents in a facility; -In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), the facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; -The facility will not employee any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related service and has completed a training program and competency evaluation program or a competency evaluation program approved by the state or has been deemed competent as provided in 483.150 (a) and (b) of the requirements of participation; -Nursing assistants failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of a facility list of current nurse aides showed NA D had a hire date of 08/05/24 (over four months prior). During an interview on 02/18/25, at 1:46 P.M., NA D said the following: -He/she was hired in August of 2024; -He/she began CNA classes toward the end of October of 2024 and completed the classes at the end of January 2025; -He/she was scheduled to take the CNA test on 03/03/25. Review of the state agency CNA registry website, on 02/26/25, showed NA D was not listed as a CNA. 2. Review of a facility list of current nurse aides showed NA E had a hire date of 08/13/24 (over four months prior). During an interview on 02/20/25, at 2:53 P.M., NA E said the following: -He/she was hired in August of last year; -He/she began taking CNA classes in October of 2024, and completed the classes 01/25/25; -He/she was scheduled to take the CNA test on 03/03/25; -He/she has worked the floor since hire and was paired with a CNA for about five days. Observations on 02/13/25, and 02/21/25, showed NA E provided direct care to residents. Review of the state agency CNA registry website, on 02/26/25, showed NA D was not listed as a CNA. 3. During an interview on 02/21/25, at 4:10 P.M., the CNA Instructor said NAs should be certified within 120 days of employment. Four NA's finished classes at the end of January 2025 and will test at beginning of March 2025. During an interview on 02/21/25, at 4:47 P.M., the Administrator said NAs should begin CNA classes within four months of their hire date. MO00249332

Based on interviews and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure documentation of oxygen administration/checks every shift per physician orders for one resident (Resident #1). The facility census was 43. Review of the facility policy titled, Oxygen Administration, revised October 2010, showed the following: -Purpose was to provide guidelines for safe oxygen administration; -Verify there is a physician's order for the procedure. Review physician's orders or facility protocol for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; -Before administering oxygen, and while the resident is receiving therapy, assess for signs or symptoms of cyanosis (blue tone to the skin and mucous membranes), signs or symptoms of hypoxia (rapid breathing, rapid pulse rate, restlessness, and confusion), signs and symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing), vital signs, lung sounds, and arterial blood gasses and oxygen saturation. 1. Review of the Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses include cerebral infarction (stroke), obstructive sleep apnea, congestive heart failure (CHF - a long-term condition where the heart can't pump blood well enough to give the body a normal supply), and acute respiratory failure with hypoxia (low levels of oxygen in the body tissues). Review of the resident's current physician order sheet showed an order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air. Review of the resident's care plan, last revised on 12/02/24, showed the following: -Resident was at risk for ineffective breathing pattern; -Resident had altered cardiovascular status; -Staff to administer oxygen as prescribed or per standing order. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool administered by staff). dated 01/31/25, showed the resident was cognitively intact and received oxygen therapy. Review of the resident's January 2025 Treatment Administration Record (TAR) showed the following: -An order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air; -Staff failed to document administration of oxygen on the A.M. shift on 01/01/25, 01/05/25, 01/08/25, 01/11/25, 01/14/25, 01/22/25, and 01/26/25; -Staff failed to document administration of oxygen on the P.M. shift on 01/02/25. Review of the resident's nurses' notes, dated 01/01/25 to 01/31/25, showed staff did not document whey the oxygen administration check was not completed. Review of the resident's February 2025 TAR for showed the following: -An order, dated 11/04/24, for oxygen at two-three liters per nasal cannula every shift for shortness of air; -Staff failed to document administration of oxygen on the A.M. shift on 02/01/25 and 02/12/25. Review of the resident's nurses' notes, dated 02/01/25 to 02/12/25, showed staff did not document whey the oxygen administration check was not completed. During an interview on 02/13/25, at 1:32 P.M., the resident said staff have forgotten to put the oxygen nasal cannula back in his/her nose following a mechanical transfer. During an interview on 02/14/25, at 1:54 P.M., Certified Nurse Aide (CNA) B said nurses document any oxygen administration or checks in the electronic record. During an interview on 02/21/25, at 10:52 A.M., Certified Medication Tech (CMT) F said nurses complete the oxygen tasks and documentation for the TAR. During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (LPN) D said the following: -If a resident had a physician order for oxygen administration for shortness of breath every shift, the nurse should complete this task and document on the TAR; -There should not be blank spaces on the TAR where documentation; -If no check is completed, the nurse should use the applicable code reasoning for not completing such as the code for the resident not in the facility. During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following: -Nurses complete the tasks and documentation on the TAR; -There should be no blank spaces on the TAR for oxygen checks as this would mean the task was not completed. During an interview on 02/21/25, at 4:47 P.M., the Administrator said the following: -If a resident had a physician order for oxygen administration/checks every shift, staff should document checks in the TAR, and if not checked, staff should document the reason. MO00249332

Based on interview and record review, the facility failed to ensure that all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to document administering medications per physician orders for three residents (Resident #1, Resident #2, and Resident #3). The facility census was 43. Review of the policy titled, Clinical Administering Medications, revised April 2019 showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before or after meal orders) for liberal medication passes; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medications will initial and circle the 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. 1. Review of the Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cerebral infarction (stroke), obstructive sleep apnea (intermittent airflow blockage during sleep), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), rectal cancer, high blood pressure, metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen, leading to a dangerously low level of oxygen blood), and gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints). Review of the resident's care plan, last revised on 02/10/25, showed the following: -Resident was on anticoagulant (helps prevent blood clots and stroke) therapy related to diagnosis of atrial fibrillation. Staff to administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift; -Resident had diagnosis of anemia. Staff to give medications as ordered and monitor side effects, effectiveness; -Resident was at risk for complications related to use of antidepressant medication. Staff to administer antidepressant medications as ordered by physician and monitor for side effects and effectiveness every shift. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool administered by staff) dated 01/31/25, showed the following: -Cognitively intact; -Resident is totally dependent on staff for bed mobility, toileting, personal hygiene, transfers, showering and dressing for upper and lower body. Review of the resident's January 2025 and February 2025 Physician Order Sheet (POS) showed an order, dated 10/25/24, for apixaban (an anticoagulant) oral tablet 5 milligrams (mg), give one tablet by mouth two times a day for prophylaxis related to cerebral infarction. Review of the resident's January 2025 and February 2025 Medication Administration Record (MAR) showed the following: -An order dated 10/25/24, for apixaban oral tablet 5 mg, give one tablet by mouth two times a day for prophylaxis related to cerebral infarction; -Staff failed to document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25; -Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/25/24, for pantoprazole sodium tablet (used to treat acid reflux) delayed release 40 mg, give one tablet by mouth two times a day for acid reflux. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/25/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth two times a day for acid reflux; -Staff did not document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25; -Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/25/24, for ziprasidone (antipsychotic) HCI oral capsule 40 mg, give 40 mg by mouth two times a day for psychosis with meals. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/25/24, for ziprasidone HCI oral capsule 40 mg, give 40 mg by mouth two times a day for psychosis with meals; -Staff did not document administering the 5:00 P.M. dose on 01/15/25, 01/18/25, 01/19/25 and 01/22/25; -Staff did not document administering the 8:00 A.M. and 5:00 P.M. doses on 02/01/25 and the 5:00 P.M. dose on 02/02/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for allopurinol (an antigout medication) oral tablet 100 mg, give one tablet by mouth one time a day for gout. Review of the resident's February 2025 MAR showed the following: -An order dated 10/25/24, for allopurinol oral tablet 100 mg, give one tablet by mouth one time a day for gout; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 11/17/24, for cetirizine (an antihistamine) hydrochloride (HCI) tablet 10 mg, give one tablet by mouth one time a day for allergy symptoms. Review of the resident's February 2025 MAR showed the following: -An order, dated 11/17/24, for cetirizine hydrochloride (HCI) tablet 10 mg, give one tablet by mouth one time a day for allergy symptoms; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for ferrous sulfate tablet (iron) 325 mg, give one tablet by mouth one time a day for anemia. Review of the resident's February 2025 MAR showed the following: -An order, dated 10/25/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for anemia; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for glycolax powder (used to treat constipation), give 17 grams by mouth one time a day for constipation in eight ounces of fluid. Review of the resident's February 2025 MAR showed the following: -An order, dated 10/25/24, for glycolax powder, give 17 grams by mouth one time a day for constipation in eight ounces of fluid; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 11/05/24, for lidocaine (pain control medication) external patch 5%, apply to right hip topically one time a day for pain on 12 hours then off 12 hours. Review of the resident's February 2025 MAR showed the following: -An order, dated 11/05/24, for lidocaine external patch 5%, apply to right hip topically one time a day for pain on 12 hours then off 12 hours; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for metoprolol succinate (an antihypertensive medication) extended release 24-hour oral tablet 50 mg, give one tablet by mouth one time a day for hypertension. Review of the resident's February 2025 MAR showed the following: -An order, dated 10/25/24, for metoprolol succinate extended release 24-hour oral tablet 50 mg, give one tablet by mouth one time a day for hypertension; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for sertraline HCI (an antidepressant) oral tablet 100 mg, give one tablet one time a day for depression. Review of the resident's February 2025 MAR showed the following: -An order, dated 10/25/24, for sertraline HCI oral tablet 100 mg, give one tablet one time a day for depression; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's February 2025 POS showed an order, dated 10/25/24, for tamsulosin HCI (used to treat BPH (condition where the prostate gland enlarges, causing urinary problems)) oral capsule 0.4 mg, give one capsule by mouth one time a day for prophylaxis. Review of the resident's February 2025 MAR showed the following: -An order, dated 10/25/24, for tamsulosin HCI oral capsule 0.4 mg, give one capsule by mouth one time a day for prophylaxis; -Staff did not document administering the 8:00 A.M. dose on 02/01/25. Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included spondylosis with myelopathy (condition where the spinal cord is compressed due to degenerative changes in the spine), cervical disc disorder with myelopathy (condition that occurs when the spinal cord in the neck is compressed) depression, generalized anxiety disorder, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and repeated falls. Review of the resident's quarterly MDS, dated [DATE], showed resident was cognitively intact and required substantial assistance with toileting and lower body dressing. Review of the resident's care plan, last revised on 02/10/25, showed the following: -Resident was at risk for uncontrolled pain. Staff to administer analgesic medication as ordered by physician and monitor/document side effects and effectiveness every shift; -Resident used antidepressant medication. Staff to administer antidepressant medications as ordered by physician, monitor/document side effects and effectiveness every shift. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for celecoxib (an antiinflamatory) oral capsule 200 mg, give one capsule by mouth two times a day for pain. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/29/24, for celecoxib oral capsule 200 mg, give one capsule by mouth two times a day for pain; -Staff did not document administrating the 9:00 A.M. dose on 01/22/25; -Staff did not document administrating the 9:00 A.M. dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for duloxetine HCI (an antidepressant) capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/29/24, for duloxetine HCI capsule delayed release sprinkle 30 mg, give one capsule by mouth one time a day for depression; -Staff did not document administrating the morning dose on 01/22/25; -Staff did not document administrating the morning dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/29/24, for gabapentin (an anticonvulsant) oral tablet 600 mg, give one tablet by mouth three times a day for neuropathy. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/29/24, for gabapentin oral tablet 600 mg, give one tablet by mouth three times a day for neuropathy; -Staff did not document administering the morning and noon dose on 01/22/25; -Staff did not document administering the morning and noon dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 11/27/24, for lidoderm patch 5%, apply to bottom of feet topically one time a day for pain related to cervical disorder with myelopathy. