Every finding on record at Advanced Care of St Joseph

Based on observation, interview and record review, the facility failed to protect two resident's right to choice when the facility did not provide written notification of room changes to two residents (Residents #1 and #2) or their family members. This affected two residents of five residents sampled. The facility's census was 155. Review of facility policy Resident Rights, revised 9/1/24, showed:- The resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed;- The resident had the right to refuse to transfer to another room in the facility if the purpose of the transfer was solely for the convenience of the staff;- The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident;1.Review of Resident #1's admission Record, dated 11/20/25 showed the resident had a diagnosis of stroke, epilepsy, depression, and an anxiety disorder. Review of Resident's Care Plan, dated 11/4/25, showed:- Resident had the right to be fully informed of advance plans of a change in rooms and roommates;- Resident used anti-anxiety medications related to anxiety disorder. Staff should involve the resident in decision making as much as possible. During an interview on 11/19/25 at 11:40 A.M., the Resident said:- He/she had six room changes over the last six weeks. He/she had not been given the choice to decline the room change. Written notifications were not provided and the move had been done the same day the resident was notified. He/She became recently distraught over a room change and begged the staff not to be moved; became upset and crying but was moved anyway and not given any choice. The resident said he/she gets upset and feels he/she had no rights.During an interview on 11/19/25 at 4:20 P.M., the resident's family member said:- He/she was the responsible party for the resident. He/she was never notified of a room change for at least five room changes that had occurred. He/she never received any written notification or discussion regarding the reason to move from one room to another. 2.Review of Resident #2's admission Record, dated 11/20/25, showed:- He/she was own responsible party;- Diagnosis of: congenital heart disease and anxiety disorder.Review of Resident's Care Plan, dated 7/24/25, showed:- Resident had the right to be fully informed of advance plans of a change in rooms and roommates;- Resident used antidepressant medication related to depression and should be involved in decision making as much as possible.During an interview on 11/20/25 at 8:25 A.M., the Resident said:- He/she was notified on the morning of 11/8/25 that he/she was changing rooms. He/she did not want to change roommates and did not want to move and expressed that to staff. While the resident was at lunch on 11/18/25 the facility staff moved his/her belongings to another room even through he/she had declined to move. The facility did not allow him/her to have a say or to be part of the room move and this made him/her very angry and felt his/her rights were violated. During an interview on 11/20/25 at 9:10 A.M., the Social Services Director (SSD) said:- Most of the moves that have happened recently are due to COVID. There were multiple room moves due to maintenance but normally the resident returns to his/her original room within a day once the maintenance project is complete. Whenever a resident is going to have a permanent move, she will talk to the resident face to face to explain the move. If a resident does not want to move that is their right and they will not be moved. Notifications are sometimes done at the last minute up to a couple of hours of notice to the resident. Resident room changes are discussed at the morning meeting with the Administrator and other staff members and then executed later that day. She likes to provide up to 72 hours' notice to a resident when there is a change in rooms. Currently there is no policy or process in place regarding room changes. If a resident is crying because of a room change staff should get her so she can handle the situation. A resident should not be forced to move unless under the direst of circumstances, such as resident safety. She has no records of sending out notices to residents about room changes and she does not provide written notices to residents or family members. She will call family members about room changes prior to the move.Intake 2640950

Based on observation, interview, and record review, the facility failed to ensure staff provided catheter care (a sterile tube inserted into the urinary bladder to drain urine) in a manner to prevent urinary tract infection (UTI) or the possibility of a UTI, when staff cleaned the catheter tubing towards rather than away from the resident's insertion site and when staff failed to empty the urinary collection bag when full. This affected one of the six sampled residents (Resident #39). The facility census was 149. Review of the facility policy titled Catheter Care, dated 9/1/21, showed: - It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;- Catheter care will be performed every shift and as needed by nursing personnel; Clean catheter tubing away from urinary opening;- Empty drainage bag when bag is half-full or every three to six hours;- Compliance Guidelines: Knock and gain permission to enter the resident's room, explain the procedure, provide privacy, gather supplies, assist resident to a lying position or most comfortable, drape resident to expose only the perineal area, perform hand hygiene, apply gloves;- Female Steps: gently separate the labia to expose the urinary meatus, wipe from front to back with a clean moistened with water cloth and perineal cleaner (soap), use a new part of the cloth or different cloth for each side, with a new moistened cloth starting at the urinary meatus moving out wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter, dry area with towel, gather all supplies used and discard items in the trash can. - The policy did not address how to clean or maintain the catheter tubing.1.Review of Resident #39's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/25, showed:- Cognitive skills intact;- Dependent on the staff for catheter care, personal care, hygiene and mobility needs;- Diagnoses included: paraplegia (partial or complete inability to move and/or feel in the lower half of the body, including the legs and feet, resulting from damage to the spinal cord or peripheral nerves), neurogenic bladder (condition where the nerves that control the bladder do not function properly, leading to difficulty with urination), anxiety, and a suprapubic urinary catheter.Review of the resident's care plan, revised 8/14/25, showed:- The resident had a indwelling suprapubic catheter (long-term urinary drainage device that is inserted directly into the bladder through a small incision in the lower abdomen);- The resident was on diuretic therapy (medications that increase urine output by promoting the excretion of sodium, water, and other electrolytes from the kidneys);- The resident was totally dependent on staff for all cares; including the care and maintenance of the suprapubic catheter and urinary collection bag; -The care plan did not address emptying of the urine collection bag more frequently to prevent back flow.Review of the resident's physician order sheet (POS) dated August 2025 showed:- Start date: 5/8/25 - suprapubic catheter care every shift and as needed;- Start date: 8/20/25 - certified nursing assistant (CNA) to empty catheter drainage bag every morning or as needed;- Start date and complete date 8/25/25 - Fluconazole (an antifungal medication) 150 milligrams give one time for UTI. Record review of the resident's catheter output collection time, each time it was emptied, for the month August 2025., showed:-8/1/25 at 1:59 P.M., 3200 cubic centimeter (cc- 1 milliliter is equal to 1 cc) output;-8/2/25 at 1:59 P.M., 1800 cc output;-8/3/25 at 9:59 P.M., 1250 cc output;-8/4/25 at 1:23 P.M., 3000 cc output;-8/10/25 at 1:56 P.M., 4800 cc output;-8/15/25 at 8:08 P.M,. 5000 cc output;-8/17/25 at 12:10 P.M., 4500 cc output;Review showed larges amounts were emptied from the catheter and the catheter was only emptied once a day on each of these days. During an interview on 8/26/25 at 10:15 A.M., the resident said:- He/She used the call light at 12:00 P.M. on 8/16/25 so staff could empty his/her catheter bag;- He/She called the reception desk number for the facility thirteen times over a 75-minute period to alert staff of his/her distress;- Licensed Practical Nurse (LPN) A answered the call light at 1:15 P.M. and drained 3200 cc of urine from the bag; - He/She was in extreme discomfort due to the volume in the bag and having to wait for over an hour;- He/She said on 8/19/25 the same type of issue occurred again;- The catheter bag was not being emptied three times a day as required; and he/she is on antibiotics again. During an interview on 8/26/25 at 11:00 A.M., LPN A said:- He/she was on duty on Sunday 8/16/25 and they were shorthanded that day;- He/she was working away from the desk with two Certified Nurse Aides (CNAs) attending to residents and did not see the resident's call light go off;- LPN A received a call from a local hospital notifying him/her the police were contacted by the resident asking for assistance;- LPN A immediately went to the resident's room and emptied the catheter bag which contained approximately 2000 cc of urine; - A full bag is 1500 cc, so 2000 cc is a lot of volume for the bag. - Any nursing staff member can empty the catheter bag. During an interview on 8/26/25 at 11:20 A.M., the Assistant Director of Nursing (ADON) said:- She had attended the resident's Care Plan meeting on 8/19/25;- The resident informed staff at the meeting he/she was concerned about his/her catheter bag not being emptied enough by staff and his/her catheter was not being well cared for by the staff. -The time frames on the catheter care were adjusted to address the resident's request. During an interview on 8/26/26 at 12:15 P.M., the Social Services Director (SSD) said:- She attended the resident's Care Plan meeting and the resident said his/her catheter bag was not being emptied due to long periods of time between staff checking on him/her;- The resident said he/she had a wait time of over one hour before staff would answer his/her call light to empty his/her catheter bag.- The resident' was not happy with the way staff had been caring for his/her catheter. - The care plan was revised on 8/19/25 to show that catheter tubing should be below the bladder to prevent back flow of urine, monitor and document urinary output from catheter each shift, monitor for signs and symptoms of UTI.Observation on 8/27/25 at 10:38 A.M., showed:- CNA A and CNA B entered resident room to perform catheter care and peri-care;- CNA A cleaned the insertion site of the catheter with a washcloth and soap and water, but did not clean down the catheter tubing; CNA A did not clean away from the insertion site and did not empty the drainage bag as it had been emptied by someone else. CNA changed gloves and did not sanitize or wash hands before putting on new gloves four times during the process. During an interview on 8/27/25 at 10:45 A.M., CNA A said the resident's catheter bag did not need emptied, but if it did he/she would put a paper towel on the ground, then place the graduate on the paper towel to empty the catheter and would clean the port with a wet wipe then place the graduate on a flat surface to measure the output. The catheter bag should be emptied when it is full and as needed, followed by documenting the amounts.During an interview on 8/27/25 at 3:55 P.M., CNA A said he/she should have cleaned away from the urinary opening.During an interview on 8/27/25 at 12:00 P.M., Registered Nurse (RN) A said:- An alcohol pad should be used to wipe the drain on a catheter bag;- Catheter bags should be checked and emptied with every round if needed.- Staff should clean away from the catheter insertion site.Observation on 8/27/25 2:55 P.M., showed CNA A:- Emptied 850 milliliters (ml) from the catheter bag then dumped the graduate, then emptied another 750ml from the catheter bag and dumped that in the toilet then cleaned the graduate; - Used a wet wipe to clean the catheter port and did not use an alcohol prep pad. During an interview on 8/27/25 at 10:15 A.M., the ADON said catheter bags should be emptied every time catheter cares is performed or as needed by nursing staff.During an interview on 8/26/25 at 1:10 P.M., the Director of Nursing (DON) said: - Staffing on the weekends had been a struggle with last minute call ins, but they had a clinical person on call in rotation to help with this issue;- She would not expect a resident to wait for over an hour for their call light to be answered; she would expect full catheter bags to be emptied if full and not wait until the end of shift.-Nursing staff are to clean away from urinary insertion site and away from the body when cleaning the tubing.Intake 2593726

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of the 18 sampled residents (Resident #88) when staff failed to administer the resident's scheduled seizure medication as ordered, per facility documentation the resident had unfortunately ran out of his/her seizure medication which likely resulted in a breakthrough seizure. The facility census was 144.Review of the facilities resident right policy dated. 9/1/2021., showed:Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 1. Review of resident #88's Face Sheet record, showed: -The resident was admitted to the facility on [DATE].-Resident is cognitively intact. -Diagnoses includes: abnormalities of gait and mobility, generalized muscle weakness, and seizures. Review of resident's care plan, dated 3/2/25., showed: The resident will be free of injury, with the intervention of administering medication as ordered by physician. The resident will be free from injury from seizure activity with the intervention of administering medication as ordered by physician. Review of the residents medical record for the month of February., showed:-Physician Order for Lacosimide (seizure medication) was not administered during HS (bedtime) medication pass on 2/17/25 as well as 2/18/25 morning medication pass. -Provider Progress Notes from nurse practitioner's (APRN) (Advanced Practice Registered Nurse] visit, dated 3/12/25 showed that the resident had a fall in the bathroom on 2/21/25 and appeared to be postictal (recovering from seizure activity) and per nursing documentation had another seizure later that day. The resident had imaging done that showed a left greater trochanteric fracture (left hip fracture). The APRN note showed that the resident had unfortunately ran out of his/her seizure medication which likely resulted in a breakthrough seizure. During an interview on 06/30/25 04:15 P.M. the Resident said he/she had to go to the hospital in January or February of 2025 because the facility had ran out of his/her seizure medication causing the resident to have a seizure, and fall with injury.During an interview on 07/03/25 at 08:26 A.M. CMT A said that if a resident runs out medications he/she would call pharmacy to get the medication. CMT A had noticed that this has happened twice with the other medications. CMT A reports that when the medication runs out and needs to be ordered it comes in the same day and it is documented that the pharmacy was called and medication was ordered in the progress notes. During an interview on 07/03/25 at 08:29 A.M. CMT B said that he/she pulls the sticker off the medication cards to be reordered when there are seven days left of the medication, unless it is a narcotic then he/she makes sure it gets reordered when there are 14 left. CMT B reports that medications get delivered between 3:00-4:00 P.M. CMT B reports that he/she has not had any instances of residents running out of medications and residents not getting their medications. CMT B stated that if a medication runs out on the medication cart he/she goes to the Emergency Medication Supply Kit that contains overflow medications to give to residents if the facility runs out of medications. CMT B reports that if a narcotic runs out he/she would call to get a script so the medication can be reordered and that the medications come in on the same day.During an interview on 07/03/25 at 11:49 AM The DON (Director of Nursing) stated that medications are to be reordered when there are three to five days of the medication left. The DON stated that staff can either reorder medication through the computer or send a fax to get the medication reordered. The DON stated that if a resident runs out of a medication the facility has a pyxis that has stock medication that can be used. If a resident runs out of a medication then the CMT will need to let the charge nurse know so the charge nurse can call the provider to let the provider know that the resident did not get the medication or to get a new order. The charge nurse will also call the pharmacy so they can get the medication sooner than typical deliveries. The medication may come in on the same day. The DON stated that the facility has revamped their pyxis so it now has stock medications as well as narcotics so if a resident runs out of narcotic medication the resident would still be able to get their medication.