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 11/27/24, for Lidoderm patch 5%, apply to bottom of feet topically one time a day for pain related to cervical disorder with myelopathy; -Staff did not document administering the morning dose on 01/22/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order,dated 10/29/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth one time a day for acid reflux. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/29/24, for pantoprazole sodium tablet delayed release 40 mg, give one tablet by mouth one time a day for acid reflux; -Staff did not document administering the morning dose on 01/22/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered. 3. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute and chronic respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen, leading to a dangerously low level of oxygen blood), acute and chronic respiratory failure with hypercapnia (a condition where the body has too much carbon dioxide in the bloodstream), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure, obstructive sleep apnea (intermittent airflow blockage during sleep), pneumonia, post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), fibromyalgia (a long-term condition that involves widespread body pain and tiredness), pulmonary embolism with acute cor pulmonale (situation where a blood clot lodges in the lung artery, causing a sudden strain on the right ventricle of the heart, leading to acute right-sided heart failure) low back pain, generalized anxiety disorder, and gastroesophageal reflux disease symptoms (GERD-acid reflux). Review of the resident's significant change MDS, dated [DATE], showed the resident was cognitively intact and independent with ADL's except required supervision for showering. Review of resident's care plan, last revised 02/14/25, showed the following: -Resident had a history of CHF. Staff to give medications as ordered; -Resident had a history of high blood pressure. Staff to give blood pressure medication as ordered and monitor for side effects; -Resident had history of GERD. Staff to give medications as ordered and monitor/document side effects and effectiveness; -Resident had a history of receiving diuretic therapy. Staff to administer diuretic medications as ordered by physician and monitor for side effects and effectiveness every shift; -Resident used anti-depressant medication. Staff to administer anti-depressant medications as ordered by physician and monitor/document side effects and effectiveness every shift; -Resident used anti-anxiety medications. Staff to administers anti-anxiety medications as ordered by physician and monitor for side effects and effectiveness every shift; -Resident was on anticoagulant therapy. Staff to administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift. Review of the resident's January 2025 and February 2025 POS showed an order, dated 11/12/24, for Zithromax (antibiotic) oral tablet 250 mg, give one tablet by mouth one time a day related to pneumonia unspecified organism. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 11/12/24, for Zithromax oral tablet 250 mg, give one tablet by mouth one time a day related to pneumonia unspecified organism; -Staff did not document administering the 8:00 A.M. dose on 01/19/25; -Staff did not document administrating the 8:00 A.M. dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for alprazolam oral tablet 0.5, give one tablet by mouth two times a day for anxiety. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for alprazolam oral tablet 0.5, give one tablet by mouth two times a day for anxiety; -Staff did not document administering the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/18/25, 01/19/25, and 01/22/25; -Staff did not document administering the 5:00 P.M. doses on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for bumetanide (diuretic) oral tablet 0.5 mg, give one tablet by mouth two times a day related to CHF. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for bumetanide oral tablet 0.5 mg, give one tablet by mouth tow times a day related to congestive heart failure; -Staff did not document administering the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/19/25, and 01/22/25; -Staff did not document administering the 5:00 P.M. dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for buspirone HCI (an antianxiety medication) oral tablet 15 mg, give one tablet by moth two times a day related to PTSD. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for buspirone HCI oral tablet 15 mg, give one tablet by moth two times a day related to post-traumatic stress disorder; -Staff did not document administrating the 5:00 P.M. doses on 01/14/25, 01/15/25, 01/19/25, 01/22/25; -Staff did not document administrating the 5:00 P.M. dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/07/24, for Eliquis (anticoagulant) oral tablet 5 mg, give one tablet by mouth two times day related to pulmonary embolism with acute cor pulmonale. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/07/24, for Eliquis oral tablet 5 mg, give one tablet by mouth two times day related to pulmonary embolism with acute cor pulmonale; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for aspirin oral capsule 81 mg, give one capsule by mouth one time a day related to peripheral vascular disease. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for aspirin oral capsule 81 mg, give one capsule by mouth one time a day related to peripheral vascular disease; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for duloxetine HCI (an antidepressant) oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day related to PTSD. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for duloxetine HCI oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day related to post-traumatic stress disorder; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 POS showed an order, dated for 10/26/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for low iron. Review of the resident's January 2025 MAR showed the following: -An order, dated 10/26/24, for ferrous sulfate tablet 325 mg, give one tablet by mouth one time a day for low iron; -Staff did not document administering the morning dose on 01/19/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 12/13/24, for metoprolol succinate extended release 24-hour tablet 50 mg, give one tablet by mouth one time a day for high blood pressure. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 12/13/24, for metoprolol succinate extended release 24-hour tablet 50 mg, give one tablet by mouth one time a day for high blood pressure; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning doses on 02/01/25 and 02/02/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for pantoprazole sodium tablet delayed released 20 mg, give one tablet by mouth one time a day related to GERD. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order, dated 10/08/24, for pantoprazole sodium tablet delayed released 20 mg, give one tablet by mouth one time a day related to GERD; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning doses on 02/01/25 and 02/02/25. Review of the resident's January 2025 and February 2025 POS showed an order, dated 10/08/24, for spironolactone (a diuretic) oral table 25 mg, give one tablet by mouth one time a day related to high blood pressure. Review of the resident's January 2025 and February 2025 MAR showed the following: -An order dated 10/08/24, for spironolactone oral table 25 mg, give one tablet by mouth one time a day related to high blood pressure; -Staff did not document administering the morning dose on 01/19/25; -Staff did not document administering the morning dose on 02/01/25. Review of the resident's January 2025 POS showed an order, dated 10/15/24, for pregabalin (an anticonvulsant) oral capsule 150 mg, give one capsule by moth two times a day related to fibromyalgia. Review of the resident's January 2025 MAR showed the following: -An order, dated 10/15/24, for pregabalin oral capsule 150 mg, give one capsule by moth two times a day related to fibromyalgia; -Staff did not document administering the 9:00 A.M. doses on 01/18/25 and 01/19/25. Review of the resident's January 2025 POS showed an order, dated 10/08/24, for tramadol HCI oral tablet 50 mg, give one tablet by mouth two times a day for pain. Review of the resident's January 2025 MAR showed the following: -An order, dated 10/08/24, for tramadol HCI oral tablet 50 mg, give one tablet by mouth two times a day for pain; -Staff did not document the pain level and administering the 5:00 P.M., dose on 01/14/25, 01/15/25, 01/18/25, 01/19/25, and 01/22/25. Review of the resident's January 2025 and February 2025 nurses' notes showed staff did not document related to the medications that were not administered as ordered. 4. During an interview on 02/21/25, at 10:52 A.M., Certified Medication Technician (CMT) F said the following: -Staff document medication administration in the MAR; -CMT's administer scheduled medications only; -Staff will either check yes in the MAR if a medication is administered or no and then the applicable code for why the medication was not administered such as resident refused or was out of the facility; -If there is a blank space on the MAR for documenting medication administration, it either means the medication was not administered or there was no documentation of any type. During an interview on 02/14/25, at 3:23 P.M., Licensed Practical Nurse (LPN) D said the following: -Staff document medication administration in the MAR; -The MAR should not contain blank spaces for scheduled medication; -Staff should check no if not administered and then enter whatever code is applicable such as out of the facility. During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following: -Staff document medication administration in the MAR; -CMTs and nurses administer medications, CMTs only administer scheduled meds and nurses administer both scheduled and as needed (PRN); -Staff should choose either yes or no in the MAR when documenting medication administration; -If the medication was not administered choosing no will then require a code for the reason such as refused or out of the facility; -A blank space on the MAR would indicate staff either did not administer the medication or did not document administration of the medication; -Management goes over MAR information during morning meetings, but a blank space would not trigger a concern. During an interview on 02/21/25, at 4:47 A.M., the Administrator said the following: -Staff administer medications according to the MAR and document the administration in the MAR; -Staff either check yes or no in the MAR and if no must give a reason with the applicable code. MO00249332

Based on interviews and record review, the facility failed to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to document administering a dietary supplement per physician's order for one resident (Resident #4). The facility census was 43. Review of the facility's policy titled, Weight Assessment and Intervention, revised March 2022, showed the following: -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in each unit's weight record chart and in the individual's medical record; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria; one month 5% weight loss is significant and greater than 5% is severe, 7.5% weight loss is significant and greater than 7.5% is severe, six-month 10% weight loss is significant and great than 10% is severe; -Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met; -The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss; -Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate; -Individualized care plans shall address, to the extent possible the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment; -Interventions for undesirable weight loss are based on resident choice and preferences, nutrition and hydration needs of resident, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing, or digestion, the use of supplementation and/or feeding tubes, and end of life decision and advance directives. 1. Review of Resident #4's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses include dementia, type III traumatic spondylolisthesis of second cervical vertebra, subsequent encounter for fracture with routine healing (severe fracture of the second cervical vertebra), high blood pressure, dysphagia (difficulty swallowing foods or liquids), and repeated falls. Review of the resident's weight record showed the resident weighed 109.8 pounds on 09/12/24, and 97.2 pounds on 10/16/24, indicating a 12.6-pound weight loss in a month. Review of the resident's nursing notes showed, dated 10/28/24, showed the Registered Dietician (RD) note the following: -RD reviewed for weight loss. On 10/28/24, resident weighed 100.4 pounds and body mass index (BMI - calculated measure of weight relative to height) was underweight status. Resident lost 10 pounds (9%) in 30 days; 10.5 pounds (9.4%) in 90 days; and 12.8 pounds (11.3%) in 180 days. -Current diet order of regular diet with supplements three times daily with meals and 30 milliliter (ml) 2 Cal (nutritional shake) three times daily with medication pass. Resident does feed self in the dining room with decreased intake at meals. -Recommended staff to add ice cream to shakes three times daily, increase 2 Cal to 60 ml (if resident accepts) and other preferences. Encourage intake of meals, shakes, and snacks. Regular diet follow as appropriate/requested. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by staff) dated 01/24/25, showed the following: -Moderate cognitive impairment; -Weight of 96 pounds; -Weight loss of 5% in the last month or 10% in the last six month and not on a physician prescribed weight loss program. Review of the resident's care plan, last reviewed on 02/14/25, showed the following: -Resident had unplanned/unexpected weight loss; -Staff to alert dietician if consumption was poor for more than 48 hours; -Staff to provide 2 Cal supplement three times daily; -Staff to provide resident supplements as ordered and alert nurse/dietician if resident not consuming on a regular basis; -Staff to provide house supplements daily; -If weight decline persists, staff to contact physician and dietician regularly; -Staff to monitor and evaluate any weight loss, determine percentage lost and follow facility protocol weight loss; -Staff to offer substitutes as requested or indicated. Resident prefers breakfast. Review of the resident's current physician order sheet showed the following: -An order, dated 07/30/24, for regular diet with regular texture, regular/thin consistency; -An order, dated 07/30/24, for house supplement with meals; -A current order for 2 Cal supplement 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -An active order for 2 Cal supplement, 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories; -Staff failed to document administering the 12:00 P.M. supplement on 01/15/25, 01/18/25, 01/19/25, and 01/22/25; -Staff failed to document administering the 5:00 P.M. supplement on 01/14/25, 01/15/25, 01/19/25, and 01/22/25. Review of the resident's January 2025 weights showed the following: -On 01/07/25, 99.6 pounds; -On 01/14/25, 99.4 pounds (a .2 pound loss); -On 01/21/25, 95.6 pounds (a 3.8 pound loss); -On 01/28/25, 98.4 pounds. Review of the resident's February 2025 MAR showed the following: -An active order for 2 Cal supplement, 30 ml each medication pass for breakfast, lunch, and dinner with meals to increase calories; -Staff failed to document administering the 8:00 A.M. supplement on 02/03/25; -Staff failed to document administering the 12:00 P.M. supplement on 02/02/25 and 02/03/25; -Staff failed to document administering the 5:00 P.M. supplement on 02/01/25, 02/02/25, and 02/03/25. Review of the resident's January 2025 weights showed the following: -On 02/05/25, 95.8 pounds; -On 02/12/25, 97 pounds; -On 02/19/25, 94.6 pounds (a one pound loss from 01/21/25); -On 02/20/25, 94.4 pounds (a .2 pound loss). During an interview on 02/21/25, at 1:22 P.M., the Dietary Manager said the following: -She completed dietary evaluations on every resident upon admission, quarterly, and upon a weight loss trigger; -The resident triggered for a weight loss and was administered a supplemental 2 Cal three times daily on medication pass and received a house shake three times a day with every meal; -The resident drank the shakes and the 2 Cal regularly; -The resident's weight has been staying stable between 93 to 97 pounds. During an interview on 02/21/25, at 1:30 P.M., Certified Medication Technician (CMT) F said the following: -The resident was given 30 ml of 2 Cal three times daily at the medication pass for weight loss; -He/she watched the resident drink the 2 Cal; -The resident only refuses if he/she was very ill, and staff should document the administration and refusals in the MAR. During the interview on 02/21/25, at 1:41 P.M., Licensed Practical Nurse (LPN) D said the following: -The resident received 2 Cal during medication pass three times per day with meals; -He/she observed the resident drink the 2 Cal; -The resident refused the 2 Cal at lunch and dinner at times; -Staff should document the administration or refusals in the MAR. During an interview on 02/21/25, at 3:02 P.M., the Director of Nursing (DON) said the following: -The resident had weight loss and was receiving 2 Cal at every meal, which should be documented in the MAR; -Blank spaces in the MAR would indicate the 2 Cal was either not documented or not given, which was a concern for a resident with weight loss. During an interview on 02/21/25, at 4:47 P.M., the Administrator said staff should administer the resident's 2 Cal per physician order and document in the MAR. MO00249332

Based on observation, interview, and record review the facility failed to provide effective pain management consistent with professional standards of practice when staff failed to administer requested pain medication timely, failed to assess the resident's pain level, failed document the administration of pain medication, and failed to follow-up with the resident regarding the effectiveness of the pain mediation for one resident (Resident #1) who displayed physical verbal signs of pain. The facility census was 34. Review of the facility's policy titled Medication and Treatment Orders. dated July 2016, showed the following information: -Drug and biological orders must be recorded on the physian's order sheet in the resident's chart; -Orders for medication must include, name and strength, dose, duration, number of doses, route of administration, clinical condition or symptoms for which the medication is prescribed, and any interim follow up related to the medication. Review showed the facility did not provide a policy regarding pain management. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information: -Cognitively intact; -Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting; -Received as needed pain medication and received non-medication pain intervention. Review of the resident's care plan, revised on 07/22/24, showed the following information: -Evaluate pain daily by using 1 to 10 pain scale; -Administer pain medications as ordered; -Assist with positional changes slowly; -Monitor for worsening of symptoms and report them to the physician. Review of the resident's Physician Order Sheet (POS), dated 08/24/24, showed the following orders for pain: -A current order for lidocaine external gel 4% (used to treat pain), apply to area of pain topically (on skin) one time a day; -A current order for tramadol 50 milligram (mg) tablet (used to treat chronic pain or moderate/severe pain), give one tablet by mouth every six hours as needed. During an interview on 08/27/24, at 10:08 A.M., the resident said often times, when he/she asked for pain medication, he/she had to wait two to three hours before someone would administer the medication. He/she was always told it will be a few minutes, or we're busy. Observation and interview on 08/27/24, at 12:24 P.M., showed the resident sat in his/her recliner. The resident was visually uncomfortable with grimacing and asked the surveyor if he/she had brought him/her a pain pill. The resident said he/she had requested a pain pill this morning and pressed his/her call light. Observation on 08/27/24, at 12:27 P.M., showed Certified Nursing Assistant (CNA) C entered the resident's room. The resident asked the aide if he/she minded asking the nurse if the resident could have some pain medication. CNA C said yes and exited the room. During an interview on 08/27/24, at 12:34 P.M., CNA C said if a resident was in pain he/she would let both the certified medication technician (CMT) and charge nurse know. The Director of Nursing (DON) was the charge nurse on this day. The CMT passed some pain medications while the charge nurse passed others, so it was best to notify them both. A resident should not have to wait two to three hours for pain medication. Observation on 08/27/24, at 1:24 P.M., showed the DON observed the resident's arm and the resident told the DON that he/she was in pain and had requested a pain pill. The DON did not ask the resident where his/her pain was or what his/her pain level, and exited the room. (Fifty minutes after the resident asked staff for pain medication.) Observation and interview on 08/27/24, at 3:22 P.M., showed the resident in the same position, in his/her recliner, visually uncomfortable with grimacing. The DON, Assistant Director of Nursing (ADON), and CNA F were present in the room. The resident said he/she was still waiting for pain medication. At this time, surveyor asked the DON if the resident had been administered any pain medication. The DON said no and the DON would go get it now. The DON did not ask the resident where his/her pain was, or pain level. The ADON and CNA F transferred the resident from the recliner to the bed with a sit to stand mechanical lift (a device that helps people who have difficulty standing up from a seated position). During the transfer, the resident was observed grimacing, moaning, and voicing pain. The resident told the staff that the lift swing was causing additional pain to his/her left arm which was visibly red, swollen, and bruised. The resident continued to voice his/her pain while laying on the bed. At 3:44 P.M., the DON re-entered the resident's room with pain medication. The ADON and CNA F transferred the resident back to his/her recliner. The DON administered the pain medication, said to be tramadol, to the resident at 3:48 P.M. (Over three hours after the resident requested pain medication from staff.) Review of the Stat Lock (a safe containing several different types of on-hand medications that can be pulled from when a resident is out of medication) form titled Sterling Pharmacy, dated 08/27/24, showed one tablet of Ultram (tramadol) for the resident obtained from the stat lock at 3:27 P.M. Review of the resident's Medication Administration Record (MAR), on 08/27/24 at 3:54 P.M., showed the DON had not documented the administration of the tramadol or the resident's pain level. Review of the resident's MAR on 08/28/24, at 9:15 A.M., showed staff did not document tramadol 50 mg as administered on 08/27/24 at 3:48 P.M. Review of the resident's medical record showed staff did not document follow-up regarding the effectiveness of the pain medication. Review on the resident's pain scale assessments, dated 08/27/24, showed staff completed one pain assessment for the resident on 08/27/24, at 10:51 P.M. The resident rated his/her pain at a 5 out of 10. During an interview on 08/28/24, at 9:50 A.M., CMT H said that nurses give all as needed pain medications. The nurse should evaluate the resident's pain. If resident complained of pain the CMT would notify the nurse. If returned and the nurse had not evaluated and provided pain medication, staff would return to the nurse or go to the DON if the nurse was busy. During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said that nursing staff should provide pain medications in a timely manner when resident requests and with the appropriate orders. The resident should not have to wait three hours for pain medication. During an interview on 08/27/24, at 12:20 P.M., the ADON said that the nurses give as needed pain medications because they will complete an assessment of the resident's pain. The CMT only gives routine ordered pain medications. During an interview on 08/28/24, at 10:14 A.M., DON said that he/she had given the resident tramadol 50 mg on the afternoon of 08/27/24. The medication was signed out from the E-Kit because the resident needed the pain medication right away. She was unable to locate the order to document the administration of the pain medication. She did not make a progress note related to the pain medication. She knew the resident needed the pain medication right then. The administration of pain medication was passed on verbally to the next shift. The DON was not aware that the resident needed pain medication prior to 3:30 P.M. The DON said no staff notified the DON previously. During an interview on 08/28/24, at 10:49, the resident's doctor said if a resident was complaining of pain, the resident should be given whatever was ordered for that pain. He/she wouldn't expect two to three hours to be an acceptable wait time for pain medication. During an interview on 08/28/24, at 12:28 P.M., the Administrator, DON, Regional Nurse Consultant, and Regional Director of Consultants said a resident should not have to wait two to three hours to receive pain medication. The nurse should perform a pain assessment, administer the medication if it is within the allotted time frame, and document the administration. MO00238842, MO00239423, & MO00239941 41787

Based on observation, interview, and record review the facility failed to provide care per standards of practice when staff failed to identify, assess, document, monitor, obtain orders for treatment of, and notify the physician of wounds for one resident (Resident #1). The census was 34. Review of the facility's policy titled Wound and Skin Care Protocols and Procedures, dated June 2021, showed the following: -The facility would include the orders on the physician's order sheet (POS); -May use facility skin and wound care protocols. Each resident's personal physician must approve of orders at the time of admission and then sign the order sheets monthly; -Each individual resident required treatment and specific telephone orders would be written based on protocols. -If a wound was not making progress, it was important to attempt to reduce the bioburden and manage infection. -Treatment included cleansing with sterile water, select appropriate type of alginate with silver property, moisten the alginate with sterile water, and cover, change every three days and ensure the alginate (assists with wound healing) stays moistened. Contact physician for the consideration of a negative pressure pump (wound vac). 1. Review of Resident #1's face sheet (brief look at resident information), showed the following information: -admitted [DATE]; -Diagnoses included kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood). Review of the resident's care plan, revised on 07/15/24, showed the following information: -Required skin to be observed daily during routine care for irritation and redness. -Required a full skin evaluation weekly with showers. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information: -Cognitively intact; -Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting; -At risk for pressure ulcers with no current pressure, venous (wounds that are due to vein and blood flow issues), or arterial (wounds that are due to poor circulation) ulcers; -Required pressure reducing devices for chair and bed, and required a turning and repositioning program. Review of the resident's weekly Skin Only Evaluation sheets showed the following information: -Staff did not document skin evaluations from 07/11/24 through 08/01/24; -On 08/02/24, staff noted the resident had no skin issues, aside from a current healing hematoma (a collection of blood that pools in an organ, tissue, or body space) to the left knee, measuring 5 centimeters (cm) by 5 cm, with 0 cm depth. Review of the resident's care plan, updated 08/07/24, showed open area to left knee with daily dressing changes as directed. Staff to notify physician if no improvements in two weeks. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheets showed the following information: -On 08/09/24, no skin issues documented (two days after care planned updated with open are to knee requiring dressing changes); -On 08/13/24, shower was rescheduled to 08/14/24 with no skin issues documented; -On 08/15/24, staff noted open area to left knee, and redness and open areas to the backs of both legs in the calf regions; -On 08/16/24, resident refused a shower; -On 08/20/24, staff noted sore to left knee, and sores to the backs of both legs. Review of the resident's care plan, updated 08/20/24, showed a new order to refer resident to wound care. Staff did not care plan related to the new sores to the back of the resident's legs. Review of the resident's care plan, updated 08/21/24, showed open areas to buttocks added. Staff to encourage resident to reposition, provide incontinent care, and apply barrier cream each shift. Review of the resident's weekly Skin Only Evaluation sheets showed the following information: -On 08/21/24, staff noted resident had no skin issues, aside from an opened scab on the left knee, measuring 2 cm by 2 cm with bloody drainage.