Based on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to wear beard nets while working in the kitchen, and failed to maintain proper standards of cleanliness in the walk-in refrigerator. This had the potential to impact all residents by placing them at risk for a food borne illness. The facility census was 144.Review of facility policy Dietary Employee Personal Hygiene, revised 9/1/22, showed all dietary staff must wear hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting food;Review of facility policy Ready to Eat, Time/Temperature, dated 5/30/19, showed leftovers have seven days before they must be discarded and not used for human consumption;A request was made for the facility policy on Kitchen Cleanliness and no policy was provided;During an observation in the Kitchen on 6/30/25 at 8:56 A.M., showed:- Dietary Aide (A) working at the dishwashing station processing dirty dishes with a full beard and no beard net on;- Weekly cleaning schedule posted for the month of May 2025 had only two completed assignments out of 7 for the first week of May. All other checks for the month were blank and no cleaning assignments had been posted for the month of June 2025. Walk-in Refrigerator showed:- Corner of the floor between two racks was moldy fruit and three single serving butter containers lying on the floor. Overall area of this corner contained dirt and grime in a 4 by 6 area on the floor;- Base of wall and floor had black grime 8 in length;- Multiple shelves had heavy rust on racking support rods throughout the refrigerator;- Leftover sauerkraut dated 6/21/25 in plastic sealed container expired;- Leftover sliced onions dated 6/18/25 in plastic sealed container expired;- Leftover sliced tomatoes in plastic container not sealed;- Leftover cheese dated 6/18/25 in plastic sealed container was expired;During an interview on 6/30/25 at 9:15 A.M., the DM (dietary manager) said:- The facility is currently short three part time positions for the evening shift dishwasher and kitchen aides;- Fresh items, such as fruit and vegetables, that are resealed have seven days before they are expired and need to be discarded;- Cooked meat and vegetables have three days only before they must be discarded. Anything re-packaged on 6/30/25 would be discarded at the end of the day on 7/2/25;During an observation on 7/2/25 at 9:45 A.M., showed Dietary Aide (A) working at the dishwashing station processing dirty dishes with a full beard and no beard net donned;During an observation on 7/2/25 at 12:35 P.M., showed:- Dietary Aide (A) delivered a cart of food trays for residents to 200 Hall. The plastic which was covering the entire food cart was touching the dessert icing of an uncovered serving of cake at the bottom level of the cart;- NA (A) passing out hall trays on 200 Hall. Several trays had spilled liquids from uncovered drink cups which had dampened resident napkins and utensils;- None of the drinks or desserts were covered on the food cart except for the plastic placed over the entire cart; During an interview on 7/2/25 at 2:30 P.M., the Registered Dietician and DM said:- [NAME] nets must be worn if the facial hair growth is longer than an eyelash and it applies to the Dietary Aide (A) while working as the dishwasher in the kitchen;- There should be a weekly cleaning schedule posted in the kitchen and initialed by staff when each task is completed. Expectations are that daily and rotated deep cleaning assignments will keep the kitchen in a continued state of high cleanliness;- Would not expect to find moldy fruit lying on the floor in the walk-in refrigerator;- Would not expect leftovers to be left in the refrigerator beyond seven days;- Would discard sliced onions, sauerkraut, and cheese if it was beyond seven days in the refrigerator and sealed as a leftover;- All leftover containers should be sealed shut against the open air while stored in the kitchen;- Items on the food carts are currently not covered except for the main course so that it retains heat. Desserts and drinks are not covered and the policy on this practice has changed back and forth over the years at the facility. It is possible for staff to cover these items during the making of each serving;During an interview on 7/3/25 at 12:15 P.M., the Administrator said:- She would expect beard nets to be worn when required in the kitchen;- There should be a weekly cleaning schedule posted in the kitchen for staff to initial and accomplish;- Would not expect to find moldy fruit on the floor of the walk-in refrigerator;- Would not expect leftovers to be in the kitchen past day seven;- Drinks and desserts should be covered when placed on the hall carts for delivery to the residents;- Would not expect spilled liquids on the hall trays, the trays should be returned to the kitchen and a new tray sent to the resident;

Based on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate when staff failed to document and screen a one resident (Resident #20) accurately during pain assessments and failed to properly document showers for two residents (Resident #12 and #121). This affected three out of 29 residents sampled. The census was 144. Review of facility policy Maintenance of Clinical Records, revised 6/2/22, showed:- The facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided as well as in a manageable size for use by the care providers;- The facility must maintain medical records on each resident that are: complete, accurately documented, and systematically organized;- The clinical record will contain: a record of the resident's assessments 1. Review of Resident #20's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/2/25, showed:- Resident is moderately cognitively impaired;- No behavioral symptoms or psychosis observed;- Diagnosis: chronic obstructive pulmonary disease (bronchitis), heart rhythm disorder, heart failure, Stage 4 cirrhosis of the liver, acid reflux, hepatitis, asthma, and respiratory failure; Review of Resident Care Plan, dated 5/28/25, showed:- Resident has life threatening illness stage 4 end of life cirrhosis of the liver. Resident will have physical and emotional needs met;- Monitor, document and report epigastric (abdominal) pain due to liver disease; Review of Resident Order Summary Report, dated 7/2/25, showed:- Acetaminophen tablet 500 mg two tablets by mouth every six hours as needed for pain, start date 5/28/25;- Gabapentin 300 mg give one capsule by mouth at bedtime for pain, start date 5/28/25; Review of Resident's Medication Administration Record, dated 7/2/25, showed:- 7/1 Assess Resident for pain every shift, day and night shifts reported pain level zero;- 612, 6/20 Assess Resident for pain every shift, day shifts reported zero pain level, night shifts reported pain level two;- 6/1-6/11, 6/13-6/19, 6/21-6/30 Assess Resident for pain every shift, day and night shifts reported pain level zero; During an interview on 6/30/25 at 10:47 A.M., Resident said:- Resident's current pain level is about an eight and it's constantly at that level;- The staff does not ask resident what his/her pain level is and resident doesn't recall staff asking about his/her pain during the month of June; 2. Review of Resident #12's Quarterly MDS, dated [DATE], showed:- Resident is cognitively intact;- Resident requires maximal assistance from staff for showering and bathing;- Diagnosis: heart failure, anxiety disorder, and respiratory failure; Review of Resident's Care Plan, revised 7/1/25, showed:- Resident is independent for most ADLs. Resident wishes to take showers on Sunday's only;- Staff will assist resident with taking showers at least two times weekly and the preferred times are Wednesday and Saturday evenings; Review of Resident's manually documented shower sheets, showed:- March 2025 Showers: 3/6, 3/13, 3/16, 3/20, 3/27 (5 of 8 required showers offered or conducted);- April 2025 Showers: 4/3, 4/10, 4/24 (3 of 8 required showers offered or conducted);- May 2025 Showers: 5/1, 5/5, 5/8, 5/22, 5/29 (5 of 8 required showers offered or conducted);- June 2025 Showers: 6/5, 6/6, 6/12, 6/19, 6/26, 6/30 (6 of 8 required showers offered or conducted); Review of Resident's Electronic Record of Showers, showed:- March 2025 Showers: (Entries with no staff member assigned or notes) 3/1, 3/5, 3/7, 3/8, 3/11, 3/13 (2 entries), 3/14, 3/15, 3/18, 3/25, 3/27; (Entries with staff member assigned) 3/6, 3/29, 3/30; Total March showers offered or given 15 documented entries;- April 2025 Showers: (Entries with no staff member assigned or notes) 4/10 (2 entries), 4/20; (Entries with staff member assigned) 4/3, 4/5, 4/13 (2 entries), 4/24 (2 entries), 4/27; Total April showers offered or given 10 documented entries;- May 2025 Showers: (Entries with no staff member assigned or notes) 5/4, 5/8 (2 entries), 5/10, 5/11, 5/15, 5/18, 5/22 (2 entries), 5/25, 5/26, 5/28, 5/29 (2 entries); (Entries with staff member assigned) 5/1 (2 entries), 5/5; Total May showers offered or given 17 documented entries;- June 2025 Showers: (Entries with no staff member assigned or notes) 6/1, 6/12, 6/22 (2 entries); (Entries with staff member assigned) 6/5 (2 entries), 6/26; Total June showers offered or given 7 documented entries; During an interview on 7/2/25 at 10:40 A.M., the ADON said:- If a resident has an order to assess them for pain each shift then staff should directly check on the resident to assess for pain. This can include verbal questions or seeing physical cues that the resident is in pain;- Nursing staff would be the staff members to monitor for pain daily for residents and chart the responses; 3. Review of Resident #121's Quarterly MDS, dated [DATE] showed:- Cognitive skills intact;- Required supervision with transfers;-Required partial to moderate assistance with showers;-Diagnoses included coronary artery disease (CAD), Congestive Heart Failure (CHF), high blood pressure, anxiety, bipolar, PTSD. Review of the resident's undated care plan showed:-The resident had an activities of daily living (ADL) self-care performance deficit relate to limited mobility. The resident required substantial to maximal assistance of one staff with bathing/showering twice weekly and as necessary. Preferred Thursday and Sunday during the day shift. Review of the resident's shower sheets for May 2025 showed the resident had a shower on the following dates:- 5/1, 5/4, 5/6, 5/8, 5/11, 5/13, 5/16, 5/18, 5/22 and 5/25. Review of the resident's point of care for May showed the resident had a shower on the following dates:-5/1 at 6:45 A.M. shower provided;-5/1 at 6:46 A.M., shower provided;-5/6 at 10:37 A.M., shower provided;-5/9 at 8:27 A.M., response not required;-5/10 at 6:47 A.M., response not required;-5/13 at 12:15 P.M., shower provided;-5/20 at 1:59 P.M., shower provided;-5/22 at 6:42 A.M., shower provided;-5/22 at 6:43 A.M., shower provided;-5/29 at 6:53 A.M., shower provided;-5/29 at 6:55 A.M., shower provided;-5/30 at 7:35 A.M., response not required. Review of the resident's shower sheets for June 2025 showed the resident had a shower on the following dates;- 6/3, 6/8, 6/12, 6/15, 6/19, 6/22, 6/24, 6/26 and 6/29. Review of the resident's point of care for June showed the resident had a shower on the following dates:-6/3 at 1:59 P.M., shower provided;-6/6 at 6:44 A.M., response not required;-6/7 at 7:18 A.M., response not required;-6/8/at 9:53 A.M., shower provided;-6/8 at 9:53 A.M., shower provided-6/12 at 10:10 A.M., shower provided;-6/12 at 10:10 A.M., shower provided;-6/12 at 4:01 P.M., response not required;-6/13 at 8:06 A.M., response not required;-6/13 at 3:37 P.M., response not required;-6/14 at 6:27 A.M., response not required;-6/15 at 7:13 A.M., shower provided;-6/15 at 7:13 A.M., shower provided;-6/20 at 7:46 A.M., response not required;-6/21 at 6:54 A.M., response not required;-6/25 at 23:05 P.M., response not required;-6/26 at 10:47 A.M., shower provided;-6/26 at 10:48 A.M., shower provided;-6/27 at 7:19 A.M., response not required;-6/28 at 7:20 A.M., response not required. During an interview on 7/3/25 at 11:24 A.M., Certified Medication Technician (CMT) E said when it said, response not required, he/she thought it meant the shower was not given. During an interview on 7/3/25 12:51 P.M., the DON said:-She was not for sure what response not required meant in the medical record;-He/She texted the Regional Registered Nurse who said it had to do with the level of assistance the resident needed.

Based on observations, interviews, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when obtaining blood sugars and the administration of insulin, failed to clean the port of the insulin pen prior to attaching the needle and failed to clean the glucometer between three of the 29 sampled residents, (Resident #64, #21, and #100) . The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed:- Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection;- Wash hands prior to administering medication per facility protocol and product;- Review Medication Administration Record (MAR) to identify medication to be administered;- Administer medication as ordered in accordance with manufacturer specifications;- Wash hands using facility protocol and product.Review of the facility's policy for Insulin Pen, revised 4/10/25 showed:- It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;- Insulin pens must be clearly labeled with the resident name, date dispensed type of insulin, amount to be given, frequency, and expiration date;- Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir;- Always review physician orders prior to administering any medication;- Procedure: perform hand hygiene and don gloves. Wipe the rubber seal with an alcohol pad and screw the pen needle onto the insulin pen. To prime the insulin, dial to two units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Turn the dose selector to ordered dose. Check the dose a second time. Cleanse the skin with an alcohol pad. Gently pinch up the skin at the injection site and hold. While still pressing plunger, keep the needle in the skin for up to six to ten seconds and then removed the needle from the skin. Remove gloves and perform hand hygiene.Review of the facility's policy for Glucometer Disinfection, revised 5/1/25 showed:-The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne disease to residents and employees;-The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use;-The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus;-Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use;-Procedure: wash hands and put on gloves. Obtain capillary blood sampling according to facility policy. Remove and discard gloves, perform hand hygiene prior to exiting room. Retrieve disinfectant wipe from container and follow manufacturer instructions on container or wipe package. Allow the glucometer to air dry;-Perform hand hygiene.1. Review of the resident's MAR, dated June 2025 showed:- Fiasp FlexTouch solution Pen-injector (fast acting insulin) 10 units before meals and at bedtime related to diabetes mellitus;- Insulin Glargine Solution pen injector (long-acting insulin) 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400;- The facility did not provide the MAR for July 2025.Review of Resident #64's Physician Order Sheet (POS) dated July 2025 showed:- Start date: 5/13/25 - Fiasp FlexTouch solution Pen-injector 10 units before meals and at bedtime related to diabetes mellitus;- Start date: 5/13/25 - Insulin Glargine Solution pen injector 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400.Observation and interview on 7/2/25 at 7:55 A.M., showed Licensed Practical Nurse (LPN) C obtained a blood sugar and administered insulin in the following manner: - He/She did not wash his/her hands and applied gloves;- He/She did not clean the port of the insulin pen and attached the needle;- He/She did not prime the Fiasp insulin pen with two units and dialed the insulin pen to 10 units;He/She did not prime the Insulin Glargine pen with two units and dialed the insulin pen to 20 units; - LPN C obtained the resident's blood sugar which was167.- LPN C administered both insulins in the back of the resident's right arm- LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.2. Review of Resident #21's MAR, dated June 2025 showed:- Humalog Kwik Pen solution pen-injector (fast acting insulin), 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400-The facility did not provide the MAR for July 2025.Review of the resident's POS dated July 2025 showed:-Start date: 5/13/25 - Humalog Kwik Pen solution pen-injector, 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400.Observation and interview on 7/2/25 at 8:02 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner:- The label on the insulin pen said 12 units in the morning;- He/She did not wash his/her hands and applied gloves;- He/She did not clean the port of the Humalog insulin pen and attached the needle;- He/She did not prime the Humalog insulin pen with two units and dialed the insulin pen to 10 units;- LPN C obtained the resident's blood sugar which was 242;- LPN C administered the insulin in the resident's right abdomen;- LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.3. Review of Resident #100's MAR, dated June 2025 showed:- Insulin NPH and Regular 70/30 (intermediate acting) insulin 10 units twice daily for diabetes mellitus before meals. Notify physician if blood sugar is less than 60 or greater than 400. Discontinued on 6/30/25.-The facility did not provide the MAR for July 2025.Review of the resident's POS, dated July 2025 showed:-Start date: 7/1/25 - Insulin NPH and Regular 70/30 insulin, 15 units twice daily for diabetes mellitus before meals. Notify the physician if blood sugar is less than 60 or greater than 400.Observation on 7/2/25 at 8:11 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner:-The label on the insulin pen said 10 units;-He/She did not wash his/her hands and applied gloves;-He/She did not clean the port of the insulin pen and attached the needle;-He/She did not prime the Novolin insulin pen with two units and dialed the insulin pen to 5 units;-LPN C obtained the resident's blood sugar which was 181;-LPN C administered the resident's insulin in his/her left upper arm;-LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.During an interview on 7/2/25 at 8:48 A.M., LPN C said:- He/She should have cleaned the insulin port with an alcohol wipe before the insulin needle was attached;- The insulin pens only must be primed when it is a new pen;- He/She should have cleaned the glucometer with a bleach wipe between each resident;- The insulin dose and the computer should have matching orders;- He/She should have washed and/or sanitized his/her hands between each resident and between glove changes.During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said;- Staff should clean the port of the insulin pen with an alcohol wipe before the needle is attached;- Staff should prime the insulin pen with two units before the insulin is administered;- Staff should wash their hands or sanitize before and after glove changes and between each resident;- Staff should clean the glucometer with a bleach wipe between each resident use.During an interview on 7/2/25 at 8:48 A.M., LPN C said:-He/She should have cleaned the insulin port with an alcohol wipe before the insulin needle was attached;-The insulin pens only must be primed when it is a new pen;-He/She should have cleaned the glucometer with a bleach wipe between each resident;-The insulin dose and the computer should have matching orders;-He/She should have washed and/or sanitized his/her hands between each resident and between glove changes.During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said;- Staff should clean the port of the insulin pen with an alcohol wipe before the needle is attached;- Staff should prime the insulin pen with two units before the insulin is administered;- Staff should wash their hands or sanitize before and after glove changes and between each resident;- Staff should clean the glucometer with a bleach wipe between each resident use.

Based on interview, observation, and record review, the facility failed to ensure that the food served to the residents was appealing and appetizing when residents at a group meeting and one Resident (#32) out of 18 sampled residents verbalized concerns over the quality of the food. The facility census was 144.Review of the facility's Food Preparation Guidelines, undated, showed:- It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition or hydration status;- Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature;- Strategies to ensure resident satisfaction include:* providing meals that are varied in color and texture;* serving hot foods/drinks hot and cold foods/drinks cold;* addressing resident complaints about foods/drinks;- Staff shall accommodate resident allergies, intolerance's, and preferences, providing appropriate alternatives when needed;- Staff shall offer residents appropriate alternatives when they choose not to consume food/drink that is initially served or when a different food/drink choice is requested.1. Review of Resident #32's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Required maximum assistance from nursing staff with ADL's;- Diagnoses included: renal failure with peritoneal dialysis (a type of dialysis that uses the lining of your abdomen (peritoneum) to filter waste and excess fluid from your blood), history of stroke, and diabetes.Review of comprehensive care plan, dated 06/01/25, showed:- Resident had potential for nutritional problems and nursing staff are required to monitor, record, and report signs and symptoms of malnutrition;- Nursing staff are to provide and serve diet as ordered. Monitor food intake and record every meal;Review of nutrition task charting for percentage of meals eaten, from 06/05/25 through 07/02/25, showed:- Resident had 26 charted meal refusals;- 20 uncharted meals;- 10 meals charted as only having 0-25% eaten.During an interview and observation on 06/30/25 at 09:38 A.M., the resident said:- He/She feels the facility food is horrible because the hot food is cold, cold food is warm, and the facility doesn't offer enough variety for meal alternatives. For instance, the facility always offers the same grilled cheese or lunchmeat sandwiches if he/she doesn't want the main option being served;- He/She barely eats the facility food and his/her family brings in food;- Observed breakfast tray sitting uneaten on the bedside table with cover in place and utensils untouched.During an interview and observation on 07/02/25 at 12:39 P.M., the resident said he/she does not like the food because of the lack of taste and seasonings and the lack of variety offered.Observation on 07/02/25 at 12:39 P.M., showed:- Staff member entered with a lunch tray and resident refused it saying he/she will have family bring something later;- Staff member said okay and exited the resident's room with the tray.2. Observation of the resident council meeting on 07/01/25 at 10:02 A.M., showed:- 24 residents were present at the meeting;- 13 hands raised when asked if the food was served cold;- Complaints regarding portion size being small and child-sized and a lack of condiments;- The food is not always served hot in the cafeteria or when brought to the room;- One resident in the group said the Salisbury steak a few days ago was unable to be cut with a knife, and too tough to chew.- Often items like orange juice, ketchup, and sugar run out quickly;- The residents would like condiments and toppings with a cheeseburger; like a tomato, onion, or pickle. The group said you can beg for it and there's a good chance you're still not going to get it for your cheeseburger;- One resident said the hamburgers are soggy, cold and had no flavor;During an interview on 07/02/25 at 02:15 P.M., the Dietary Supervisor said: Dietary staff use insulated plates and plate covers to keep food warm. Dietary staff will fill the carts with hot food from the serving line and then wheel the carts out to the halls and let the CNAs know they are ready to be passed out. We don't have control of how long it takes for the food to get delivered to the residents once we deliver it to the hall. Expectations is that food is 120F or greater when delivered to the room.During an interview on 07/03/25 at 07:30 A.M., the Assistant Director of Nursing (ADON) said food for the residents should look good and taste good and the residents should have choices on what they receive;During an interview on 07/03/25 at 07:50 A.M., CNA C said:- Food for the residents should taste and look good, not be cold and residents should have choices;During an interview on 07/03/25 at 08:10 A.M., the Director of Nursing (DON) said the food for the residents should look and taste good.During an interview on 07/03/25 at 10:05 A.M., the Administrator said the food for the residents should look and taste good and residents should get choices.

Based on observations, interviews, and record review, the facility failed to ensure there were no loose pills in the medication carts and failed to date opened vials of Lorazepam (used to treat anxiety) for four of the 29 sampled residents, (Resident #25, #76, #52 and #9). Additionally, staff failed to ensure medication was not left at the bedside for Resident #11. The facility census was 144.Review of facility policy Medication Storage, revised 9/1/22, showed:- It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdate, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed.- All drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls;- During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart;- Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed;Refrigerated Products: All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room; Review of facility policy Medication Administration, revised 9/1/22, showed:- Keep medication cart clean, organized, and stocked with adequate supplies;- Cover and date fluids and food;- Review MAR to identify medication to be administered to resident;- Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time;- Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician;- Identify expiration date. If expired, notify nurse manager;- Remove medication from source, taking care not to touch medication with bare hand;- Administer medication as ordered in accordance with manufacturer specifications;- Provide appropriate amount of food and fluid;- Crush medication as ordered. Do not crush medications with do not crush instructions;- Observe resident consumption of medication; 1.Observation on 7/2/25 at 4:31 A.M., of the nurse's cart for the 100 and 300 halls showed: One round pink pill, four round white pills, and two half white pills were loose in the drawer of the medication cart. Observation and interview on 7/2/25 at 4:56 A.M., of the Certified Medication Technician (CMT) cart for the 300-hall showed: Resident #25 had a bubble pack of Lasix (water pill). An unknown staff had punched a pill out, but the pill was still in slot; Nine round white pills, one round pink pill, two oblong pink pills, one oblong yellow pill, one round yellow pill, half of a round yellow pill and half of a round white pill were loose in the drawer of the medication cart. Observation and interview on 7/2/25 at 4:56 A.M., of the CMT cart for the 100-hall showed: There were five round loose white pills, one round pink pill, one oblong yellow pill and four halves of a round white pill. Registered Nurse (RN) B said the pharmacy does an audit of the medication carts and there should not be any loose pills in the drawer of the medication cart. Staff should make sure the pill was popped out of the bubble pack. 2. Observation and interview on 7/2/25 at 5:15 A.M., of the 100 hall and 300 hall medication room showed: Resident #76 had an opened vial of Lorazepam oral concentrate without a date to indicate when staff opened it. Resident #76 had a second vial of Lorazepam oral concentrate and staff dated it was opened on 1/19/25. The box indicated it was good for 90 days after it had been opened. 3. Resident #52 had an opened vial of Lorazepam and did not have a date when it was opened. It did not have a pharmacy label to indicate who it belonged to or how it was to be administered. Unknown staff wrote the resident's last name on the box. It had 3 labels of the local Hospice on it, but it did not have any instructions. Resident #9 had an opened vial of Lorazepam, dated 3/4/25 and expired 6/2/15. The box indicated it was good for 90 days after it had been opened. There were six unopened bottles of sterile water which expired February 1, 2025: one bottle expired March 2025 and one expired April 2025. - During an interview on 7/3/25 at 12:51 P.M., Director of Nursing (DON) said: The Lorazepam should be dated when opened and should not be used if it was expired. The sterile water should have been discarded. If the bubble pack had been punctured, then the medication should have been destroyed. There should not be any loose pills in the medication carts. The nurses are responsible to check their carts and the CMTs are responsible to check their carts. The Lorazepam should have been dated when it was opened and once it is opened, it is only good for 90 days. The Lorazepam should not be used if it is expired. The expired sterile water should have been discarded. Medication should have a pharmacy label on them to indicate who it belonged to and how it was to be administered. During an interview on 7/3/25 at 3:39 P.M., RN B said she/her should not use any medication that is expired and the Lorazepam should have been dated when opened and should have a pharmacy label to indicate who it belonged to and how it was to be administered. 4. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/18/25, showed:- Resident is moderately cognitively impaired;- Diagnosis: anemia, coronary artery disease, kidney impairment, diabetes, Alzheimer's Disease, and dementia; Review of Resident's Care Plan, revised 6/9/25, showed:- Resident has impaired cognitive function due to Alzheimer's and dementia. Administer medications as ordered, monitor/document side effects and effectiveness;- Care Plan did not contain self-administration of medications for resident; Review of Resident Order Summary Record, dated 7/2/25, showed: No orders for self-administration of medications and no orders for Tums medication bedside; Observation of Resident's room on 7/1/25 at 9:12 A.M., showed: One plastic pill cup with one white and one blue medium sized pills on the bedside table next to resident's bed; During an interview on 7/1/25 at 9:15 A.M., the Resident said: The two pills on the table are tums and that he/she doesn't know how long they've been there or remember how they got there; During an interview on 7/2/25 at 9:15 A.M., RN (A) said: If he/she saw a pill cup on a bedside table in a resident's room without any medication technician around she would remove the pills from the room, dispose of them, and notify the DON; During an interview on 7/3/25 at 11:45 A.M., the DON said: If there are medications in a resident's room without a medical technician there then the resident must be care planned and ordered by a physician to self-administer those medications. If not, then the pills must be removed and discarded;

Based on observations, interviews, and record review, the facility failed to ensure staff did not make significant medication errors when staff failed to prime the insulin pens with two units prior to administration which affected three of the 29 sampled residents, (Resident #64, #21, and #100). The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed:-Review Medication Administration Record (MAR) to identify medication to be administered;-Administer medication as ordered in accordance with manufacturer specifications.Review of the facility's policy for Insulin Pen, revised 4/10/25 showed:- It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;-Insulin pens must be clearly labeled with the resident name, date dispensed type of insulin, amount to be given, frequency, and expiration date;-Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir;-Always review physician orders prior to administering any medication;-Procedure: perform hand hygiene and don gloves. Wipe the rubber seal with an alcohol pad and screw the pen needle onto the insulin pen. To prime the insulin, dial to two units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Turn the dose selector to ordered dose. Check the dose a second time. Cleanse the skin with an alcohol pad. Gently pinch up the skin at the injection site and hold. While still pressing plunger, keep the needle in the skin for up to six to ten seconds and then removed the needle from the skin. Remove gloves and perform hand hygiene. 1. Review of the resident's MAR, dated June 2025 showed:-Fiasp FlexTouch solution Pen-injector (fast acting insulin) 10 units before meals and at bedtime related to diabetes mellitus;-Insulin Glargine Solution pen injector (long-acting insulin) 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400;-The facility did not provide the MAR for July 2025. Review of Resident #64's Physician Order Sheet (POS) dated July 2025 showed:-Start date: 5/13/25 - Fiasp FlexTouch solution Pen-injector 10 units before meals and at bedtime related to diabetes mellitus;-Start date: 5/13/25 - Insulin Glargine Solution pen injector 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400.Observation and interview on 7/2/25 at 7:55 A.M., showed Licensed Practical Nurse (LPN) C obtained a blood sugar and administered insulin in the following manner:-LPN C did not have a computer to verify the resident's orders;- He/She did not wash his/her hands and applied gloves;- He/She did not clean the port of the insulin pen and attached the needle;- He/She did not prime the Fiasp insulin pen with two units and dialed the insulin pen to 10 units;He/She did not prime the Insulin Glargine pen with two units and dialed the insulin pen to 20 units;-The resident said he/she had already eaten breakfast;-LPN C obtained the resident's blood sugar which was167.-LPN C administered both insulins in the back of the resident's right arm-LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.2.Review of Resident #21's MAR, dated June 2025 showed:-Humalog Kwik Pen solution pen-injector (fast acting insulin), 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400-The facility did not provide the MAR for July 2025. Review of the resident's POS dated July 2025 showed:-Start date: 5/13/25 - Humalog Kwik Pen solution pen-injector, 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400.Observation and interview on 7/2/25 at 8:02 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner:-LPN C did not have a computer to verify the resident's orders;-The label on the insulin pen said 12 units in the morning;-He/She did not wash his/her hands and applied gloves;-He/She did not clean the port of the Humalog insulin pen and attached the needle;-He/She did not prime the Humalog insulin pen with two units and dialed the insulin pen to 10 units;-The resident said he/she had already eaten breakfast;-LPN C obtained the resident's blood sugar which was 242;-LPN C administered the insulin in the resident's right abdomen;-LPN C removed gloves, did not wash his/her hands and did not clean the glucometer. 3.Review of Resident #100's MAR, dated June 2025 showed:- Insulin NPH and Regular 70/30 (intermediate acting) insulin 10 units twice daily for diabetes mellitus before meals. Notify physician if blood sugar is less than 60 or greater than 400. Discontinued on 6/30/25.-The facility did not provide the MAR for July 2025.Review of the resident's POS, dated July 2025 showed:-Start date: 7/1/25 - Insulin NPH and Regular 70/30 insulin, 15 units twice daily for diabetes mellitus before meals. Notify the physician if blood sugar is less than 60 or greater than 400.Observation on 7/2/25 at 8:11 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner:-LPN C did not have a computer to verify the resident's orders;-The label on the insulin pen said 10 units;-He/She did not wash his/her hands and applied gloves;-He/She did not clean the port of the insulin pen and attached the needle;-He/She did not prime the Novolin insulin pen with two units and dialed the insulin pen to 5 units;-LPN C obtained the resident's blood sugar which was 181;-LPN C administered the resident's insulin in his/her left upper arm;-The resident said he/she has not had breakfast;-LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.During an interview on 7/2/25 at 8:48 A.M., LPN C said:- He/She did not use the computer but made him/herself a cheat sheet to use when he/she obtained the blood sugars and administered the insulin;- He/She should have cleaned the insulin port with an alcohol wipe before the insulin needle was attached;- The insulin pens only must be primed when it is a new pen;- He/She should have cleaned the glucometer with a bleach wipe between each resident;- The insulin dose and the computer should have matching orders;- He/She should have washed and/or sanitized his/her hands between each resident and between glove changes.During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said;-Staff should have the computer with computer when they obtain blood sugars and administer medications;-Staff should clean the port of the insulin pen with an alcohol wipe before the needle is attached;-Staff should prime the insulin pen with two units before the insulin is administered;-Staff should wash their hands or sanitize before and after glove changes and between each resident;-Staff should clean the glucometer with a bleach wipe between each resident use.