(Staff did not document area on buttocks requiring treatment noted on the same day.) -On 08/23/24, staff noted the resident had no skin issues, aside from a pressure ulcer injury to the posterior (back side) left thigh that measured 6 cm by 2 cm with a 0.2 cm depth with bloody drainage. Staff also noted the resident had multiple pinpoint areas on the buttocks with bloody drainage. Review of the resident's Physician Order Sheet (POS) showed the following: -A current order for an appointment with wound care clinic on 08/28/24 for left knee wound; -A order, dated 08/27/24, to change wound dressing every three days and as needed with island dressing to left knee. (The orders did not include orders to address the wounds on the resident's buttocks, thigh, or calf.) During an interview on 08/27/24, at 10:08 A.M., the resident said he/she did have wounds. He/she had one on his/her left knee and he/she is supposed to be going out to have it treated at a wound clinic soon. The staff change the bandage every couple days. During an interview on 08/27/24, at 1:02 P.M., the Director of Nursing (DON) said if a resident were to have wounds, he/she would expect to see documentation of that in the progress notes and skin assessments. If the staff are aware that a resident has wounds, the facility outsourced and worked with a wound company and/or will send the resident across the street to be treated in a wound care clinic. The floor nurses complete wound treatments daily and there should be orders within the physician's order sheet as well as care plan for them to follow. The DON said the resident does have wounds. The resident had a wound on the left knee, on his/her bottom, and on the backs of both legs in the thigh area. The DON said the resident's physician was aware of all wounds. The DON looked the resident's record and said there were technically no doctor orders at this time for the areas. He/she is just keeping a dry patch on them for now. She expects staff treat the wounds without the physician orders following the facility protocol book for wounds. Review showed the facility did not provide a facility protocol book for wounds signed off on by the physician or medical director. Observation and interview on 08/27/24, at 3:10 P.M., showed the resident had 4 x 4 gauze squares on top of left knee wound that were secured with paper tape with dried red substance, appearing to be blood, on the gauze. The resident's his/her left knee had a yellow and red substance seen on the pad underneath the residents' legs. The resident said none of his/her treatments have been done in a couple days. Observation on 08/27/24, at 3:30 P.M., showed the resident transferred into his/her bed. Upon assessment of the resident, two wounds were located on the back of the upper legs. One wound on the left appearing as an open area with a red wound bed approximately 5 cm long with some bruising alongside of the wound and yellow drainage coming from wound. One wound on the right appearing as an open area with a red and yellow wound bed approximately golf ball sized, with yellow drainage. The Assistant Director of Nursing (ADON) sprayed both areas with wound cleanser and left open. The resident also had two open areas on the left knee. Both areas had black and yellow tissue inside, draining a red and yellow substance, with the surrounding tissue was red. ADON sprayed this area with wound cleanser and covered with a dry dressing. During an interview on 08/27/24, at 3:54 P.M., the DON said the wounds to the resident's backs of legs had been there approximately a week and intervention of encouraging the resident to get off of his/her bottom had been put in place. As far as treatments for all the resident's wounds, she followed the nursing protocols book. If a new wound was found for any resident, she expected staff to assess the area, measure it, notify the doctor, and family, follow the wound care protocol, and document. During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said the following: -The computer system notified nursing staff when a skin assessment or wound care was due to be completed; -The aides also do skin assessments with baths and bring skin concerns to the nurse, often having the nurse come evaluate the skin while still in the shower; -Nursing staff should document all skin concerns; -The RN was not aware of any areas on the back of the resident's leg or bottom; -He/she was only aware of the wound on the left knee. During an interview on 08/28/24, at 11:56 A.M., the Social Services Director (SSD) said wounds and wound treatments should be included in the care plan. If there was no improvement in a wound within two weeks, the physician should be notified. There should also be wound care orders in the physician orders sheet. Those orders should be followed. Any staff member can add information to the care plan, and she will then review it. The resident does have wounds, one on the knee and one on the bottom. The bottom wound is being treated with barrier cream and the wound to the knee is being treated with a dry dressing. During an interview on 08/27/24, at 3:10 P.M., DON said the resident did not like to move out of his/her recliner. The staff encourage him/her to get off his/her bottom. The resident had an upcoming appointment with the wound care clinic. The nursing staff should see the resident's bottom at least once per day. The resident had a couple of random open areas on his/her bottom and thighs. There was no treatment order, staff were only putting barrier cream and encouraging to get into the bed. During an interview on 08/28/24, at 10:49 A.M., the resident's physician said she saw the resident a few weeks ago. At that time, the resident had a wound to his/her left knee. She referred to it as a popped hematoma and the wound bed was clean. The physician referred the resident to the wound care clinic for treatment. The physician believed she made specific in-house wound care orders, but could not verify them at this time. She did tell a nurse to be treating the area with the in house wound care protocol. The physician said she was not aware of any other wounds to the resident. The physician expected nursing staff to assess new wounds, measure, notify her, begin treatment, and document. During an interview on 08/28/24, at 9:00 A.M., the Corporate Nurse said that staff should use the wound protocol and should add to the physician's orders for nurses to know the treatment plan. During an interview on 08/28/24, at 12:11 P.M., with the DON and Regional Nurse Consultant, the DON said if a new wound was brought to her attention or another nurses attention, they should go down and assess the wound, measurements should be obtained, and it should be documented. The staff are to be completing treatments on all wounds, staff should use the wound care protocol for those treatment orders, and those orders should be found in the POS. The Regional Nurse Consultant said there are weekly skin assessments for all residents. Once Wound Care Plus or wound care clinic is established, the facility used their measurements. Otherwise, wounds were monitored with skin assessments and the electronic medical record should trigger this every seven days for all residents. During an interview on 08/27/24, at 1:35 P.M., the Administrator the resident had some wounds on his/her left knee and buttock area. The resident was going to see the wound clinic soon. The nursing staff should be treating the wounds until seen at the clinic and received new orders. The staff was probably treating the areas per facility protocol. There should be an order for the nurses to know when a treatment was to be done. During an interview on 08/28/24, at 12:28 P.M., the Administrator, DON, Regional Nurse Consultant, and Director of Regional Consulting said wounds should be documented and monitored. The wound care treatment protocol should be activated, and those orders should be found in the POS. MO00239310 41787

Based on observation, interview, and record review the facility failed to ensure residents were as free from accident hazards as possible when staff failed to transfer one resident (Resident #1) in a safe manner and failed to follow-up on possible injury from the transfer. The facility census was 34. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following: -The purpose of the procedure was to promote cleanliness, promote comfort, and to observe the condition of the resident's skin; -Staff should observe the skin for any rashes, reddened areas, and swelling and document all assessment data including reddened areas, and sores on the resident's skin. 2. Review of Resident #1's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism (long term condition that occurs when a clump of material, most often a blood clot gets stuck in an artery in the lungs, blocking the flow of blood). Review of the resident's care plan, revised on 07/15/24, showed the following information: -Required skin to be observed daily during routine care for irritation and redness; -Required a full skin evaluation weekly with showers; -Potential for bruises due to anticoagulant (medicines that help prevent blood clots) therapy; -Staff to be gentle in working with the resident; -Staff to inspect skin daily for bruises; -Assistance of one staff for all ambulation. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool that is filled out by facility staff), dated 07/18/24, showed the following information: -Cognitively intact; -Required substantial to maximum assistance from staff for dressing, bathing, and mobility, and completely dependent on staff assistance for toileting; -No current skin conditions. Observation and interview on 08/27/24, at 10:08 A.M., showed the following: -The resident said he/she was in pain due to something that happened on Friday (08/23/24); -The resident pulled up his/her left shirt sleeve and showed his/her arm. The resident's skin was red and swollen starting at his/her inner elbow, and moving up the arm. In the bicep region, there was a dark blue to purple golf ball sized area. Past the bruise was more redness and swelling up to and including the resident's armpit. -The resident said this occurred during an improper transfer. He/she was supposed to be transferred with a mechanical lift called a sit-to-stand (helps a resident into a standing position with the use of a sling). The resident said he/she was sitting on the side of his/her bed and requested to be assisted into the recliner. Certified Nursing Assistant (CNA) A grabbed his/her arm when transferring him/her to the recliner and pulled at the arm roughly leaving the bruising and redness. -The resident said he/she reported this to Licensed Practical Nurse (LPN) B as well as the therapy department. During an interview on 08/28/24, at 8:30 A.M., CNA A said on 08/23/24, he/she helped another aide transfer the resident with the sit-to-stand. The resident let go of the handles and let his/her body drop in the sling. The CNA reported this to the Assistant Director of Nursing (ADON). The CNA did not know if the nurse evaluated the resident. If at any time saw any skin issues on a resident, he/she would notify the charge nurse and if they did not check the resident, he/she would tell the Administrator. During an interview on 08/27/24, at 2:31 P.M., Physical Therapist (PT) D said he/she had not been made aware of any bruising that would affect therapy. The resident had mentioned to him/her that his/her left shoulder was hurting. The resident did report to him/her that the pain was from an improper transfer the side of the bed to the recliner. PT D said the resident was a sit-to stand lift and sometimes the resident would let go and go limp on the lift, unable to stand. In those cases staff should advance to a different mechanical lift called a Hoyer (a mechanical lift that lifts a resident up off the ground with a sling). Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheets, dated 08/09/24 to 08/27/24, showed staff did not document regarding bruising to the resident's arm. The resident refused a shower on 08/23/24. Review of the resident's weekly Skin Only Evaluation sheets, dated 08/02/24 to 08/27/24, showed staff did not document regarding bruising to the resident's arm. Review of the resident's progress notes, dated 08/23/24 to 08/27/24, showed staff did not document regarding the bruising or an investigation into the bruising or transfer. During an interview on 08/27/24, at 5:37 P.M., LPN B said the expectation when a bruise was reported, was for the nurse to assess the area, and notify the Administrator so she can report it to the state if it is suspicious. New bruising should be documented in the skin assessment notes and progress notes in the electronic medical record. The resident was difficult and didn't like to stand or help when using the sit-to stand, but that's what should be used for transfer. No new bruising to the resident had been reported to him/her. The resident did complain of left shoulder pain on 08/23/24. LPN B assessed the resident's arm at that time and said the resident had good range of motion and he/she didn't see a new bruise at the time. He/she did see a bruise that was quarter size, but believed it to be in the healing process and not related. During an interview on 08/27/24, at 12:34 P.M., CNA C said he/she wasn't aware of any bruising to the resident. If he/she seen or was reported to him regarding new bruising to a resident he/she would report it to the charge nurse, and the charge nurse would take it from there. During an interview on 08/27/24, at 1:02 P.M., the Director of Nursing (DON) said she has not had any bruising to the resident reported to her. Bruising should be documented on the weekly skin assessments. She would expect new bruising to be reported to her. The resident is transferred with a sit-to stand so she is unsure of how a CNA could have caused the bruising. During an interview on 08/28/24, at 9:50 A.M., Certified Medication Tech (CMT) H said he/she would let the charge nurse know of any skin issues, bruises, redness, or open areas on a resident especially if unaware if the nurse was aware of the area. The CMT was aware that the resident had a bruise on his/her left arm that was from the sit-to-stand lift. He/she did not notify the nurse as this was not a new bruise. When staff transfer the resident, the resident would lean back and his/her arms rest on the lift sling. The resident complained of pain in his/her arm area to the CMT on Monday 8/26/24 and he/she notified the nurse. During an interview on 08/28/24, at 10:42 A.M., Registered Nurse (RN) G said the following: -Nursing staff should document all skin concerns; -The resident had told the RN of the bruise over the weekend, however he/she did not document any information about the bruise because he/she thought it was a pre-existing concern; -The RN did not look at the resident's arm or document any information related to the bruise. During an interview on 08/27/24, at 2:10 P.M., the Assistant Director of Nursing (ADON) said that nursing staff should look at resident skin, measure and document when notified of new areas. If staff were unable to document under the skin assessment portion of the chart, the staff should at least document a progress note. The ADON said on 08/23/24 she and CNA A transferred the resident with the sit-to-stand lift at about 3:00 P.M. The resident was not compliant and would not try to hold self-up and let go of the handles. The resident's arms were resting on the lift pad. During an interview on 08/28/24, at 11:56 A.M., the Social Services Director said that she updates the care plans. Care plans should include a good overview of the resident including any skin issues. If she was aware of any new bruising, that is something she would include in the care plan. During an interview on 08/28/24, at 10:49 A.M., the resident's doctor said she had seen the resident a few weeks ago and wasn't aware of any new bruising, but the resident was on anticoagulants (a medication that prevents blood from clotting) and bruises easily. Staff should report new skin issues her. During an interview on 08/27/24, at 1:36 P.M., the Administrator said he/she wasn't aware of any bruising on the resident and none had been reported to her. She expected staff to report, assess, and monitor bruising. There have never been any other issues with CNA A. During an interview on 08/28/24, at 12:28 P.M., the Administrator, Director of Regional Consulting, Regional Nurse Consultant, and Director of Nursing said expectations for bruising include the charge nurse assessing the bruise, reporting it to the DON and Administrator. The Administrator said she was not aware of the bruising to the resident. Regardless, it should be documented on daily and investigated. The physician and family should be notified and there should be a 72-hour follow up per the Director of Regional Consulting.