Based on observations, interviews, and record review the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made eight errors out of 37 opportunities for error, which resulted in an error rate of 24.32%. This affected four of the 29 sampled residents, (Resident #64, #21, #100, #34) and three unknown residents who had their medications preset. The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; Wash hands prior to administering medication per facility protocol and product; Review Medication Administration Record (MAR) to identify medication to be administered; Administer medication as ordered in accordance with manufacturer specifications; Wash hands using facility protocol and product.Review of the facility's policy for Insulin Pen, revised 4/10/25 showed:It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; Insulin pens must be clearly labeled with the resident name, date dispensed type of insulin, amount to be given, frequency, and expiration date; Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; Always review physician orders prior to administering any medication;-Procedure: perform hand hygiene and don gloves. Wipe the rubber seal with an alcohol pad and screw the pen needle onto the insulin pen. To prime the insulin, dial to two units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Turn the dose selector to ordered dose. Check the dose a second time. Cleanse the skin with an alcohol pad. Gently pinch up the skin at the injection site and hold. While still pressing plunger, keep the needle in the skin for up to six to ten seconds and then removed the needle from the skin. Remove gloves and perform hand hygiene. The facility did not provide the MAR for July 2025. 1.Review of Resident #64's Physician Order Sheet (POS) dated July 2025 showed-Start date: 5/13/25 - Fiasp FlexTouch solution Pen-injector 10 units before meals and at bedtime related to diabetes mellitus; Start date: 5/13/25 Insulin Glargine Solution pen injector 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400.Review of the resident's MAR, dated June 2025 showed: Fiasp FlexTouch solution Pen-injector (fast acting insulin) 10 units before meals and at bedtime related to diabetes mellitus and Insulin Glargine Solution pen injector (long-acting insulin) 20 units twice daily related to diabetes mellitus. Notify physician if blood sugar is less than 60 or greater than 400.Observation and interview on 7/2/25 at 7:55 A.M., showed Licensed Practical Nurse (LPN) C obtained a blood sugar and administered insulin in the following manner: LPN C did not have a computer to verify the resident's orders; did not wash his/her hands and applied gloves; did not clean the port of the insulin pen and attached the needle; did not prime the Fiasp insulin pen with two units and dialed the insulin pen to 10 units; and did not prime the Insulin Glargine pen with two units and dialed the insulin pen to 20 units; The resident said he/she had already eaten breakfast; LPN C obtained the resident's blood sugar which was167.LPN C administered both insulins in the back of the resident's right arm; LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.2.Review of Resident #21's MAR, dated June 2025 showed: Humalog Kwik Pen solution pen-injector (fast acting insulin), 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400;The facility did not provide the MAR for July 2025.Review of the resident's POS dated July 2025 showed: Start date: 5/13/25 - Humalog Kwik Pen solution pen-injector, 10 units before meals related to diabetes mellitus. Hold if blood sugar is less than 150 or missed meal. Notify the physician if greater than 400.Observation and interview on 7/2/25 at 8:02 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner: LPN C did not have a computer to verify the resident's orders; The label on the insulin pen said 12 units in the morning and did not wash hands prior to applying gloves; did not clean the port of the Humalog insulin pen and attached the needle; did not prime the Humalog insulin pen with two units and dialed the insulin pen to 10 units; The resident said he/she had already eaten breakfast; LPN C obtained the resident's blood sugar which was 242; LPN C administered the insulin in the resident's right abdomen; LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.3.Review of Resident #100's MAR, dated June 2025 showed:Insulin NPH and Regular 70/30 (intermediate acting) insulin 10 units twice daily for diabetes mellitus before meals. Notify physician if blood sugar is less than 60 or greater than 400. Discontinued on 6/30/25.The facility did not provide the MAR for July 2025. Review of the resident's POS, dated July 2025 showed: Start date: 7/1/25 - Insulin NPH and Regular 70/30 insulin, 15 units twice daily for diabetes mellitus before meals. Notify the physician if blood sugar is less than 60 or greater than 400. Observation on 7/2/25 at 8:11 A.M., showed LPN C obtained a blood sugar and administered insulin in the following manner: LPN C did not have a computer to verify the resident's orders; The label on the insulin pen said 10 units; LPN C did not wash hands prior to applying gloves; did not clean the port of the insulin pen when attached the needle; did not prime the Novolin insulin pen with two units and dialed the insulin pen to 5 units; LPN C obtained the resident's blood sugar which was 181; LPN C administered the resident's insulin in his/her left upper arm; The resident said he/she has not had breakfast; LPN C removed gloves, did not wash his/her hands and did not clean the glucometer.During an interview on 7/2/25 at 8:48 A.M., LPN C said: he/she did not use the computer but made him/herself a cheat sheet to use when he/she obtained the blood sugars and administered the insulin; he/she should have cleaned the insulin port with an alcohol wipe before the insulin needle was attached; the insulin pens only must be primed when it is a new pen; he/she should have cleaned the glucometer with a bleach wipe between each resident; the insulin dose and the computer should have matching orders; he/she should have washed and/or sanitized his/her hands between each resident and between glove changes. During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said: Staff should have the computer with computer when they obtain blood sugars and administer medications; Staff should clean the port of the insulin pen with an alcohol wipe before the needle is attached; Staff should prime the insulin pen with two units before the insulin is administered; Staff should wash their hands or sanitize before and after glove changes and between each resident; Staff should clean the glucometer with a bleach wipe between each resident use.4.Review of the facility's policy for Nasal Spray Administration, revised 3/4/25 showed: Nasal spray medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice; wash your hands thoroughly before beginning the procedure. [NAME] gloves; Agitate the contents in accordance with the manufacturer's instructions; Occlude opposite nostril with your finger, and insert tip of medication container into desired nostril; Spray medication into nostril while instructing resident to inhale with mouth closed. Instruct resident to exhale through the mouth as ordered, spray the nostril again, repeating the procedure in the other nostril as ordered. Instruct to not blow nose for about 15 minutes; Remove and discard gloves.Review of the package leaflet for Flonase nasal spray, revised March 2016, showed: Shake the bottle gently; Blow your nose to clear the nostrils; Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; Start to breath in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; Repeat in the other nostril.Review of Resident #34's MAR, dated June 2025 showed an order for Flonasenasal suspension 50 mcg., one spray in each nostril twice daily for allergies.Review of the resident's POS dated July 2025 showed a start date: 5/8/25 - Flonase nasal suspension 50 mcg., one spray in each nostril twice daily for allergies.Observation on 7/2/25 at 8:19 A.M., showed: Certified Medication Technician (CMT) D administered one spray in the right nostril then administered one spray in the left nostril; CMT D did not have the resident blow his/her nose, did not shake the bottle and did not close one side of the nostril.During an interview on 7/3/25 at 12:45 P.M., CMT D said: He/she should have followed the manufacturer's guidelines with the administration of the Flonase nasal spray; should have had the resident blow his/her nose, shook the bottle of Flonase nasal spray and closed one side of the nostril with each administration.During an interview on 7/3/25 at 12:51 P.M., the DON said staff should follow the manufacturer's guidelines for the administration of the Flonase nasal spray. 5. Observation and interview on 7/2/25 at 4:31 A.M., of the 100 hall and 300 hall medication carts showed: The top left drawer of the medication cart had a medication cup with one round pink pill and did not have any initials on it or any identifying indicators; Another medication cup had three round white pills in it and did not have any initials on it or any identifying indicators; The third medication cup had one round white pill in it and did not have any initials on it or any identifying indicators; Registered Nurse (RN) B said he/she knew who the pills belonged to from memory; At 6:45 A.M., RN A removed the pills from the medication cart and went and administered the medications to room [ROOM NUMBER] and room [ROOM NUMBER].During an interview on 7/3/25 at 3:39 P.M., RN B said: he/she should not have pre-set the medications; should not have administered the medications he had preset.During an interview on 7/3/25 at 12:51 P.M., the DON said the staff should not pre-set medications, and staff should not have used the medications that RN B had pre-set, they should have been discarded.

Based on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned and failed to properly store oxygen accessories at the bedside for three residents (Residents #71, #28, and #43) resulting in possible exposure to bacteria during oxygen usage. This affected three of 18 sampled residents. The facility census was 144. Review of facility oxygen administration, infection control measures policy, revised on 07/03/2024, showed infection control measures to include: - Follow manufacturer recommendations for the frequency of cleaning equipment filters- Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated- Change humidifier bottle when empty, weekly or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.- If applicable, change nebulizer tubing and delivery devices weekly or per facility policy and as needed if they become soiled or contaminated. - Keep delivery devices covered in plastic bag when not in use.1. Review of Resident # 43's updated care plan, showed: - Cognition intact, resident is able to make all needs known and understands others.- Diagnoses includes: COPD (Chronic obstructive pulmonary disease), lung cancer, asthma, weakness , heart disease, anxiety disorder.- Resident is dependent on staff for all aspects of care.Review of physician orders on 06/11/25 at 6:00 A.M. showed, change oxygen tubing, humidifier bottle, plastic holding bag for oxygen tubing and change/clean concentrator filter when in use, every night shift on Wednesday and as needed.Review of resident TAR(treatment administration record) in the month of June showed, staff had signed off changing oxygen tubing, humified bottle and plastic holding bag for tubing and cleaning concentrator and filters.Observation on 07/01/25 at 8:39 A.M., showed oxygen concentrator in residents room. Oxygen was set on 3.5 liters, concentrator filter covered with dust, humidified cup on concentrator was empty. Oxygen tubing was dated 07/01/25, no date on oxygen mask and plastic bag for accessories was missing.During an interview on 07/03/25 at 8:10 A.M., CNA( A) said the resident was on continuous oxygen and the care plan said for humidified air 2.5L and titrate (increase) to 5L via mask as needed for comfort, CNA A also stated that they have all the equipment for the humidified air and the sterile water but some residents choose not to have the humidified air and resident #43 chose not to have the humidified air.During an interview on 07/03/25 at 8:13 A.M. the resident said he/she does not like the humidified air, it has to much moisture and that made him/her feels like he/she was drowning2. Review of Resident #28's Quarterly MDS, dated [DATE], showed:- Resident is cognitively intact;- Diagnosis: GERD (acid reflux), diabetes, and asthma;Review of Resident's Care Plan, dated 10/28/24, showed:- Resident is on oxygen therapy. Administer oxygen at 2 liters per minute via nasal cannula as needed;- Resident has emphysema, administer oxygen as ordered;Observation on 6/30/25 at 4:19 P.M., showed:- Oxygen concentrator had a piece of tape placed with the date of 6/3/25 as the last date it was cleaned;Observation on 7/3/25 at 10:55 A.M., showed:- Last date changed remained 6/3/25 on oxygen concentrator. Eight feet of tubing was lying on the floor next to the bed of the resident;- Nebulizer bag was on the side table empty with the date of 2/17/25 on it. The Nebulizer was sitting next to the bag;During an interview on 7/2/24 at 10:25 A.M., RN (A) said:- After a resident is done with their breathing treatments the nebulizer, mask, and mouthpiece are all cleaned. The tubing is changed out weekly and entered into the Medical Administration Record electronically. When tubing is changed out a piece of tape is also wrapped around the tubing with the date of change so staff can know the last time it was done;- Tubing should not be on the floor and the nebulizer should be in a bag when not in use;- Putting tape on the machine to show when it was last changed is technically acceptable but she would prefer the tubing be dated;During an interview on 7/3/24 at 11:45 A.M., the DON said:- The tubing for the oxygen concentrator should be changed out weekly, filters cleaned weekly;- There should be orders in the medical records for oxygen and the requirement for cleaning and the tubing needs to have a piece of tape with the last date it was cleaned and changed out;

Based on observations, interviews, and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene when staff did not provide showers in a timely manner for three of the 29 sampled residents, (Resident #10, #12 and #203). The facility census was 144.Review of facility policy Resident Showers, dated 9/1/21, showed:- Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety;- Partial baths may be given between regular shower schedules as per facility policy; Review of facility policy Resident Rights, revised 9/1/22, showed the resident has the right to receive services in the facility with reasonable accommodation of resident needs and preferences; Review of facility policy Activities of Daily Living (ADLs), revised 4/23/25, showed care and services will be provided for bathing. 1.Review of the resident’s admission MDS, dated [DATE] showed:- Cognitive skills moderately impaired.- Required partial to moderate assistance with showers, dressing and transfers.- Diagnoses included cancer, high blood pressure, diabetes mellitus and depression. Review of the resident’s undated care plan showed: The resident had an activities of daily living (ADL) self-care performance deficit. Staff to provide a sponge bath when a full bath or shower cannot be tolerated, and avoid scrubbing and pat dry sensitive skin. Review of Resident #203’s medical record showed the resident was admitted on [DATE]. Review of the resident’s shower sheet showed the resident had only one shower on 6/18/23, with the opportunity for five showers for the month of June. During an interview on 7/1/25 at 8:36 A.M., the resident said:- He/She did not always get a shower;- It made him/her feel bad when he/she went eight days without a shower; During an interview on 7/2/25 at 7:00 A.M., LPN C said:- They did not have a designated shower aide;- The aides who worked on the hall provided the residents’ showers. During an interview on 7/3/25 at 10:32 A.M., Certified Medication Technician (CMT) F said:- He/She has had residents complain about not getting their showers;- When a resident complained about wanting a shower, he/she would notify the aide on the hall or if he/she had time, he/she would provide a shower for the resident. During an interview on 7/3/25 at 12:51 P.M., the DON said she would expect the residents to have their showers per their preference. 2. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/22/25, showed:- Resident was moderately impaired cognition;- Resident requires staff supervision for toileting hygiene and bathing;- Diagnosis: heart failure, diabetes, anxiety disorder, respiratory failure, and depression; Review of Resident's Care Plan, revised 5/1/25, showed:- Resident was dependent on staff for meeting physical needs;- Resident had an adult daily living (ADL) self-care deficit. Resident will bath or shower twice weekly and as necessary. Provide a sponge bath when a full bath or shower cannot be tolerated; Review of resident electronic medical documentation of showers, showed:- March 2025 Showers: 3/4, 3/19, 3/20, 3/25, 3/28 (5 of 8 required showers offered or conducted);- June 2025 Showers: 6/3, 6/6, 6/26, 6/27 (4 of 8 required showers offered or conducted); During an interview on 6/30/25 at 4:43 P.M., Resident said:- He/she is not getting two showers per week which does not provide relief for his/her feet and causes discomfort. Normally he/she is only getting one shower a week; 3. Review of Resident #12's Quarterly MDS, dated [DATE], showed:- Resident is cognitively intact;- Resident requires maximal assistance from staff for showering and bathing;- Diagnosis: heart failure, anxiety disorder, and respiratory failure; Review of Resident's Care Plan, revised 7/1/25, showed:- Resident is independent for most ADLs. Resident wishes to take showers on Sunday's only;- Staff will assist resident with taking showers at least two times weekly and the preferred times are Wednesday and Saturday evenings; Review of Resident manually documented shower sheets, showed:- March 2025 Showers: 3/6, 3/13, 3/16, 3/20, 3/27 (5 of 8 required showers offered or conducted);- April 2025 Showers: 4/3, 4/10, 4/24 (3 of 8 required showers offered or conducted);- May 2025 Showers: 5/1, 5/5, 5/8, 5/22, 5/29 (5 of 8 required showers offered or conducted);- June 2025 Showers: 6/5, 6/6, 6/12, 6/19, 6/26, 6/30 (6 of 8 required showers offered or conducted); During an interview on 6/30/25 at 9:41 A.M., Resident said:- He/she is only getting one shower a week. Normally only getting them on Mondays when it should be on Monday and Thursdays. I prefer two showers a week otherwise I feel dirty; During an interview on 7/3/25 at 10:45 A.M., the ADON said:- Normally the CNA on duty will fill out the shower sheets and record that they have been accomplished or refused;- Resident should be getting two showers per week; During an interview on 7/3/25 at 11:40 A.M., the DON said residents should be offered two showers per week; MO256385, MO256469

Based on interviews and record reviews, the facility failed to schedule care plan meetings for two of the 29 sampled residents, (Resident #90, #121) and failed to ensure staff developed and updated a care plan consistent with the resident's specific conditions and needs which affected Resident #129. The facility census was 144.Review of the facility's policy for Care Planning - Resident Participation, reviewed 9/27/24 showed:- This facility supports the resident's right to be informed of, and participate in, his/her care planning and treatment (implementation of care);- The facility will inform the resident, in a language he/she can understand, of his/her rights regarding planning and implementing care, including the right to be informed of his/her total health status;- The facility will honor the resident's choice of individuals to be included in the care planning process;- The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care;- The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and /or resident representative after discussion or viewing of the care plan;- If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record. 1. Review of Resident #90's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/25 showed:- Cognitive skills moderately impaired;- Diagnoses included Coronary Artery Disease (CAD, a condition where the heart's blood vessels become narrowed or blocked due to a buildup of plaque), Congestive Heart Failure (CHF), diabetes mellitus, anxiety, depression, and Chronic Obstructive Pulmonary Disease (COPD). During an interview on 6/30/25 at 11:33 A.M., the resident said he/she had not been invited to his/her care plan meeting and probably would not go if he/she was invited. During an interview on 7/2/25 at 12:19 P.M., the Social Services Director (SSD) said:- He/She had been in the position for two years;- He/She set up the care plan meetings and invited the residents and their family members, responsible parties, guardians or Durable Power of Attorney (DPOA);- He/She scheduled the care plan meetings based on the MDS schedule;- The resident was admitted in March;- He/She did not have the resident on his/her calendar for a care plan meeting;- The resident should have had a care plan meeting in June but did not have a care plan meeting. 2. Review of Resident #121's Quarterly MDS, dated [DATE] showed:- Cognitive skills intact;- Diagnoses included CAD, Congestive Heart Failure (CHF), high blood pressure, diabetes mellitus, anxiety, bipolar and PTSD. During an interview on 6/30/25 at 12:19 P.M., the resident said he/she had not been invited to his/her care plan meeting. During an interview on 7/2/25 at 12:19 P.M., the Social Services Director (SSD) said:- The resident should have had a care plan meeting in February, but she was unable to locate the information in the computer. He/She was on the calendar and in the computer but did not have any documentation to indicate the resident had attended the care plan meeting;- The resident should have had another care plan meeting in May but he/she was unable to locate any documentation to indicate the resident had attended the care plan meeting. During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said residents should be invited to their care plan meetings. 3. Review of Resident #129's Quarterly MDS, dated [DATE], showed:- Resident is cognitively intact;- Diagnosis: coronary artery disease, hypertension, anxiety disorder, and epilepsy;Review of Resident Care Plan, revised 3/26/25, showed no care plan for anticoagulant medications.Review of Resident's Medication Administration Record, showed:- 7/1/25 every shift checked for side effects from Anticoagulant medication;- 7/1/25 administered Xarelto 20 mg in the evening, anticoagulant;- 6/1-6/30/25 every shift checked for side effects from Anticoagulant medication;- 6/1/-6/30/25 administered Xarelto 20 mg in the evening, anticoagulant;During an interview on 7/2/25 at 1:25 P.M., RN (A) said anticoagulants should be care planned for each resident that is taking them. This is done so staff can monitor for side effects and bruising on the resident.During an interview on 7/3/25 at 10:45 A.M., the ADON said anticoagulant medications should be care planned for each resident as applicable.During an interview on 7/3/25 at 11:40 A.M., the DON said anticoagulant medications should be care planned for each resident as applicable.

Based on interviews and record review, the facility failed to ensure residents knew how to file a grievance and failed to ensure residents' grievances were fully addressed, steps taken to resolve the grievances, notification of the residents of the results of the grievance and follow up with the residents to ensure the issues were resolved. This had the potential to affect any resident who resided in the facility. The facility census was 144.Review of the facility's policy, Resident Council Meetings, dated 9/1/21 showed;- This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. this policy provides guidance to promoting structure, order, and productivity in these group meetings;- The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's policy, Resident and Family Grievances, revised 9/1/21 showed:- It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal;- Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance;- Community Administrator has been designated as the Grievance Official;- The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;- A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long-term care stay;- Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: the contact information of the grievance official with whom a grievance can be files, including his/her name, business address (mailing and email) and business phone number; the contact information of independent entities with whom grievances may be filed, that is, the pertinent State Agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; the time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his/her grievance;- Grievances may be voiced in the following forums: verbal complaint to a staff member of Grievance Official; written complaint to a staff member of Grievance Official; written complaint to an outside party; verbal complaint during resident or family council meetings; via the company toll free Customer Service Line (if applicable);- A grievance may be filed anonymously;- Procedure: this facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance; the staff member receiving the grievance will record the nature and specifics of the grievance won the designated grievance from, or assist the resident or family member to complete the form; forward the grievance form to the Grievance Official as soon as practicable; - The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know;- The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances;- I accordance with the resident's right to obtain a written decision regarding his/her grievance, the conclusion of the investigation. The written decision will include at a minimum: the date the grievance was received. The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the resident's concerns. A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued; - The facility will make prompt efforts to resolve grievances. 1, Review of the resident council meeting minutes, dated 4/17/25 showed:- Nine residents in attendance;- The minutes did not indicate if it was discussed how to file a grievance. 2. Review of the resident council meeting minutes, dated 5/22/25 showed:- 12 residents in attendance;- The minutes did not indicate if it was discussed how to file a grievance. 3. Review of the resident council meeting minutes, dated 6/19/25 showed:- 14 residents were in attendance;- The minutes did not indicate if it was discussed or how to file a grievance.4. During the Resident Council meeting and interview with surveyors on 7/1/25 at 10:02 A.M., showed:- 21 residents were in attendance;- 10 of the 21 residents said they did not know how to file a grievance. During an interview on 7/2/25 at 12:18 P.M., the Social Services Director (SSD) said;- He/She had been in the current position for almost two years;- He/She is the grievance counselor;- There are grievance forms at each nurse's station and on the wall as you enter the building;- If a resident filled out a grievance form after hours, they would either hold onto it until morning or slide them under his/her door. Sometimes the staff would place it in his/her mailbox up by the front office;- The facility does not have a box or anything to place the grievance forms in anonymously;- Once she gets the grievance form she disperses them to departments involved. The department head was to notify the resident of the findings and if the resident agreed it was resolved, then the resident signed the bottom of the grievance;- He/She did not attend the resident council meetings and did not know who discussed the findings of the resident's concerns. During an interview on 7/2/25 at 1:06 P.M., the Activity Assistant said:- When the residents voice concerns during the resident council meetings, she fills out the grievance forms, makes a copy to keep, then gives the originals to the SSD, who then disperses them to the correct department;- When they discuss old business during the resident council meetings, and he/she asks if there is any improvement, there might be some minor tweaks made but basically no changes;- The residents council does not regularly get any follow up on how the issues had been corrected;- He/She would expect the department heads to either address the issues with the resident council or with the activity department so they could follow up with the residents. During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said:- During the resident council meetings, the Activity Assistant wrote up the grievances, made a copy for them then gave the originals to SSD who dispersed them to the correct department;- If it named a specific staff, he/she would go to that staff and it would be verbal or disciplinary. He/She would follow up with the resident to see if the issue had been resolved. If the resident felt like it had been resolved, he/she would have the resident sign it;- The resident council should be informed of how issues were addressed.

Based on observations, interviews, and record review, the facility failed to act promptly upon the grievances of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding the resident's concerns. This had the potential to affect all the residents who lived in the facility. The facility census was 144.Review of the facility's policy, Resident Council Meetings, dated 9/1/21 showed;- This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. this policy provides guidance to promoting structure, order, and productivity in these group meetings;- The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Review of the facility's policy, Resident and Family Grievances, revised 9/1/21 showed:- It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal;- Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance;- Community Administrator has been designated as the Grievance Official;- The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;- A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long-term care stay;- Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: the contact information of the grievance official with whom a grievance can be files, including his/her name, business address (mailing and email) and business phone number; the contact information of independent entities with whom grievances may be filed, that is, the pertinent State Agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; the time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his/her grievance;- Grievances may be voiced in the following forums: verbal complaint to a staff member of Grievance Official; written complaint to a staff member of Grievance Official; written complaint to an outside party; verbal complaint during resident or family council meetings; via the company toll free Customer Service Line (if applicable);- A grievance may be filed anonymously;- Procedure: this facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance; the staff member receiving the grievance will record the nature and specifics of the grievance won the designated grievance from, or assist the resident or family member to complete the form; forward the grievance form to the Grievance Official as soon as practicable; - The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know;- The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances;- In accordance with the resident's right to obtain a written decision regarding his/her grievance, the conclusion of the investigation. The written decision will include at a minimum: the date the grievance was received. The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the resident's concerns. A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued; - The facility will make prompt efforts to resolve grievances. 1. Review of the resident council meeting minutes, dated 4/17/25 showed:- Nine residents in attendance;- Additional comments: went over old business- same complaints about food (its cold, gross, quality is bad). Nursing complaints the same;- Old business - dietary - cold food, small portions; nursing - foul language, cell phone/ ear bud use, call lights, oral care;- The resolution of concern from dietary indicated they were changing the menus, and the dietary manager spoke to the dietary department about making the meals more attractive. - No response from dietary managers. 2. Review of the resident council meeting minutes, dated 5/22/25 showed:- 12 residents in attendance;- Additional comments: went over old business. Same dietary and nursing concerns. Dietary concerns are the same when it comes to eggs. Quality of food is bad. Nursing concerns the same concerning showers and ice water not getting passed at night;- New business - nursing - ice water not getting passed, staff being rude, not showering properly, staff taking too many smoke breaks and not doing two hour checks on residents. Dietary - eggs are cold, wet, and burnt. too much chicken, not getting the drinks ordered when eating in room;- No response from department managers noted. 3. Review of the resident council meeting minutes, dated 6/19/25 showed:- 14 residents were in attendance;- Old business was addressed and no improvements made. Nursing - ice water was not passed, staff being rude, not showering properly, staff taking too many smoke breaks and not doing two hour checks on residents. Dietary - eggs cold, wet and burnt, too much chicken, and not getting drinks you ordered;- New business - Nursing - ice water doesn't get passed, staff is rude, more at night, no checks every two hours, not properly showering and too many smoke breaks from staff. Dietary - staff eating from prep table, no knives, portion size too small, staff are never in the dining room to serve;- No response from department managers;- No resolution to the concerns. 4. During the Resident Council meeting and interview with surveyors on 7/1/25 at 10:02 A.M., showed:- 21 residents were in attendance;- 16 of the 21 residents present said they do not feel like the facility listens or acts on any grievances;- 18 of the 21 residents present said they feel like the facility seldom follows up on any grievances or concerns;- 18 of the 21 residents present said they do not feel like they complain about anything for fear of retaliation from the staff.During an interview on 7/2/25 at 12:18 P.M., the Social Services Director (SSD) said;- He/She had been in the current position for almost two years;- He/She was the grievance counselor;- There are grievance forms at each nurse's station and on the wall at the entrance of the building;- If a resident filled out a grievance form after hours, they would either hold onto it until the next morning or slide the grievance under his/her door. Sometimes the staff would place it in his/her mailbox up by the front office;- Does not have a box or anything to place grievance form in anonymously;- Once she gets the grievance she disperses them to departments involved. The Department head notifies the resident of the findings and if the resident agreed it was resolved, then the resident signed the bottom of the grievance;- He/She did not attend the resident council meetings and did not know who discussed the findings of the residents concerns. During an interview on 7/2/25 at 1:06 P.M., the Activity Assistant said:- When the residents voice concerns during the resident council meetings, she fills out the grievance forms, makes a copy to keep, then gives the originals to the SSD, who then disperses them to the correct department;- When the counsel discusses old business during the meetings, she asks if there had been any improvement, there might be some minor tweaks made but basically no changes;- The residents council does not regularly get any follow up on how the issues had been corrected;- She would expect the department heads to either address the issues with the resident council or with the activity department so they could follow up with the residents. During an interview on 7/2/25 at 1:35 P.M., an anonymous staff member said there is no confidentiality when a resident files a grievance, all of the staff are aware of it;During an interview on 7/3/25 at 12:51 P.M., the Director of Nursing (DON) said:- During the resident council meetings, the Activity Assistant wrote up the grievances, made a copy for them then gave the originals to SSD who dispersed them to the correct department;- If it named a specific staff, he/she would go to that staff and it would b e verbal or disciplinary. He/She would follow up with the resident to see if they felt like the issue had been resolved. If the resident felt like it had been resolved, he/she would have the resident sign it;- The resident council should be informed of how the issues were addressed.