Based on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices to prevent the risk of contamination and spread of infection while transporting clean laundry uncovered throughout the facility. This had the potential to affect 26 of 27 residents in the facility. Review of the facility's policy titled, Policy and Procedure Regarding Laundry and Bedding Soiled, issued 09/22 and reviewed 03/14/24, showed clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. 1. During an observation and interview on 03/12/24, at 2:55 P.M., Laundry Aide (LA) 2 was observed pushing a clothes cart down the hallway. LA2 said that he/she delivered the clothes to the residents. When asked should the clothes be covered, LA2 did not respond. During an interview on 03/14/24, at 9:12 A.M., LA1 said no one had ever told him/her that clean clothes should have been covered when transported and delivered back to residents' rooms. He/she said that the only clean items that he/she covered were linen and bath towels. During an interview on 03/14/24, at 10:45 A.M., the Infection Preventionist (IP) confirmed that residents' clean clothes should have been covered when transported down the hallways and delivered back to the residents. During an interview on 03/14/24, at 11:24 A.M., the Administrator said clean clothes should have been covered when transported back to the residents.

Based on record review and interview, the facility failed to ensure adequate steps had been put into place to prevent accidents when the staff failed to document fall investigations were complete and included a root cause analysis for three of four residents (Residents #8, #21, and #12) reviewed for falls of 18 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Review of the facility's policy titled, Fall Risk Assessment, dated 03/18, showed staff staff will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan. 1. Review of Resident #8's Face Sheet, showed the following: -admitted [DATE]; -Diagnoses included atrial fibrillation (irregular heart rhythm) and major depressive disorder. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 01/03/24, showed the following: -Resident had severely impaired cognition; -No fall history; -Had not sustained any falls in the facility since admission. Review of the resident's Resident Incident Report, dated 02/18/24, showed the following: -Nurse was sitting at nurses' station talking with another resident when a loud noise was heard down the hallway. This nurse ran down the hallway and saw resident laying on stomach on the floor just out of the bedroom doorway. Resident was breathing heavy and not responding to questions with eyes open. Nurse call 911 and when the nurse returned to resident he/she was talking. The resident said I don't know when asked what happened. The resident's nose was bleeding. Due to the way the resident was laying it was unsafe to try and move resident until EMS (Emergency Medical Services) arrived. Unable to assess resident for wounds; -Staff did not document a root cause analysis or resident-specific interventions to keep the resident safe when he/she returned from the hospital. 2. Review of Resident #21's Face Sheet, showed the following: -admitted [DATE]; -Diagnoses included dementia. Review of the resident's Nursing Progress Note, dated 11/12/23, located in the Progress Notes tab of the EMR, showed a CNA (certified nurse aide) observed resident on floor next to bed lying on bed spread. Staff asked resident if he/she fell out of bed. Resident responded I don't know. Resident assessed and assisted to standing position with max assist times two. Resident was having difficulty following simple commands assisted to bed no apparent injury. Noted to have old bruise to left hip from a previous fall about a week ago. (Staff did not document a root-cause analysis or what interventions were put into place to prevent future falls.) During an interview on 03/14/24, at 10:49 A.M., the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant (RNC) said staff do the post fall 24-hour report however, they did not do an investigation to determine a root cause analysis and any interventions. 3. Review of Resident #12's Admission Record, under the Resident Profile tab of the EMR, showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included anxiety, adult failure to thrive, and dementia. Review of the resident's quarterly MDS assessment located under the MDS tab of the EMR with an ARD of 01/17/24, showed the resident had severe cognitive impairment. Review of the resident's Progress Note, located under the Progress Notes tab in the EMR and dated 11/20/23 at 2:30 PM, showed the resident was in his/her room and resident in room next door heard yelling for help. Staff went to room and found resident on the floor resting on his/her right side with his/her right arm in front of her and head against the wall. (Staff did not document a root cause analysis or any steps taken to prevent future falls.) Review of Resident #12's Resident Incident Report, dated 11/20/23, showed staff did not document a root cause analysis or steps taken to prevent future falls. During an interview on 03/12/24, at 4:08 P.M., the RNC said there was no investigation and the facility had not been conducting root cause analysis 24 hour follow up. 4. During an interview on 03/14/24, at 10:44 A.M., the Administrator and RNC said the expectation was to have investigations after each fall and new interventions added to the care plan.

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained when staff failed to ensure catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bags were kept in a privacy bag for two residents (Resident #16 and #23) reviewed for catheter care out of 18 sampled residents. 1. Review of Resident #16's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included chronic kidney disease, cellulitis of groin, and retention of urine. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessment with an Assessment Reference Date (ARD) of 01/09/24, showed the resident was cognitively intact. During an observation on 03/11/24, at 1:07 P.M., the resident's catheter was in place without a privacy bag over the collection bag. The bag and urine was visible to others. During an observation on 03/11/24, at 1:40 P.M., the resident's catheter bag hung on the side of bed without a privacy bag in place. The bag was visible from doorway, contained a clear yellow liquid, and was approximately 25% full. During an observation on 03/13/24, at 11:00 A.M., the resident's catheter bag hung on the side of the bed without a privacy bag and a small amount of yellow liquid visible. 2. Review of Resident #23's Face Sheet, located the EMR under the Profile tab, showed the following: -admitted [DATE] with a readmitted [DATE]; -Diagnoses included chronic kidney disease, retention of urine, and heart failure. Review of the resident's admission MDS assessment with an ARD of 01/03/24, showed the resident was severely cognitively impaired. During an observation and interview on 03/12/24, at 9:00 A.M., the resident was in bed. His/her catheter bag was lying flat on the floor, urine side down. The bag was noted to be 1/2 full and appeared cloudy. The catheter bag was not in a dignity bag. Registered Nurse (RN) 1 confirmed the lack of a privacy bag when he/she attached it to the bed. 3. During an interview on 03/13/24, at 4:30 P.M., the Regional Nurse Consultant (RNC) said catheter bags should be contained in a privacy bag. It is the expectation that they should be bagged appropriately.

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when water temperatures in the facility exceeded safe parameters (greater than 120 degrees Fahrenheit) in three common shower rooms where residents received showers and baths, and five resident halls where 30 cognitively impaired residents resided. Eighteen of the 30 cognitively impaired residents could directly access the hot water without staff assistance. The facility had a capacity for 120 residents and a census of 80. Record review of the "Scald Injury Prevention Educator's Guide" (a community fire and burn prevention program supported by the United States Fire Administration Federal Emergency Management Agency), published by the American Burn Association showed: -Older adults, people with disabilities, and young children are most likely to incur scald burns. -Most scald injuries occur from exposure to hot tap water in bathtubs or showers, or in connection with the preparation or serving of hot food or beverages. -The severity of a scald injury depends on the temperature to which the skin is exposed and how long exposed. -The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to tap is 120 degrees Fahrenheit. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. -When the temperature of a hot liquid is increased to 140 degrees Fahrenheit it takes only five seconds or less for a serious burn to occur. -Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower; -Individuals who may have physical, mental or emotional challenges or require some type of assistance from care givers are at high risk for all types of burn injuries including scalds; -A water temperature of 124 degrees Fahrenheit takes three minutes for a third degree burn to occur; -A water temperature of 127 degrees Fahrenheit takes one minute for a third degree burn to occur; -A water temperature of 133 degrees Fahrenheit takes 15 seconds for a third degree burn to occur; -A water temperature of 140 degrees Fahrenheit takes five seconds for a third degree burn to occur; -Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. 1. Observations on 8/21/14, beginning at 3:00 P.M., showed the sink faucets in resident rooms throughout the facility had separate hot and cold knobs. Staff and/or a resident would have to turn on both knobs at the same time to regulate the temperature of the water. Using a digital long stem thermometer, the following hot water temperatures were obtained in the upper level of the facility: -The upper level shower across from room 223 registered 132 degrees Fahrenheit (F) at the sink; -Room 208 registered 129.3 degrees F at the sink; -Room 218 registered 132 degrees F at the sink; -Room 224 registered 130 degrees F at the sink. Observation on 8/21/14 at 3:50 P.M., showed the hot water at the sink in room 224 registered 134.7 degrees F when using the long stem digital thermometer. During an interview on 8/21/14, at 3:56 P.M., Certified Nursing Assistant (CNA) K said sometimes the water "gets too hot". It depends on the room. He/she has to turn up the cold water to adjust the temperature. He/she does not want a resident to get burned. During an observation and interview on 8/21/14, at 3:58 P.M., the Maintenance Supervisor (MS) turned on the faucet in the upper level shower across from room 223. He pointed a heat sensitive thermometer toward the water and said, "Well, that reads 132 degrees. That's not good". The MS said the scalding valve needed to be changed and that he had a new valve on his work bench. During an interview on 8/21/14, at 4:00 P.M., Licensed Practical Nurse (LPN) E said the following: -There are 16 cognitively impaired residents on the second (upper) floor who use the shower room. -All 16 cognitively impaired residents use the shower room. -No resident would be able to go into the shower room without assistance from the staff. -Three cognitively intact residents shower alone after the staff assists them into the shower room. -Eight cognitively impaired residents would be capable of using the water faucets in their rooms without assistance. During observation on 8/21/14, at 4:10 P.M., the water temperature of the upper level shower room across from room 223 registered 126 degrees F at the sink, using a long stem digital thermometer. 2. Observation on 8/21/14, beginning at 3:00 P.M., using a digital long stem thermometer, the following hot water temperatures were obtained in the lower level of the facility: -The lower level shower room registered 133.1 degrees F at the sink; -The Alzheimer's Special Care Unit (SCU) shower room registered 133.3 degrees F at the sink; -Room 103 registered 131.7 degrees F at the sink; -Room 119 registered 134.2 degrees F at the sink; -Room 131 registered 136.4 degrees F at the sink; -Room 132 registered 135.4 degrees F at the sink. During an interview on 8/21/14, at 3:45 P.M., LPN E said: -There are 14 cognitively impaired residents in the lower level of the facility who use the shower room. -No resident would be able to go into the shower room without assistance from the staff. -Fourteen cognitively impaired and one cognitively intact resident use the lower level shower room. -Ten residents would be able to wash their hands unassisted at the faucet in their rooms. Observation on 8/21/14, at 4:05 P.M., showed the water temperature in the SCU shower room registered 123 degrees F at the sink, using a long stem digital thermometer. During an interview on 8/21/14, at 4:42 P.M., Resident #6 (who resided on the lower level) said staff adjusts the water temperatures in the shower. However, there have been a few times it was "too hot" and the resident had to have the staff turn down the water temperature. 3. During observation and interview on 8/21/14, at 4:35 P.M., the administrator observed the calibrated long stem digital thermometer used to check the water temperatures. The temperature reading on the digital thermometer read 32.2 degrees F, after placing the thermometer stem into ice water. During the observation, the administrator acknowledged the hot water temperatures and said the water heater temperature controls were turned up too high. During interviews on 8/21/14, at 4:13 P.M. and 5:00 P.M., the MS said the scalding valve needed changed. The MS said the valve kept water temperatures from getting too high. The MS said the valve stopped working correctly about six months ago and he changed the valve, but he did not have any maintenance records to show exactly when he changed the valve. The MS said for some reason an unknown staff person turned the water heaters up to 160 degrees F. The MS said the water heaters supplied hot water to all shower/bathing rooms (including the Alzheimer's Unit), and resident rooms in the facility except for the resident rooms in the Alzheimer's Unit. The MS said a separate water heater provided hot water for the resident rooms in the Alzheimer's Unit. The MS said he only checked the water temperatures when someone complained. He had not checked the water temperatures in over a year. During an interview on 8/21/14, at 5:14 P.M., the administrator said he thought the MS had been relying on the scalding valve and had not been checking water temperatures. The administrator said he was present when the scalding valve was changed in the last six months. He said the building had six water heaters, three of the water heaters were used for the residents. NOTE: At the time of the 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 that time. During the onsite visit, the facility turned down the temperature control on the water heaters, changed the scalding valve, drained the hot water from the water heaters, and conducted two-hour water temperature checks for 72 hours, then will test water temperatures on a weekly basis. The facility also educated staff on proper water temperatures, to use cold water mixed with hot water, and to notify administrative staff if the water temperatures exceed 120 degrees Fahrenheit. The facility will continue to monitor and document water temperatures on a weekly basis, adjust the temperatures as needed, and will change the scalding valve every six months. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with the 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 staff failed to monitor the resident's weight as recommended by the dietary manager, failed to contact the physician of continued weight loss, failed to refer the resident to the registered dietitian for evaluation of continued weight loss and failed to care plan new interventions to prevent additional weight loss for one resident (Resident #2) that the facility identified as being a weight loss risk. Staff failed to care plan weight loss interventions in a timely fashion, failed to monitor the resident's weight as care planned and failed to notify the physician of the resident's weight loss for one resident (Resident #1) that the facility identified as being a weight loss risk. The facility staff failed to update the resident's care plan with new interventions and failed to monitor the resident's weight as recommended by the dietary manager for one resident (Resident #3) that the facility identified as being a weight loss risk. The facility census was 85. 1. Record review of the facility's Weight Monitoring policy, dated 2011, showed the following information:- To monitor nutrition and hydration staff will obtain height and weight. - Nursing staff will record a resident's weight upon admission, monthly and more often if risk is identified. - The electronic weight-monitoring program is a tool used by staff to review all weights for significant changes and trends. - Staff should enter and monitor weights through the software identified by the corporation. - The suggested parameters for evaluating significance of unplanned and undesired weight loss are as follows: - One month significant weight loss of five percent and severe weight loss of greater that five percent. - Three months significant weight loss of 7.5 percent and severe weight loss of greater than 7.5 percent. - Six months significant weight loss of ten percent and severe weight loss of greater than ten percent. - When weight change is significant or severe, the licensed nurse will notify the resident's physician, and obtain and carry out treatment orders if given. The licensed nurse will notify the resident's family member or legal representative. The facility staff will notify the dietitian. - The nutritional screen will be completed by the dietary services manager and referred to the dietitian for any resident needing additional nutritional intervention. - Each facility will have a Nutrition Risk Committee. This committee should meet regularly to determine possible reasons for weight loss and gains and to make recommendations to prevent further unplanned changes. 2. Record review of Diet Manual, a Comprehensive Resource and Guide (2006), showed the following information: - A copy of monthly weights should be forwarded to the registered dietitian, each month to review and calculate significant change over 5% in one month, 7.5% in three months, and 10% in six months. - A copy of all significant weight losses and gains should be given to the facility's Interdisciplinary Team for appropriate review and documentation. - The registered dietitian should review and document all significant weight changes. - The physician and family should be notified of any individual with a significant loss. - All individuals with significant weight variances should be re-weighed prior to reporting this to the physician. - The facility is responsible for obtaining correct weights on a regular basis. 3. Record review of Resident #2's significant change minimum data set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/17/14, showed the following information: - The facility readmitted the resident on 03/07/14. - The resident's [DIAGNOSES REDACTED]. - The resident's Brief Interview for Mental Status (BIMS) assessment score was a three. (A score of zero to seven indicates the resident has severely impaired cognitive skills.) - The resident required supervision and one person physical assist for eating. - The resident weighed 142 pounds. - The resident had weight loss of more than 5% in the last month, or more than 10% in the last six months. - The resident was not on a physician prescribed weight loss regimen. - The resident was on a therapeutic diet. - The resident was on hospice care. Record review of the resident's current care plan, last reviewed on 04/25/14, showed the following information: - The resident was at nutritional risk related to being on a therapeutic diet for diabetes, [MEDICAL CONDITION] (a condition that develops when the arteries that supply blood to the internal organs, arms, and legs become completely or partially blocked) and poor appetite. - The resident was to maintain nutritional status as evidenced by no significant weight change by the next review. - Staff were to provide the diet ordered. - The resident was on hospice services. - Staff were to offer the resident fluid and snacks from the refreshment cart. - Staff were to provide the resident with supplement as ordered. - Staff were to weigh the resident as directed. Record review of the resident's weight record showed the following information: - On 01/13/14, the resident weighed 172 pounds. - On 01/14/14, the resident weighed 156.8 pounds (in a wheelchair). (This was a 15.2 pound difference in one day. Staff did not discuss the difference in the weights.) Record review of the resident's nutrition assessment, dated 01/20/14 and completed by the registered dietitian (RD), showed the following information: - The resident's nutrition intake did not meet his/her needs. - The RD recommended staff to continue to provide a consistent carbohydrate diet with supplements four times day to the resident. (The RD did not recommend any new interventions to prevent weight loss due to the resident's nutrition intake not meeting the resident's needs.) Record review of the resident's weight record showed the following information: - On 01/21/14, the resident weighed 155.6 pounds. (This is 1.2 pounds less than the resident's weight on 01/14/14.) - On 02/02/14, the resident weighed 155.2 pounds. (This is .4 pounds less than the resident's weight on 01/21/14.) - On 02/10/14, the resident weighed 160 pounds (in a wheelchair). (This is 4.8 pounds more than the 02/02/13 weight.) Record review of the resident's Nutrition Data V2 form, dated 02/10/14 and completed by the dietary manager (DM), showed the following information: - The resident's average intake was 75% of meals. - The resident returned from a short hospital stay. - The resident was on a consistent carbohydrate diet with supplements three times a day. (The DM did not address the variances in the resident's weights. The DM suggested the resident receive supplements three times a day, however the RD's previous recommendation was for the resident to receive supplements four times a day.) Record review of the resident's case management meeting notes, dated 02/25/14, showed the resident remained in the hospital for a [MEDICAL CONDITION] completed on 02/24/14. Record review of the resident's nurse's note, dated 03/07/14 at 1:18 P.M., showed the facility readmitted the resident from the hospital. Staff noted the resident's readmission weight was 170.6 pounds. (This was 10.6 pounds more than the resident's weight on 02/10/14, before the the amputation. Staff did not discuss the weight difference.) Record review of the resident's current order summary showed the following information: - An order, dated 03/07/14, for staff to provide the resident with a consistent carbohydrate diet. - An order, dated 03/07/14, for staff to provide the resident a supplement four times a day. - Staff to complete monthly weights on the 6th of each month. Record review of the resident's Nutrition Data V2 form, dated 03/10/14 and completed by the DM, showed the following information: - The resident eats a consistent carbohydrate diet by him/herself. - The resident receives a supplement four times daily. - The DM recommended staff to continue the current diet with weights as directed. - The resident's intake was 63% of meals. - The resident needed supervision when eating. (The RD did not address the variance in the resident's weight. The RD did not have the resident's monthly weight, ordered to be completed on the 6th, available to determine if the resident had lost weight since returning to the facility.) Record review of the resident's weight record showed the following information: - On 03/11/14, the resident weighted 164 pounds (in a wheelchair). (This was a 6.6 pound weight loss from the resident's readmission weight on 03/07/14.) - On 03/18/14, the resident weighed 151.6 pounds. (This was 12.4 pound weight loss in one week and a total weight loss of 19 pounds, or 11.1 percent, since the facility readmitted the resident after his/her amputation.) Record review of the resident's nutrition assessment, dated 03/18/14 and completed by the registered dietitian, showed the following information: - The recommendation to continue with a consistent carbohydrate diet and supplement four times a day. - The resident consumed an average of 68% of meals since readmission. - The resident had experienced weight loss due to amputation and [MEDICAL CONDITION]. (The RD did not make any new recommendations of interventions to prevent future weight loss and did not discuss why new interventions were not put into place.) Record review of the resident's nurse's note, dated 03/20/14 at 1:42 P.M., showed the DM documented weight loss was noted on the MDS from admission. The resident went from 164 pounds to 152 pounds. The resident was on a consistent carbohydrate and no salt packets diet. The resident received a supplement three times a day. The resident had a recent [MEDICAL CONDITION]. The resident's intakes had been 68% the prior three days. Staff would continue to monitor the resident's intake. (The DM did not document notifying the physician of the weight loss or implementing any new interventions to prevent further weight loss. The DM noted the resident ordered to receive a supplement three times a day and the RD and physician ordered it four times a day.) Record review of the resident's nurse's note, dated 04/02/14, showed the dietary manager documented the resident triggered for a weight loss of 16%. The DM asked for the staff to reweigh the resident. The resident received a supplement four times a days. Staff would add extra calories with butter on potatoes and vegetables at lunch and supper. Staff would add ice cream to the resident's lunch. The resident's weight was now 142. The resident took [MEDICATION NAME] and had a amputation of the leg below the knee. The dietary manager recommended weekly weights for April. (Staff did not update the care plan with these new interventions. The staff did not document notifying the resident's physician of the weight loss. The staff did not document referring the resident to the registered dietitian for evaluation of the continued weight loss.) Record review of the resident's weight record showed on 04/04/14 the resident weighed 142 pounds. (This is 9.6 pounds, or 6.3 percent, less than the resident's weight on 03/18/14. The record did not show any additional weights for April 2014 as the DM has recommended on 04/02/14.) Record review of the resident's nurse's note, dated 04/09/14, at 12:08 P.M., showed hospice services admitted the resident for hospice care. Record review of the resident's weight record showed on 05/08/14, the resident weighed 138 pounds (in a wheelchair). (This was four pounds less than the resident's weight on 04/04/14.) During an interview on 05/28/14, at 11:40 A.M., the resident said sometimes he/she eats and sometimes he/she is hungry. The resident said he/she can ask for something different at meals, but he/she does not really ask. The resident said he/she does not receive snacks and does not get enough to drink. Observations of the noon meal on 05/28/14, showed the resident was served at 12:25 P.M. Staff asked the resident if he/she needed help with anything and the resident declined. The resident sat at the table through 12:50 P.M. During this time no staff stopped and sat down to offer the resident assistance with his/her meal. Staff did not offer an alternative meal. Observation of the evening meal on 05/28/14, showed the resident received his/her food at 5:24 P.M. From 5:24 P.M. to 5:41 P.M., staff completed one verbal cue to the resident and offered an alternative. Staff did not sit down to try and assist the resident until 5:41 P.M. During an interview on 05/29/14, at 2:28 P.M., Licensed Practical Nurse (LPN) H said the resident does not want to live and it is hard to get the resident to eat. All the staff try to encourage him/her to eat. The resident takes his/her supplement good and will take a shake when made. During an interview on 05/29/14, at 3:13 P.M., Certified Nurse Aide (CNA) I said staff try and encourage the resident to eat because the medications he/she takes can make him/her nauseous. The staff can try to offer different foods, but the resident usually declines. During an interview on 05/29/14, at 3:25 P.M., LPN E said the resident does not like to eat and says the food tastes bad. Staff encourage the resident to eat due to his/her medication. During an interview on 05/29/14, at 10:25 A.M., the DM said the resident receives a supplement, but no appetite stimulant. She had not contacted the physician about the resident's weight loss, but she should have based on his/her weight loss. The resident has a poor appetite. During an interview on 06/05/14, at 3:41 P.M., the RD said she had not been asked to review the resident since 03/18/14. 