Based on observation, interview, and record review, the facility failed to maintain resident dignity when staff failed to remove unwanted facial hair for two residents (Residents #21 and Resident # 58), failed to provide timely incontinence cares for three residents (Residents #5, #58, and #145), and failed to create a safe environment causing one resident to feel retaliated against or intimidated (Resident #83). This affected 11 out of the 18 sampled residents. The facility census was 144.Review of the facility's Accommodation of Needs policy, dated 09/01/21, showed:- The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident;- Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible.Review of the facility's Resident and Family Grievances policy, dated 09/01/21, showed:- It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal;- This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance;- The facility will make prompt efforts to resolve grievances.Review of the facility's Resident Council Meetings policy, dated 09/01/21, showed:- The facility supports the rights of residents to organize and participate in resident groups, including a Resident Council;- The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the council.Review of the facility's Resident Showers policy, dated 09/01/21, showed:- It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice;- Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.Review of the facility's Resident Rights policy, dated 09/01/21, showed:- The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility;- The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported but the facility in the exercise of his or her rights;- The right to receive the services and/or items included in the plan of care;- The resident has a right to be treated with respect and dignity;- The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice;- The resident has a right to personal privacy and confidentiality of his or her personal and medical records;- The resident has a right to a safe, clean, comfortable and homelike environment;- The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished; and the behavior of staff and of other residents; and other concerns regarding their long term care (LTC) stay;- The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.Review of the facility's Activities of Daily Living (ADL's) policy, dated 04/23/25, showed:- The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable;- Care and services will be provided for the following ADL's:* Bathing, dressing, grooming, and oral care;* Transfer and ambulation;* Toileting;- A resident who is unable to carry out ADL's will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility's Promoting/Maintaining Resident Dignity, dated 10/01/23, showed:-It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality;- During interactions with residents, staff must report, document and act upon information regarding resident preferences;- Respond to requests for assistance in a timely manner;- Groom and dress residents according to resident preference;- Speak respectfully to residents; avoid discussions about residents that may be overheard;- Maintain resident privacy.1. Review of Resident #5's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 05/15/25, showed:- Resident was cognitively intact;- Required maximal assistance from nursing staff with ADL's;- Was always incontinent of bowel and bladder;- Diagnoses included: heart failure, paralysis of the legs and lower body, and seizure disorder.Review of the comprehensive care plan, dated 06/17/25, showed:- Resident was frequently incontinent and nursing staff are required to provide peri care every shift and with each incontinent episode;- Was at risk for pressure ulcers due to decreased mobility and nursing staff are required to apply moisture barrier as needed after incontinence episodes and encourage repositioning frequently assisting as needed;- Required nursing staff assistance for all ADL's.Review of the Physician Order Sheet (POS), dated 07/02/25, showed:- Resident received oral antibiotics for a urinary tract infection (UTI) from 6/11/25 through 06/16/25;- Received antibiotic injections injection for a UTI from 06/17/25 through 06/26/25;- Was prescribed a diuretic (medication to remove excess fluids from the body) daily.During an interview on 07/01/25 at 02:10 P.M., the resident said:- Nursing staff answering call lights can take 45 minutes;- My bed is wet in the morning because they don't take good care of me, specifically nights;- Day shift toilets me in the morning and before bed then nights doesn't check on me all night;- The lack of care makes him/her feel not worthy, and humiliated.During an interview on 07/02/25 at 04:25 A.M., the resident said the last time nursing staff checked on him/her was 10:30 P.M.During an interview on 07/02/25 at 09:50 A.M., the resident said:- He/She thinks facility staff would retaliate against him/her for complaining;- I'm having trouble now, they wouldn't let me go to the bathroom because I bitched;- He/She feels safe but wouldn't elaborate on what trouble he/she was having.2. Review of Resident #58's Quarterly MDS, dated [DATE], showed:- Resident had moderate cognitive impairment;- Required maximal assistance from nursing staff with ADL's;- Was frequently incontinent of bowel and bladder;- Diagnoses included: stroke, hemiplegia (paralysis on one side of the body), and respiratory failure.Review of the comprehensive care plan, dated 07/01/25, showed:- Resident had an ADL self-care performance deficit related to activity intolerance and required extensive assistance from nursing staff for toileting and bed repositioning;- Was at high risk for falls and nursing staff are required to have call light within reach and prompt response to all requests for assistance;- Had bowel incontinence and nursing staff are required to check resident every two hours and assist with toileting as needed;- Was incontinent of bowel and bladder and nursing staff are required to check resident frequently.Review of the POS (Physician Order Sheet) dated 07/02/25, showed the resident was prescribed a diuretic daily.Review of recent shower sheets, dated 05/16/25 through 06/23/25, showed:- Resident had last full shower and shave documented on the shower sheet on 05/16/25;- Resident had bed bath with no shave on 05/23/25;- Resident refused showers on 05/27/25, 06/02/25, 06/05/25, and 06/10/25;- Resident had shower but there were no razors available documented on 06/13/25;- Resident had bed bath with no shave on 06/23/25.During an interview and observation on 06/30/25 at 10:45 A.M., the resident said: - He/She had been left overnight in a wet bed recently and had happened always at night;- He/She was not sure why, but when it happens it makes him/her feel disgusting;- Resident was observed lying in bed with hair appearing greasy and approximately a half inch of facial hair present on chin;- He/She would like the facial hair gone.During an interview on 07/02/25 at 04:26 A.M., the resident said he/she couldn't remember the last time nursing staff checked on him/her that night but needed cleaned up.During an interview on 07/02/25 at 09:58 A.M., the resident said the facility is just short staffed and that is why he/she was left in a wet bed.3. Review of Resident #145's admission MDS, dated [DATE], showed:- Resident was cognitively intact;- Required maximum assistance with nursing staff for ADL's;- Was frequently incontinent of bowel and bladder;- Diagnoses included: high blood pressure, renal failure, and diabetes.Review of the comprehensive care plan, dated 07/01/25, showed:- Resident had potential for pressure ulcers related to impaired mobility and incontinence and nursing staff are required to assist with turning, repositioning, and incontinent care;- Had bladder incontinence and nursing staff are required to clean peri area with each incontinent episode and monitor for signs and symptoms of UTI;- Was at risk for falls and nursing staff are required to be sure the call light is within reach and encourage the resident to use it.During an interview on 06/30/25 at 09:07 A.M., the resident said:- The facility had been short handed;- He/She had layed two hours in a wet bed after a bowel movement while in a incontinent brief a couple weekends ago over night, and was upset about it. He/She said the facility was short handed of nursing assistants;- There is a problem in the lack of supplies, including running out of XXXL briefs and having to wear size smaller that were tighter and not as absorbent.During an interview on 07/02/25 at 04:50 A.M., Licensed Practical Nurse (LPN) B said nursing staff should round every two hours on residents and some more depending on situations or if frequently incontinent.During an interview on 07/02/25 at 05:11 A.M., CNA B said nursing staff should check residents every 2 hours and some more often if they are known to be frequently incontinent.During an interview on 07/03/25 at 07:30 A.M., the Assistant Director of Nursing (ADON) said:- Staff should absolutely not retaliate against residents who have complaints and doesn't believe that it has happened;- Nursing staff should perform rounds every two hours minimum and more for those with heavy incontinence and others that might need it more often;- Residents shouldn't go all night in a wet bed, two hours at the longest but should be checked more often;- Call lights should be answered by nursing staff in one to two minutes;- Residents should get showers at least twice weekly;- After a resident refuses a shower for a week, nursing staff will talk to them, bribe them if possible, or call a family member to speak with the resident to encourage them to shower.During an interview on 07/03/25 at 07:50 A.M., CNA C said:- Residents can submit complaints anonymously and he/she has not heard of any retaliation but has had residents complain and ask for their names not to be given;- Nursing staff should do rounds every two hours at a minimum, at shift change, and when needed. The residents should not be wet very long;- His/Her goal is to keep the residents clean, dry and with no sores;- Call lights should be answered in three minutes maximum;- Staff should not cancel a call light, leave, then come back later;- Residents get showers at least twice a week;- After a resident refuses a shower twice, the nursing staff will encourage them or try to convince them to try.During an interview on 07/03/25 at 08:10 A.M., the Director of Nursing (DON) said:- He/She hasn't heard of any staff retaliation against residents with complaints or grievances and it wouldn't be tolerated;- Nursing staff should round every two hours at least;- He/She agreed a resident should not go all night in a wet bed;- Call lights should be answered in 15 minutes maximum, per policy based on the needs of the residents;- Nursing staff should not cancel call lights and not return;- Showers should be given to residents two times a week;- After a resident refuses a shower, the nursing staff will attempt to find another staff member or nurse with a better rapport with the resident to talk into a shower or get the resident family involved.During an interview on 07/03/25 at 10:05 A.M., the Administrator said:- Residents can fill out complaints or grievances and it gets routed to the specific department head, then staff will discuss at morning meeting and either sign off or if not completed return to the resident to finish filling out;- Staff retaliation for complaints or grievances is not tolerated;- Nursing rounds should be completed every two hours and some resident more often if needed;- Call lights should be answered around five to 10 minutes but can vary depending on time of day or which hall;- Nursing staff should not turn off the call light and not return;- Residents should get showers at least twice a week and if the resident refuses the staff is to get the nurse to try and if more than once, should try to speak with the resident's family to try to get help and document when this occurs. 5. Review of Resident #21's Face Sheet., showed:- admission date of 1/2/25;- Diagnoses included- stroke, diabetes, impaired cognition with communication deficit, and dementia; Review of resident's comprehensive care plan, un-dated., showed:- The resident was unable to bath or provide hygiene cares independently, dependent on nursing staff to provide all cares.- The resident had the right to his/her dignity.- The care plan does not address the resident's management of facial hair by the nursing staff.Observation on 6/30/25 at 12:45 P.M. showed the resident sitting at the dining room table with other resident eating cereal with facial hair greater than 1 inch to upper lip, around mouth, chin and extending down the neck.Observation on 7/1/25 at 7:24 A.M., showed the resident sitting at the dining room table waiting for breakfast to be served with facial hair greater than 1 inch to upper lip, around the mouth, chin and extending down the neck.Observation on 7/2/25 at 8:30 A.M., showed the resident sitting at the dining room table eating breakfast with facial hair greater than 1 inch to upper lip, around the mouth, chin and extending down the neck, and dried food from a previous meal dried to outside of resident's mouth and facial hair.Observation on 7/3/25 at 2:15 P.M., showed the resident had been shaved.During an interview on 7/1/25 at 9:32 A.M., the resident said, he/she would like to have facial hair removed and that having the hair on his/her face bothered him/her.During an interview on 7/1/25 at 10:41 A.M., CNA B said, he/she did not realize the resident had unwanted facial hair, and it should be removed with showers, or offered as needed in between showers.During an interview on 7/3/25 at 4:45 P.M., the Director of Nursing said residents who wish not to have unwanted facial hair can be shaved by nursing staff on shower days and as needed.

Based on observation, interview, and record review, the facility failed to provide quality of care when, facility staff documented they had administered prescription eye drops to one resident (Resident #95) and showed the prescription eye drops were opened and dated on 05/02/25, the bottle was still full on 07/02/25 at 04:35 A.M. indicating several doses of the eye medication were missed, but documented. This affected one resident out of the sampled 18 residents. The facility census was 144.Review of facility administration of eye drops policy, revised on 09/24/24., showed: Label new bottle with date opened and follow facility policy or manufacturers instruction for when to discard and replace.Record administration of medication as ordered by the physician.1.Review of resident #95's Quarterly MDS(Minimum Data Set) (A federally mandated assessment completed by facility staff), dated 05/04/25., showed:- Cognition intact, resident is able to make all needs known and understand others.- Diagnoses includes: Insulin dependent diabetic , glaucoma with blindness- Needing assistance of one with personal hygiene and grooming - Resident requires staff assist with all administration of medications.Review of undated care plan, showed:- Resident has history of PTSD- Resident has the right to individual preferences, dignity and self determination- Resident has impaired visual function. - Care plan does not address eye medications or interventions for eye medicationsReview of current physician orders on 07/02/25 at 04:35AM showed, - Dorzolamide HCl Solution 2 %, Instill 1 drop in both eyes three times a day for glaucoma- Order active and the bottle opened on 05/02/25 as dated.Review of medication administration record for the month of June showed facility staff had documented providing the prescribed eye drops.Review of pharmacy reorder sheet for the month of May thru July showed the medication was reordered in 07/02/25, 2 months past the refill time.Observation on 07/02/25 at 04:35 A.M. showed the residents eye drop prescription Dorzolamide HCl Solution 2 %, Instill 1 drop in both eyes three times a day, had been opened on 05/02/25 and was still full.During an interview on 06/30/25 at 10:05 A.M., the resident said, he was blind and was having trouble with staff not bringing him his eye drops.During an interview, on 07/03/25 at 08:16 AM CMT D said that the eye drop bottle would normally last only a month and could not explain why the bottle was still full. Eye drops should be documented after they are given to the resident.During an interview on 07/03/25 at 10:45 AM the DON (Director of Nursing) said staff are to label both the box and the medication bottle when opened. Eye drops should be administered as ordered by the physician.

Based on observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one of 29 sampled residents (Resident #20). The facility census was 144. Review of facility policy Pain Management, revised 4/23/25, showed:- The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences;- The facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated;- Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;- Facility staff will observe for nonverbal indicators which may indicate the presence of pain;- Observe for difficulty in sleeping;- Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain;- The facility will use a pain assessment tool which is appropriate for the resident's cognitive status to assist staff in consistent assessment of a resident's pain;- Based upon evaluation, the facility in collaboration with the attending physician and the resident will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain;- If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated;1.Review of Resident #20's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/2/25, showed:- Resident is moderately cognitively impaired;- No behavioral symptoms or psychosis observed;- Resident requires staff assistance for all activities of daily living (ADLs);- Diagnosis: chronic obstructive pulmonary disease (bronchitis), heart failure, Stage 4 cirrhosis of the liver;Review of Resident Care Plan, dated 5/28/25, showed:- Resident has life threatening illness stage 4 end of life cirrhosis of the liver. Resident will have physical and emotional needs met;- Monitor, document and report epigastric (abdominal) pain due to liver disease;Review of Resident Order Summary Report, dated 7/2/25, showed:- Acetaminophen tablet 500 mg two tablets by mouth every six hours as needed for pain, start date 5/28/25;- Gabapentin 300 mg give one capsule by mouth at bedtime for pain, start date 5/28/25;Review of Resident's Medication Administration Record, dated 7/2/25, showed:- 7/1 Assess Resident for pain every shift, day and night shifts reported pain level zero;- 612, 6/20 Assess Resident for pain every shift, day shifts reported zero pain level, night shifts reported pain level at a two;- 6/1-6/11, 6/13-6/19, 6/21-6/30 Assess Resident for pain every shift, day and night shifts reported pain level zero;During an observation in resident's room on 6/30/25 at 10:45 A.M., showed:- Resident walking with an irregular gait and and sat down on the side of his/her bed with a slight facial grimace;During an interview on 6/30/25 at 10:47 A.M., the resident said:- That his/her current pain level was about an eight and it's constantly at that level. - Pain is mainly in the back and in the neck vertebras and that he/she has had many surgeries during his/her lifetime which can cause pain. Cannot sleep due to the pain at night;- When resident told staff that he/she was in pain, the staff told me resident he/she had to see the DON if he/she wanted to get a higher pain medication than what was ordered. Resident became discouraged and stopped going up to staff and telling them he/she was in pain because they were not going to give resident anything stronger to alleviate the discomfort;- The staff does not ask him/her what the pain level is and resident doesn't recall the staff asking about his/her pain during the month of June;During an interview on 7/2/25 at 10:40 A.M., the ADON said:- She was not familiar with Resident #20. She had not done a pain assessment on him/her;- If a resident has an order to be assess for pain each shift then staff should directly check on the resident to assess for pain. This can include verbal questions or seeing physical cues that the resident was in pain;- Gabapentin is sometimes ordered for pain management;- If a resident has an order for medication to control pain staff should be checking the resident to make sure they are not in pain;- A pain level of 8 would immediately cue staff to ask more questions of the resident to ascertain what medical issues the resident is dealing with;- Next step would be to call the physician and update them and possibly get new orders to help with pain management;- Nursing staff would be the staff members to monitor for pain daily for residents and chart the responses;During an interview on 7/3/25 at 11:45 A.M., the DON said:- A resident who has an order to monitor pain levels should have staff asking them each shift if they are having pain and where it is if applicable;- There are physical cues staff can use if the resident is non-verbal; like facial grimacing, restlessness, agitation;- The pain level and observations with interventions should be documented in the Medical Administration Record and nurses' notes when applicable;- Stage 4 cirrhosis of the liver can be painful;- If a resident cannot sleep due to the pain the physician should be notified;