4. Record review of Resident #1's admission MDS, dated [DATE], showed the following information: - The facility readmitted the resident on 04/16/14. - The resident had unclear speech. - The resident had short and long-term memory problems. - The resident had severely impaired cognitive skills. - The resident had a poor appetite and trouble concentrating on things two to six of the previous 14 days. - The resident required extensive assistance of one staff for eating. - The resident's [DIAGNOSES REDACTED]. - The resident coughed and choked during meals or when swallowing medications. - The resident had weight loss (greater than five percent in last month, or greater than ten percent in the lat six months). - The resident was not on a physician prescribed weight loss regimen. - The resident received a mechanically altered diet. - The resident was on hospice care. Record review of the resident's electronic weight record showed the following information: - On 12/02/13, the resident weighed 94 pounds. - On 01/06/14, the resident weighed 91 pounds. - On 02/04/14, the resident weighed 90 pounds. - On 03/10/14, the resident weighted 91 pounds. Record review of the resident's orders, dated 04/16/14, showed staff were to provide the resident with a house supplement three times a day. Record review of the resident's immediate plan of care, dated 04/16/14, showed the following information: - The resident received a mechanically altered diet. - Staff were to monitor the resident's daily dietary intake. - Staff were to weigh the resident weekly for four weeks and then monthly. - Staff were to provide assistance with eating. (Staff did not care plan the physician ordered supplement. Per the immediate care plan staff would weigh the resident on, or about, 04/16/14, 04/23/14, 04/30/14 and 05/07/14.) Record review of the resident's electronic weight record showed on 04/17/14 the resident weighed 87 pounds. (This was four pounds less than the resident weighed on 03/10/14.) Record review of the resident's Nutrition Data V2 form, dated 04/17/14 and completed by the DM, showed the following information: - Staff identified the resident as having had weight loss that was not significant weight loss. - The resident required extensive assistance. - The resident's average meal intake was 33%. - The resident lost weight while in the hospital. - Staff were to provide the resident with a supplement at meals. - The dietary manager recommended the staff to continue the resident's current diet as ordered and weigh the resident as directed. Record review of the resident's April 2014 Documentation Record form showed staff were to weigh the resident and document the resident's weights weekly. The weights were scheduled to be checked by staff on 04/22/14 and 04/29/14. (Staff did not document the resident's weights for either date on the form.) Record review of the resident's nutrition assessment, dated 04/29/14 and completed by the RD, showed the following information: - The resident had inadequate oral intake. - The RD recommended the resident continue on a pureed diet with nectar consistency liquids and receive a house supplement three times a day. (The last weight the RD had access to in the system was the admission weight on 04/17/14. The RD did not know if the resident had lost additional weight since returning to the facility. The RD made no new recommendations.) Record review of the resident's current care plan, dated 04/29/14, showed the following information: - The resident was at risk for weight loss related to [MEDICAL CONDITION] and resident having difficulty swallowing. - Staff were to help the resident with meals. - Staff were to provide his/her diet as ordered. - Staff were to provide thickened liquids on the refreshment cart three times a day. - Staff were to weigh the resident as directed. (Staff did not included the physician ordered supplements on the care plan.) Record review of the resident's electronic weight record showed the following information: - On 05/07/14, the resident weighted 78 pounds. - On 05/12/14, the resident weighed 78.6 pounds. (Staff failed to weigh the resident as care planned the week of 04/23/14 and the week of 04/30/14. The resident lost nine pounds, or 10.3 percent, between 04/17/14 and 05/07/14. The resident's physician was not notified of this weight loss.) Record review of the resident's current care plan, dated 04/29/14, showed on 05/15/14 staff updated the care plan with the intervention of supplements as ordered. (This was 28 days after the physician ordered the supplements.) Record review of the resident's nurses' notes, dated 04/16/14 through 05/24/14 showed staff did not document a discussion of the resident's weight or interventions for weight loss. During an interview on 05/29/14, at 10:25 A.M., the DM said the resident had lost weight and his/her diet was downgraded. The resident was having problems with choking. The DM thought the physician had signed off that the weight loss was unavoidable, but the letter was not in the medical record. During an interview on 06/05/14, at 3:41 P.M., the RD said she reviewed the resident on 05/20/14 and suggested staff discontinue the finger food order since the resident was on a pureed diet. Staff did not talk to the RD about any swallowing or choking problems. 5. Record review of Resident #3's electronic medical record showed the facility admitted the resident on 01/18/13. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: - The facility readmitted the resident on 11/12/13. - The resident's BIMS score was a four. - The resident had fluctuating periods of inattention and disorganized thinking. - The resident required supervision with encouragement and cueing for eating. - The resident had [DIAGNOSES REDACTED]. - The resident had weight loss of five percent or more in the prior month, or ten percent or more in the last six months. - The resident was not on a physician prescribed weight loss regimen. - The resident's weight was 147. - The resident received a therapeutic diet. Record review of the resident's Order Summary Report, dated 05/29/14, showed the following information: - The resident's [DIAGNOSES REDACTED]. - The resident was on a no salt packet diet. - An order, dated 12/06/13, for staff to weigh the resident monthly on the sixth of each month. Record review of the resident's care plan, last reviewed on 04/25/14, showed the following information: - The resident needed assistance for staff for activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting). - Staff will assist with ADLs and encourage the resident to do as much for his/her self as possible. - Resident is at nutritional risk related to a therapeutic diet and [DIAGNOSES REDACTED]. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), [MEDICAL CONDITION] (a rapid irregular heartbeat) and high blood pressure. - The resident is to maintain nutritional status as evidenced by no significant weight loss by the next review. - Staff to provide diet as ordered. - Staff to weigh as directed. Record review of the resident's medical record showed the following weights: - On 12/02/13, the resident weighed 156 pounds. - On 01/02/14, the resident weighed 150 pounds. - On 02/04/14, the resident weighted 147 pounds. - On 03/09/14, the resident weighed 156 pounds. (Staff noted this was in a wheelchair.) - On 04/04/14, the resident weighed 147 pounds. Record review of the resident's Nutritional Data V2 form, dated 04/07/14 and completed by the dietary manager showed the following information: - The resident's admit weight was 167 and his/her current weight was 147. (An 11.9 percent loss.) - The resident's average intake is 83% of meals. - The resident feeds self with encouragement and was on a heart healthy diet. - The resident triggered for weight loss. - Staff to add extra calories to the resident's meals and add a sandwich to breakfast and as a bedtime snack. - Staff to add ice cream to supper. - Staff to weigh the resident weekly in April and then as directed. - Staff to continue the resident's diet as ordered. Record review of the resident's care plan, last reviewed on 04/25/14, showed the following information: - Staff updated the care plan on 04/07/14 for extra calories at breakfast and supper. - Staff updated the care plan on 04/25/14 with an sandwich for a bed time snack. Record review of the resident's Order Summary Report, dated 05/29/14, showed an order dated 04/30/14 for staff to administer [MEDICATION NAME] (an appetite stimulant) to the resident daily. (Staff did not update the care plan with this intervention.) Record review of the resident's medical record showed on 05/12/14 the resident weighed 145 pounds. (This was two pounds less then the resident's weight on 04/04/14. Staff had not weighed the resident weekly in the month of April 2014 as the DM has recommended.) Record review of the resident's nurses' notes from 05/01/14 through 05/27/14 showed no discussion of the resident's weight loss or monitoring of the resident's weight. Record review of the resident's Medical Nutrition Therapy Recommendations form, dated 05/20/14, showed the RD recommended liberalizing the resident's diet to regular with no salt packets. The resident had lost 15 pound and his/her intake was 80 percent. The resident was on [MEDICATION NAME] for an appetite stimulant. During an interview on 05/28/14, at 2:45 P.M., the Director of Nursing (DON) said staff were not completing weekly weights for the resident. An order was never entered in the computer system for the weights. If the DM made the suggestion for weekly weights the order should have been entered. The DON said she thought the March 2014 weight was an incorrect weight. During an interview on 05/29/14, at 10:25 A.M., the DM said the resident was not seen by the RD until 05/20/14 when the DM made the reccommendation to liberalize the resident's diet. During an interview on 06/05/14, at 3:41 P.M., the RD said she had not been asked to review the resident since January. On 05/20/14 she did pick the resident at random and looked at liberalizing his/her diet. 6. Record review of the Weight/Vital's Record forms showed the following information: - The forms did not include a spot for staff to document what day the weight of a resident was obtained. - On 05/29/14, staff had weighed and documented the weight of 13 residents on the June 2014 form for the Cherry Hall on the upper level. - On 05/29/14, staff had weighed and documented the weight for seven residents on the June 2014 form for Cedar Hall. 7. During an interview on 05/28/14, Registered Nurse (RN) G said all residents are weighed monthly. Some are also weighed weekly or daily. The computer system will prompt staff for the weekly and daily weights. Nurses put the weights in the system. The dietary manager monitors residents for weight loss. If there are any recommendations, the dietitian provides a sheet that they can review and it will list what they will be doing. The dining room has plenty of help to assist residents. Staff can offer alternatives, however some residents just do not want to eat. During an interview on 05/29/14, at 1:42 P.M., LPN A said the overnight shift completes weights on residents. There is a clip board where the staff write the weights down and then someone puts the weights in the system. Monthly weights are normally completed the first week of the month. Daily or weekly weights are weighed on specific dates. Staff puts an order in the computer system for the daily and weekly weights. A newly admitted resident will have weekly weights for four weeks. Staff will reweigh someone if there is a variance of three to five pounds. Staff reweigh the resident the next day. During an interview on 05/29/14, at 2:00 P.M., LPN B said residents are weighed once a week for four weeks upon admission to the facility. The staff have lists at the nurses' stations of residents who need weekly or daily weights. Staff have to put monthly weights in the system by the sixth of the month. The staff start weighing the residents on the first of the month. The CNAs on the third shift weigh the residents. The DM goes over weight losses in the morning meeting. The RD also reviews them. If there are any diet recommendations the nurse calls the physician and they ask for his suggestions. These new orders are put into the system. The nurses receive a piece of paper that lists which residents need to have their physicians notified. During an interview on 05/29/14, at 2:28 P.M., LPN H said the overnight shift staff complete weights on the residents. There is a weight book that weights are written down in monthly. The DM evaluates what needs to be done in regards to weight loss. The DM runs reports that identifies which residents are weight loss residents. Staff start completing weights at the end of the month before the month the weights are due to be put into the computer system. The DM tells the staff who has weight loss. The nurse calls the physician and gets guidance on interventions. The DM decides what residents need reweighed and staff complete them by the next day. During an interview on 05/29/14, at 2:45 P.M., CNA C said night shift weighs the residents, but the day shift could do it also. There is a sheet on the clipboard that staff write weights on. The CNA did not know who completed computer input of weights. The DM reviews the weights and if a resident needs reweighed she highlights them and staff reweigh them within the day. During an interview on 05/29/14, at 3:00 PM., CNA D said the charge nurse tells them of any weights that need to be completed. During an interview on 05/29/14, at 3:25 P.M., LPN E said all residents are weighed monthly. The nurses receive a list of residents who need weekly and daily weights. The nurses contact the physician about weight loss and the dietitian also looks at them. The DM and RD monitor the weight losses. During an interview on 05/29/14, at 10:25 A.M., the DM said residents are weighed monthly. She prints the report monthly and puts them in the nursing notebooks for the weights to be completed. She runs the weight loss report twice a month to make sure no residents are missed. The monthly weights should be entered by the tenth of each month. If she has a concern about a resident with weight loss the concern is discussed at stand up meeting and at care plan meetings. The DM said she will make notes about weights when the quarterly MDS is due. The DM said she needs to make more notes about what is reviewed and what actions are taken. If a resident's weight loss is unavoidable there should be a copy of a statement from the physician in medical record. She also keeps a copy in her office. She updates the care plan for any weight loss concerns. If any supplements are asked for this would be in the medical record also. The RD had been coming twice a month, but in May 2014 she has been coming weekly. If the DM wants weekly weights kept track of she puts a sheet out to the nurses. If a resident needs to be re-weighed, the DM highlights the weight in the monthly weight book. Staff know to look at this periodically. Any interventions that need to be put into place are dependent on the RD and the physician. The DM does not make recommendations. Staff can complete weights as early as the 26th of the month prior to the month the weights are entered for. The policy is for the nurses to contact the physician about weight loss, but the DM is the one that does it. The DM said the report triggers for weight loss in the last 30, last 90 and last 180 days. The report only triggers for significant weight loss. The facility does not look at the 90 day numbers since the MDS does not ask for these. During an interview on 05/29/14, at 12:10 P.M., RN Assessment Coordinator said she completes MDSs and care plans. The DM completes the weight/nutrition part of the care plan and completes updates of this part of the care plan. The RD reviews the weight report and staff discuss weights at stand-up meetings and at care plan meetings. During an interview on 06/05/14, at 3:41 P.M., the RD said she has been at the facility weekly recently, but is there a minimum of twice a month. The RD does assessments on all resident who have annual, initial or significant change MDSs. She can pull a report that shows weight loss and if she sees someone she has not reviewed recently she will look at them. She tries to not change interventions too quickly because she wants to give them time to work. For this reason she will not necessarily review someone on the weight loss list if she has recently reviewed them and made recommendations. Any recommendations are written on the Medical Nutrition Therapy Recommendation form that she gives to DM and DON for any recommendations. Residents are weighed at least monthly. During an interview on 05/29/14, the DON said all residents are weighed monthly. Dietary staff enter the monthly weights in the computer. The CNA on the night shift normally completes the weights. Residents are weighed for four weeks upon admission to the facility. Those weights are entered by the nurses. She does not know how often the DM pulls the weight loss report to review it. Weights are discussed in morning meeting. Staff begin weighing residents the 25th or 26th of the month before the month the weights are put in for so they can be inputted in the system the first of the next month. The date entered is not necessarily the date the resident was weighed. Staff do this because dietary enters the monthly weights. Nursing staff notify the physician of weight losses and recommendations. MO 980

Based on interview and record review the facility failed to identify one resident's (Resident #1) risk for choking on bread products, failed to care plan the resident's risk for choking on bread products and failed ensure staff were aware of the resident's risk for choking on bread product when the resident was readmitted to the facility. This resulted in staff providing the resident bread during a meal when assisting the resident with eating. The resident choked on the bread provided by facility staff. Facility staff had to administer the Heimlich Maneuver to dislodge the piece of bread. The facility census was 85. 1. Record review of Resident #1's electronic medical record showed the following information: - The facility admitted the resident on 11/26/13. - The facility discharged the resident to the hospital on [DATE]. - The facility readmitted the resident on 04/16/14. - The resident passed away on 05/24/14. - The resident's [DIAGNOSES REDACTED]. Record review of the resident's immediate plan of care, dated 02/07/14, showed the resident had swallowing and choking problems on untoasted bread. Staff was to only provide the resident with toasted bread. Record review of the resident's hospice clinical note, dated 02/28/14, showed the resident chokes, especially on bread products. Record review of the resident's hospice clinical note, dated 03/07/14, showed the resident had dysphagia and chokes. The staff had care planned staff to eliminate bread product from the resident's diet due to choking. Record review of the resident's care plan, updated 03/12/14, showed staff did not update the resident's care plan to show the resident was not to receive any bread products. Record review of the resident's nutritional update, dated 03/12/14, showed the resident was a risk for weight loss related to Alzheimer's disease. The resident had difficulty swallowing and choking on untoasted bread. (The update did not include hospice's update that the resident was not to receive any bread products.) During an interview on 05/29/14, at 1:42 P.M., Licensed Practical Nurse (LPN) A said the resident had choking issues when he/she was in the special care unit prior to her last hospital stay. When the resident returned he/she was placed on the main floor. The resident's throat had narrowed and he/she would choke on bread products. The resident seemed to do better if the bread was toasted. The staff on the unit decided to eliminate bread products due to the resident's choking risk. The nurse should update this on the care plan. Record review of the resident's discharge summary from the Cass Regional Medical Center, dated 04/16/14, showed staff was to provide the resident with a soft diet with regular liquids. The staff were not to provide the resident with bread due to the choking risk. Record review of the resident's transfer form, dated 04/16/14, showed the staff were to provide the resident a soft diet with no straws. The staff were to provide resident was to receive finger foods if possible. The resident was not to receive any bread. Record review of the resident's admission nurse's note, dated 04/16/14 at 3:16 P.M., showed staff did not document any special diet or diet restrictions for the resident. Staff did not document the resident was a choking risk or that he/she had problems swallowing. Record review of the resident's immediate plan of care for nutritional risk, dated 04/16/14, showed the following information: - The resident was on a mechanically altered diet. - Staff were to monitor the resident's daily dietary intake. - Staff were to provided the resident assistance with eating. (Staff did not include the resident's choking risk or his/her difficulty swallowing. The staff did not include the direction from the hospital for the resident to not have bread products.) Record review of the resident's nurse's note, dated 04/17/14 at 3:20 P.M. and 04/18/14 at 3:30 P.M., showed the staff did not document anything about any special diet or diet limitation of the resident. Staff did not document the resident's choking risk or swallowing problems. Record review of the resident's nurses' notes showed the following information: - On 04/18/14, at 5:28 P.M., LPN B documented a certified nurse aide (CNA) noted the resident appeared to be choking in the main dining room at the table during the afternoon meal. The medication nurse extracted a piece of bread by providing the Heimlich Maneuver. Staff notified hospice of the incident. - On 04/18/14, at 5:30 P.M., Registered Nurse (RN) F documented the resident had a choking episode in the main dining room. The resident was assisted to his/her room. The resident was able cough up a small piece of green bean. Staff notified hospice of the incident. Record review of the resident's change of condition nurse's note, dated 04/21/14, at 11:29 A.M., showed the resident had two choking episodes on Friday and hospice gave orders to change the resident's diet to pureed diet for a trial run. (Staff did not discuss the resident receiving bread when the hospital directed the staff to not provide bread to the resident.) Record review of the resident's physician's orders [REDACTED]. Record review of the resident's admission minimum data set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 04/23/14, showed the following information: - The resident had short and long-term memory problems. - The resident had severely impaired cognitive skills. - The resident required extensive assistance of one staff for locomotion and eating. - The resident used a wheelchair for mobility. - The resident coughs or chokes during meals or when swallowing medications. - The resident received a mechanically altered diet. Record review of the resident's current care plan, last reviewed on 04/29/14, showed the following information: - The resident was at nutritional risk for weight loss related to his/her [DIAGNOSES REDACTED]. - The resident had difficulty swallowing. - Staff to assist the resident with meals. - Staff to provided ordered diet. - Staff to provide thicken liquids for the resident on the refreshment cart three times a day. (Staff did not include the direction for the resident to not have bread due to the choking hazard.) During an interview on 05/29/14, at 10:25 A.M. and 1:23 P.M., the dietary manager said if a resident had a risk for choking, or trouble swallowing, that should be located on the care plan. If the resident had a risk for choking on a specific food that would not be placed on the care plan. This would be located on the resident's meal ticket (a slip of paper placed on resident's meal trays at each meal). Resident #1 was a risk for choking. The resident was changed to a pureed diet due to the resident choking on a green bean. The dietary manager was not aware the resident choked on bread on 04/18/14. During an interview on 05/29/14, at 12:10 P.M. and 1:30 P.M., the RN Assessment Coordinator said she completed the MDS's and care plans. The dietary manager completes the nutrition part of the care plan. A resident's choking risk, or swallowing problem, could be care planned by her if the if therapy services were being received. If there were no therapy services involved the dietary manager would place the risk on in the nutritional care plan. The RN said food preference, or the inability to have a specific food, would be located on the meal ticket from the kitchen with meals and not necessarily on the care plan. The RN was not aware of the the resident's choking risk and was not aware the resident was not to have bread. During an interview on 05/29/14, at 2:00 P.M., LPN B said if a resident has a choking risk this should be on the care plan and on the resident's meal ticket. The CNAs should check the meal tickets at each meal when assisting residents. Resident #1 had a hard time with a regular diet. The staff tried a mechanical soft diet for him/her and then a pureed diet. Bread was the factor in the resident's choking episode. The LPN said he/she is confident it was bread the resident choked on. A CNA assisted the resident with the meal and the bread had been part of the meal. The CNA did not know the resident was not supposed to have bread. The staff on the floor where the resident lived was not familiar with the resident because the resident had been located in the unit before his/her last hospital stay. During an interview on 5/29/14, at 2:45 P.M., CNA C said he/she was familiar with the resident. She did not know anything about the resident not receiving bread products. During an interview on 05/29/14, at 3:00 P.M., CNA D said the meal ticket provided by the kitchen lists anything special about each resident's diet on it. The CNA was familiar with the resident and did not remember the resident having any restrictions regarding what he/she could eat. He/she does not remember any problems with the resident eating bread products. During an interview on 05/29/14, at 3:25 P.M., LPN E said the diet and diet restrictions should be located on the care plans so it can be looked at. The LPN will use that as a reference when family asks if they can give the resident something. He/she did not work the day the resident choked and had to have the Heimlich Maneuver. The LPN said the unit staff told the floor staff the resident can eat bread fine as long as it is toasted. During an interview on 05/29/14, at 4:00 P.M., the Director of Nursing (DON) said the dietary manager takes care of the nutrition care plans. If a resident has a swallowing, or a choking problem, this should be care planned by the dietary manger. If a resident cannot have a specific food this should be on the care plan and on the meal ticket provided by the kitchen. The DON was not aware the resident was not to receive bread. The DON was aware the resident had choked on the green bean, but was not aware the resident had chocked on bread. During an interview on 06/05/14, the registered dietitian said the resident's swallowing and choking problems were not discussed with him/her. MO 980