Based on observations, interviews, and record review, the facility failed to ensure staff provided catheter (a sterile tube inserted into the urinary bladder to drain urine) care in a manner to prevent urinary tract infection (UTI) or the possibility of a UTI, which affected one of the 29 sampled residents, (Resident #9). The facility census was 144. Review of the facility's policy for Catheter Care, revised 5/24/24 showed: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;- Catheter care will be performed every shift and as needed by nursing personnel;- Gently separate the skin folds to expose the urinary meatus. Wipe from front to back with a clean cloth. Use a new part of the cloth or different cloth for each side. With a new cloth, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. 1. Review of the resident's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/25 showed:-Cognitive skills moderately impaired;-Dependent on the assistance of staff for toilet use, dressing and personal hygiene;-Had a urinary catheter;-Always incontinent of bowel;-Diagnoses included neurogenic bladder, stroke, arthritis, Alzheimer's disease, anxiety and depression. Review of Resident #9's urinalysis (UA, a test to analyze urine contents) and urine culture (C & C, a test that identifies the amount and type of bacteria and medications to treat the infection), dated 2/14/25 showed:-The presence of bacteria indicative of a possible UTI;-The C & S showed the presence of organisms indicative of a UTI. Review of the resident's care plan revised 6/30/25 showed the resident had a catheter, staff to monitor for signs and symptoms of discomfort on urination and frequency. Staff to monitor, document for pain/discomfort due to catheter. Observation on 7/2/25 at 9:49 A.M., showed:-Certified Nurse Aide (CNA) E and Certified Medication Technician (CMT) E sanitized their hands and applied gloves;-CNA E and CMT E did not don a gown;-CNA E did not separate and clean all areas of the front perineal folds with fecal material noted;-CNA E and CMT E turned the resident on his/her side;-CNA E wiped down the buttocks with fecal material on the wipe;- CNA E used a new wipe and wiped back to front with fecal material on the wipe;- CNA E wiped the rectal area and wiped down towards the front perineal fold with fecal material on the wipe;- CNA E wiped from back to front four times with fecal material on each new wipe;- CNA E wiped back to front with a light smear of fecal material on the wipe, did not anchor the catheter tubing and wiped down the tubing;- CNA E and CMT E placed a clean incontinent brief on the resident;- CNA E placed a paper towel on the floor and placed the graduate on it. CNA E removed the drainage spout and emptied 250 cc. of dark hay colored urine into the graduate. CNA E cleaned the drainage spout with a disposable wipe and replaced it in the sleeve. During an interview on 7/3/25 at 11:24 A.M., CMT E said:- He/She had worked at the facility for three weeks;- He/She should have worn a gown when catheter care was provided;- Should have wiped from front to back;- Should have separated and cleaned all areas of the skin where fecal material had touched;- The catheter tubing should have been anchored when it was cleaned;- The drainage spout should have been cleaned with an alcohol wipe. During an interview on 7/3/24 at 12:51 P.M., the Director of Nursing (DON) said:- Staff should not wipe from back to front;- Staff should separate and clean all the skin folds;- Staff should clean the drainage spout with an alcohol wipe;- Staff should anchor the catheter tubing when they cleaned it. During an interview on 7/11/25 at 12:03 P.M., CNA E said:- They should have worn a gown when catheter care was provided;- He/She should have separated and cleaned all areas of the skin where feces had touched;- He/She was trained to wipe down the buttocks and down the hips when cleaning fecal material. Should wipe from clean to dirty;- He/she should have wiped from the rectal area up and not down.

Based on interviews and record review the facility failed to complete neurological assessment's for one resident (Resident #1), after the resident reported to Registered Nurse (RN) A on he/she had fallen the night prior and someone picked him/her off the floor. The resident was noted to have bruise to his/her torso and increased confusion. RN A did not initiate neurological assessment's. Additionally, the facility Certified Nurses Aide (CNA) A failed to notify the nurse immediately when he/she found the resident on the floor during the night of 12/4/24. CNA A and CNA B assisted the resident off the floor and back to bed. The facility census was 139. Review of the fall policy dated 2020 showed: - The staff were supposed to assess the resident after a fall; - The staff were supposed to complete a post-fall assessment. Review of the head injury policy dated 9/1/21 showed: - The staff were expected to assess if there is a known, suspected or verbalized head injury; - Perform neurological assessments as indicated. 1. Review of the Resident #1's Admission Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 11/5/24 showed: - Diagnoses included: Diabetes Mellitus (DM) type two (a disease in which the body does not process blood sugar properly), history of falls, anticoagulant (medicine to prevent blood clots) use, and heart failure. - Brief Interview for Mental Status (BIMS) score of 14, indicating the resident did not have a cognitive deficit; - The resident required assistance for staff to use the toilet, get dressed and shower; - The resident used a wheel chair for mobility; - The resident had a history of falls prior to admission. Review of the resident's comprehensive care plan dated 11/1/24 showed: - 11/1/24 The resident was at risk for falls; - 11/30/24 The resident had an actual unwitnessed fall on 11/30/24; - 12/2/24 The staff were to anticipate the resident's needs; - 12/2/24 The staff were supposed to initiate neurological assessments for an unwitnessed fall and ensure the resident had a clear path; - 12/6/24 The resident had an unwitnessed fall with an intervention to obtain lab work. Review of the resident's record showed: - A fall assessment was completed on 11/30/24 with a score of eight, indicating the resident was at a low risk for falls; - A fall assessment was completed on 12/6/24 with a score of 48, indicating the resident was a high risk for falls; - Facility staff documented on 12/5/24 at 8:49 A.M. the resident was more confused than usual and was incontinent of urine; - LPN A documented on 12/5/24 at 9:47 A.M. he/she obtained an order for them resident's physician to check the resident for a Urinary Tract Infection (UTI); - Another staff member documented on 12/5/24 at 12:00 P.M. the resident was not feeling well and in bed sleeping; - Staff documented on 12/5/24 at 12:07 P.M. they attempted to obtain a urine sample from the resident and was unsuccessful; - RN A documented on 12/5/24 at 4:01 P.M. he/she saw new bruises to the resident's left hip, and flank (side/rib area). the resident reported to RN A he/she had fallen the night prior, he/she yelled and somebody lifted him/her off the floor; - The facility staff did not document the resident fall on 12/4/24; - RN A did not initiate neurological assessments; - X-ray was obtained on 12/6/24 and found the resident had a fractured right collar bone; - The resident was sent to the hospital on 12/7/24 due to increased confusion and a fractured collar bone. During and interview on 12/12/24 at 2:35 P.M. CNA A said: - He/She was completing 5:00 A.M. rounds on 12/5/24 and heard the resident yelling help; - The resident was sitting on his/her bottom on the floor in front of his/her wheelchair; - The resident had a small open area to his/her left upper leg and bruising; - The resident said he/she needed to use the bathroom; - CNA A got CNA B and both CNA's picked the resident up off of the floor and placed him/her into his/her wheel chair; - The CNA's did not tell the charge nurse of the resident's fall before they got him/her up off the floor; - CNA A knew the nurse was supposed to assess the resident before getting the resident up; - CNA A notified the charge nurse of the fall once the resident was taken to the bathroom and placed back in his/her wheel chair. During an interview on 12/12/24 at 12:05 P.M. RN A said: - He/She was helping the charge nurse on 12/5/24 obtain a urine sample from the resident and he/she had his/her shirt off; - RN A saw bruises to the resident's right flank area and a bruise to the top of his/her right hand; - The resident reported to RN A he/she had fallen the night before and someone lifted him/her off the floor; - RN A documented the observation the nursing record, but did not start neurological assessments; - He/She should have initiated neurological assessments. During an interview on 12/12/24 at 12:28 P.M. Family Member A said: - The facility nurse called him/her on 12/6/24 and reported the resident needed more help with his/her cares; - He/She visited the resident the morning of 12/7/24 while the resident was at the breakfast table and saw a pool of blood under the resident's chair and discovered a skin tear; - The resident was not able to feed him/herself that morning and was able to on 12/5/24; - He/She saw a large bruise on the resident and the resident was confused; - The facility staff did not report a fall of any injuries to him/her; - The resident was sent to the hospital at that time. During an interview on 12/12/24 at 12:45 P.M. the Director of Nursing (DON) said: - He/she expected CNA A and CNA B to wait for the nurse to assess the resident before repositioning the resident after being found on the floor; - He/She expected neurological assessments to be completed on all falls that were not witnessed. During an interview on 12/12/24 at 1:25 P.M. The Administrator said: -The CNA's should not have picked the resident up before the charge nurse could assess the resident for injuries; - The staff should have initiated neurological assessments when the resident had an unwitnessed fall. During an interview on 12/13/24 at 9:15 A.M. the residents Primary Care Physician said: - He/She would have expected the nurses to complete neurological assessments on the resident once they discovered he/she had fallen; - It is his/her expectation that neurological assessments are completed on all falls that are not witnessed; - It would be his/her expectation CNA's would not pick up or reposition the resident until the nurse has assessed the resident for injuries. MO246258

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse, when one resident, Resident #3 reported being sexually abused by another resident, Resident #4. The facility census was 123. On 2/14/24, the Administrator was notified of the past noncompliance situation which occurred on 2/4/24. On 2/5/24, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 2/9/24. Review of the facility policy regarding Abuse, revised 8/22/22, showed: - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, paint or mental anguish which can include certain resident to resident altercations. - Sexual abuse is non-consensual sexual contact of any type with a resident. - Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain and mental anguish, including sexual abuse. Review of Resident #3's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/19/23, showed: -Brief Interview Mental Status (BIMS), a cognitive assessment tool used by nursing homes to determine mental status, score of 4 which indicated severe cognitive impairment. -He/She had clear comprehension, usually was understood, and clear speech; -The resident was dependent for eating, oral care, toileting, bathing, upper and lower body dressing, personal hygiene, and mobility; -Diagnoses included quadriplegia (a form of paralysis that affects all four limbs, plus torso), dysarthria of speech (a weakness in the muscles used for speech which causes slowed or slurred speech), need for assistance with personal care, muscle wasting and atrophy (loss of muscle tissue), and asthma. Review of Resident #4's quarterly MDS, dated [DATE], showed: -BIMS of 15, indicating he/she was cognitively intact; -Dependent on walker for mobility; -Diagnoses included aneurysm and dissection (a condition causing a weak spot in the wall of the aorta), repeated falls, osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down), generalized muscle weakness, lack of coordination, and difficulty in walking. Review of the undated facility investigation showed: -Resident #4 was interviewed by a Case Manager. Staff did not document the date or time; -Resident #3 was interviewed by a Case Manager via a communication board. Staff did not document the date or time; -Resident #3 told the Case Manager Resident #4 got in bed with him/her on the side of the bed by the window. -Resident #4 had gotten into bed with him/her on previous occasions as well. -Resident #3 said Resident #4 touched in his/her private areas; -Interview with police officer and Resident #3 at 11:20 A.M., showed Resident #3 told police that Resident #4, got in bed last night and touched him/her in his/her private crotch area and it had happened several times before. - The contact was sexual on his/her genitals for a short time, less than an hour. - Resident #3 was unable to answer the officer when asked if he/she was wearing a brief when the touching occurred. - Resident #3 said Resident #4 told him/her, I love you. - Resident #3 responded yes when asked if Resident #4 had touched him/her with anything other than his/her hand. - Resident #3 responded yes when asked if Resident #4 touched him/her on top of his/her brief. - Resident #3 responded yes when asked if Resident #4 touched him/her inside and under his/her brief. Staff did not document the date this interview was conducted; -Registered Nurse (RN) B was interviewed on 2/5/24 at 12:20 P.M. and said he/she became aware of an allegation by Certified Nurse Aide (CNA) B. CNA B told him/her, Resident #3 said Resident #4 had been getting into his/her bed and touching him/her. -When RN B asked the resident about the incident, Resident #3 was visibly shaking too much to use his/her communication board. -An unidentified staff member was interviewed and said Resident #3 was in his/her wheelchair and headed down to the dining room, when he/she arrived the resident was upset and was yelling. When the unknown staff member got to resident and asked him/her what was going on, he/she told him/her on the communication board that his/her roommate had got into his/her bed. Staff did not document the date, time, or person who conducted the interview. Review of the case summary report, dated 2/5/24, included: -On 2/5/24 at 10:51 A.M., law enforcement interviewed Resident #3. Resident #3 communicated through a communication board. -Officer asked Resident #3 if his/her roommate, Resident #4 got in his/her bed last night and Resident #3 pointed to yes. -Officer asked Resident #3 if Resident #4 touched his/her genitals and Resident #3 pointed to yes. -Officer asked if this had happened before, Resident #3 pointed to yes. -Officer asked it happened for a long time, Resident #3 pointed to no. -Officer asked Resident #3 if it was for a short time, Resident #3 pointed to yes. -Officer asked Resident #3 if he/she spooked Resident #4 when he/she woke up and he/she pointed to yes. -Officer asked Resident #3 if Resident #4 got out of bed when he/she woke up and he/she pointed to yes. -Officer asked Resident #3 if he/she was wearing a brief when this happened and the resident did not answer. -Officer asked if Resident #4 said anything to Resident #3 and Resident #3 pointed to an area on the board with I love you. -Officer asked Resident #3 if Resident #4 touched him/her with anything other than his/her hand and Resident #3 pointed to yes. -Officer asked Resident #3 if Resident #4 touched him/her on top of brief and resident #3 pointed to yes; -Officer asked Resident #3, so Resident #4 he/she didn't reach inside of your brief and Resident #3 pointed to yes; -Officer asked Resident #3 if Resident #4 reached inside brief and Resident #3 pointed to yes; -Officer asked Resident #3 if Resident #4 reached under his/her brief and Resident #3 pointed to yes. During an interview on 2/14/24 at 4:00 P.M., Resident #3 said via communication board: -Resident #4 touched him/her sexually; -Resident #4 had done it twice before. During an interview on 2/14/24 a 4:16 P.M., Resident #4 said: -Resident #3 accused him/her of climbing in bed and fondling him/her; -He/She never touched Resident #3. During an interview on 2/14/24 at 2:50 P.M., CNA C said: -He/She was working the floor as a CNA on the night Resident #3 reported Resident #4 sexually assaulted him/her; -Resident #3 reported the incident after he/she completed his/her shift. During an interview on 2/15/24 at 3:23 P.M., CNA D said: -He/She was working with Resident #3 and Resident #4 on the night of allegation; -Resident #3 had not made prior allegations of abuse against the roommate. During an interview on 2/14/24 at 4:27 P.M., RN B said: -He/She completed a physical assessment of Resident #3 and found no signs of trauma. During an interview on 2/14/24 at 4:38 P.M., the Director of Nursing said: -When Abuse and Neglect occurs in the facility staff should separate residents involved, make sure both are safe, notify their supervisor, then Administrator, or him/her; -The Administrator is the facility investigator. During an interview on 2/14/24 at 4:44 P.M., the Administrator said: -He/She asked RN B to assess Resident #3 after the allegation; -CNA C saw no semen when providing pericare and stated Resident #3's brief was on tight. During an interview on 2/14/24 at 4:52 P.M., the Regional Nurse Consultant said: -He/She was notified of the resident allegation while the administrator was out on leave; -He/She completed the facility abuse and neglect checklist that included obtaining statements; -Facility staff were interviewed by law enforcement; -Resident interviews were completed. During an interview on 2/20/24 at 11:06 A.M., the Case Manager said: -He/She became aware of allegation of sexual abuse between Resident #3 and Resident #4 during the morning clinical meeting; -He/She notified the Administrator -He/She moved Resident #4 to a room on a different hall; -He/She interviewed Resident #4 and then Resident #3 to find out what their statements were; -He/She provided verbal statement to the Regional Nurse Consultant and he/she typed his/her statement up. During an interview on 2/15/24 at 4:19 P.M., the Regional Nurse Consultant said: -He/She was made aware of abuse on 2/5/24 at 9:50 A.M.; -He/She was advised the allegation was made by Resident #3 that he/she had been touched by Resident #4; -Staff kept Resident #3 at the nurses station and got the Case Manager involved; -Resident #4 was moved to a different room and the facility ensured there was no further contact from Resident #4 to Resident #3; -Facility completed trauma assessments and skin assessments with no findings. MO231407

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse, when one resident, Resident #3 reported being sexually abused by another resident, Resident #4. The facility census was 123. On 2/14/24, the Administrator was notified of the past noncompliance situation which occurred on 2/4/24. On 2/5/24, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 2/9/24. Review of the facility policy regarding Abuse, revised 8/22/22, showed: - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, paint or mental anguish which can include certain resident to resident altercations. - Sexual abuse is non-consensual sexual contact of any type with a resident. - Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain and mental anguish, including sexual abuse. Review of Resident #3's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/19/23, showed: -Brief Interview Mental Status (BIMS), a cognitive assessment tool used by nursing homes to determine mental status, score of 4 which indicated severe cognitive impairment. -He/She had clear comprehension, usually was understood, and clear speech; -The resident was dependent for eating, oral care, toileting, bathing, upper and lower body dressing, personal hygiene, and mobility; -Diagnoses included quadriplegia (a form of paralysis that affects all four limbs, plus torso), dysarthria of speech (a weakness in the muscles used for speech which causes slowed or slurred speech), need for assistance with personal care, muscle wasting and atrophy (loss of muscle tissue), and asthma. Review of Resident #4's quarterly MDS, dated [DATE], showed: -BIMS of 15, indicating he/she was cognitively intact; -Dependent on walker for mobility; -Diagnoses included aneurysm and dissection (a condition causing a weak spot in the wall of the aorta), repeated falls, osteoarthritis (a type of arthritis that occurs when flexible tissue at the end of bones wears down), generalized muscle weakness, lack of coordination, and difficulty in walking. Review of the undated facility investigation showed: -Resident #4 was interviewed by a Case Manager. Staff did not document the date or time; -Resident #3 was interviewed by a Case Manager via a communication board. Staff did not document the date or time; -Resident #3 told the Case Manager Resident #4 got in bed with him/her on the side of the bed by the window. -Resident #4 had gotten into bed with him/her on previous occasions as well. -Resident #3 said Resident #4 touched in his/her private areas; -Interview with police officer and Resident #3 at 11:20 A.M., showed Resident #3 told police that Resident #4, got in bed last night and touched him/her in his/her private crotch area and it had happened several times before. - The contact was sexual on his/her genitals for a short time, less than an hour. - Resident #3 was unable to answer the officer when asked if he/she was wearing a brief when the touching occurred. - Resident #3 said Resident #4 told him/her, I love you. - Resident #3 responded yes when asked if Resident #4 had touched him/her with anything other than his/her hand. - Resident #3 responded yes when asked if Resident #4 touched him/her on top of his/her brief. - Resident #3 responded yes when asked if Resident #4 touched him/her inside and under his/her brief. Staff did not document the date this interview was conducted; -Registered Nurse (RN) B was interviewed on 2/5/24 at 12:20 P.M. and said he/she became aware of an allegation by Certified Nurse Aide (CNA) B. CNA B told him/her, Resident #3 said Resident #4 had been getting into his/her bed and touching him/her. -When RN B asked the resident about the incident, Resident #3 was visibly shaking too much to use his/her communication board. -An unidentified staff member was interviewed and said Resident #3 was in his/her wheelchair and headed down to the dining room, when he/she arrived the resident was upset and was yelling. When the unknown staff member got to resident and asked him/her what was going on, he/she told him/her on the communication board that his/her roommate had got into his/her bed. Staff did not document the date, time, or person who conducted the interview. Review of the case summary report, dated 2/5/24, included: -On 2/5/24 at 10:51 A.M., law enforcement interviewed Resident #3. Resident #3 communicated through a communication board. -Officer asked Resident #3 if his/her roommate, Resident #4 got in his/her bed last night and Resident #3 pointed to yes. -Officer asked Resident #3 if Resident #4 touched his/her genitals and Resident #3 pointed to yes. -Officer asked if this had happened before, Resident #3 pointed to yes. -Officer asked it happened for a long time, Resident #3 pointed to no. -Officer asked Resident #3 if it was for a short time, Resident #3 pointed to yes. -Officer asked Resident #3 if he/she spooked Resident #4 when he/she woke up and he/she pointed to yes. -Officer asked Resident #3 if Resident #4 got out of bed when he/she woke up and he/she pointed to yes. -Officer asked Resident #3 if he/she was wearing a brief when this happened and the resident did not answer. -Officer asked if Resident #4 said anything to Resident #3 and Resident #3 pointed to an area on the board with I love you. -Officer asked Resident #3 if Resident #4 touched him/her with anything other than his/her hand and Resident #3 pointed to yes. -Officer asked Resident #3 if Resident #4 touched him/her on top of brief and resident #3 pointed to yes; -Officer asked Resident #3, so Resident #4 he/she didn't reach inside of your brief and Resident #3 pointed to yes; -Officer asked Resident #3 if Resident #4 reached inside brief and Resident #3 pointed to yes; -Officer asked Resident #3 if Resident #4 reached under his/her brief and Resident #3 pointed to yes. During an interview on 2/14/24 at 4:00 P.M., Resident #3 said via communication board: -Resident #4 touched him/her sexually; -Resident #4 had done it twice before. During an interview on 2/14/24 a 4:16 P.M., Resident #4 said: -Resident #3 accused him/her of climbing in bed and fondling him/her; -He/She never touched Resident #3. During an interview on 2/14/24 at 2:50 P.M., CNA C said: -He/She was working the floor as a CNA on the night Resident #3 reported Resident #4 sexually assaulted him/her; -Resident #3 reported the incident after he/she completed his/her shift. During an interview on 2/15/24 at 3:23 P.M., CNA D said: -He/She was working with Resident #3 and Resident #4 on the night of allegation; -Resident #3 had not made prior allegations of abuse against the roommate. During an interview on 2/14/24 at 4:27 P.M., RN B said: -He/She completed a physical assessment of Resident #3 and found no signs of trauma. During an interview on 2/14/24 at 4:38 P.M., the Director of Nursing said: -When Abuse and Neglect occurs in the facility staff should separate residents involved, make sure both are safe, notify their supervisor, then Administrator, or him/her; -The Administrator is the facility investigator. During an interview on 2/14/24 at 4:44 P.M., the Administrator said: -He/She asked RN B to assess Resident #3 after the allegation; -CNA C saw no semen when providing pericare and stated Resident #3's brief was on tight. During an interview on 2/14/24 at 4:52 P.M., the Regional Nurse Consultant said: -He/She was notified of the resident allegation while the administrator was out on leave; -He/She completed the facility abuse and neglect checklist that included obtaining statements; -Facility staff were interviewed by law enforcement; -Resident interviews were completed. During an interview on 2/20/24 at 11:06 A.M., the Case Manager said: -He/She became aware of allegation of sexual abuse between Resident #3 and Resident #4 during the morning clinical meeting; -He/She notified the Administrator -He/She moved Resident #4 to a room on a different hall; -He/She interviewed Resident #4 and then Resident #3 to find out what their statements were; -He/She provided verbal statement to the Regional Nurse Consultant and he/she typed his/her statement up. During an interview on 2/15/24 at 4:19 P.M., the Regional Nurse Consultant said: -He/She was made aware of abuse on 2/5/24 at 9:50 A.M.; -He/She was advised the allegation was made by Resident #3 that he/she had been touched by Resident #4; -Staff kept Resident #3 at the nurses station and got the Case Manager involved; -Resident #4 was moved to a different room and the facility ensured there was no further contact from Resident #4 to Resident #3; -Facility completed trauma assessments and skin assessments with no findings. MO231407

Based on interview and record review, facility staff failed to call emergency personnel in a timely manner and failed to provide basic life support, including cardiopulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped, for one resident (Resident #1). The facility census was 91. The administrator was notified on [DATE] at 3:30 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the administrator became aware of the violation of the facility CPR policy. The facility inserviced the staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. 1. Review of the facility's undated CPR policy showed the following: - Basic life support including initiation of CPR is provided to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) who do not show obvious clinical signs of irreversible death (rigor mortis, dependent lividity, decapitation, transection or decompensation) in accordance with the resident's advance directive and any related physician's orders [REDACTED]. - CPR would be initiated when [MEDICAL CONDITION] occurred for residents who requested CPR in their advance directive, who have not formulated an advance directive, or who do not have a valid do not resuscitate order signed by a physician; - CPR certified team members are available at the facility at all times; - Residents' code status will be designated prominently in front of the residents' chart. 2. Review of Resident #1's Health Care Directive dated [DATE], showed the resident wanted everyone who cared for him/her to understand his/her wishes if he/she could not communicate or make decisions on his/her own. He/she made this directive to provide clear and convincing proof of his/her wishes and instructions about health care and treatment. If his/her doctor believed a medical treatment would lead to recovery, he/she wanted to have treatment including CPR. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated [DATE], showed: - The resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact Review of the resident's care plan updated on [DATE], showed; - The resident was at risk for abnormal bleeding related to being on anticoagulant therapy; - The resident had an advance directive that included a full code; - Staff should administer CPR if the resident had a [MEDICAL CONDITION]. Review of the hospital discharge orders dated [DATE], showed the resident's code status was a full resuscitation. Review of the nurses' notes dated [DATE] at 7:00 P.M. showed the nurse entered the resident's room and after the nurse cared for the resident's roommate, the nurse found the resident on the floor next to the bed with large amounts of blood and blood clots on the resident's bed and floor. The nurse rubbed the resident's arm and shouted the resident's name with no response from the resident. The nurse noted the resident was very gray in color and the resident's eyes were open. The nurse immediately called for staff assistance and removed the roommate from the resident's room. A call was made to 911 and the nurse notified the director of nursing the resident already appeared to be deceased . First Responders arrived at the facility and the resident's bed had been removed from the room and the resident was moved on his/her back at that time. The nurse noted a puncture/opening to the left antecubital (inner area of the elbow) . During an interview on [DATE] at 5:10 P.M., Licensed Practical Nurse (LPN) A said he/she went into the resident's room before 7:00 P.M., to give the resident's roommate a breathing treatment. He/she moved the curtain back and saw the resident's bed was covered in blood and the resident was on the floor on his/her right side facing the window. He/she rubbed the resident on the shoulder and shook the resident's arm and the resident did not respond. He/she realized the resident's eyes were open and the resident's neck and face were gray. There were blood clots and blood all around the resident and a blood clot the size of a kidney on the resident's bed. He/she went and got the resident's roommate up out of bed and walked the roommate out of the room to the hallway and another staff member assisted the roommate down the hall. He/she went around the corner and down the hall to the nurses' station and yelled for help from LPN B. They went back to the resident's room and he/she said he/she was going to go call 911. He/she went and called 911 and then he/she called the director of nursing who said she was coming right to the facility. He/she went back into the resident's room and LPN B said the resident had no pulse and that was about the same time the first responders arrived. He/she never checked the resident's pulse or initiated any type of resuscitation, because it was obvious there were no signs of life, so he/she went and got assistance. Staff should initiate CPR if a resident does not have a pulse. He/she never checked the resident's pulse and he/she did not initiate CPR. During an interview on [DATE] at 4:47 P.M., LPN B said LPN A came around the corner and said he/she needed help in Resident #1's room. When he/she walked into the resident's room, he/she saw all of the blood and asked LPN A if he/she called 911 and LPN A said no. He/she told LPN A to go call 911 and LPN A went to make the call. He/she moved the resident's bed and turned the resident onto his/her back and checked the resident's pulse. The resident did not have a pulse or respirations. He/she tried to find the source of the bleeding and found where the bleeding came from, so he/she applied pressure to the area. The area was not difficult to find, because there was a lot of blood coming from the site. About that time, LPN A returned to the room and emergency services arrived. He/she asked LPN A why he/she did not start CPR and LPN A said he/she thought the resident was a no code. LPN B thought the resident was a full code because there was an order to send the resident to the hospital with any oxygen non-compliance. During an interview on [DATE], at 1:50 P.M., Certified Nurse Aide (CNA) A said he/she heard staff yell for help and he/she went to the resident's room and put gloves on. He/she was CPR certified and asked the charge nurse if he/she should start CPR and the nurse said no. Review of the First Responders medical records dated [DATE], showed at 7:01 P.M., they were dispatched to the nursing home for a possible suicide. They arrived on the scene at 7:05 P.M., and found the resident on the floor in a supine position (on his/her back) and unresponsive. There was a large amount of blood pooled around the resident. The resident appeared very pale and cool to the touch. The resident was pulseless and not breathing. Chest compressions were started and a laceration to the left arm was noticed. The resident's shirt was removed and the resident was rolled to the side to look for additional injuries and none were found. The First Responders began ventilating the resident with a mask until an ambulance and the police department arrived. Review of the Emergency Medical Services (EMS) notes dated [DATE], showed they received a call at 7:00 P.M., and arrived at the facility at 7:12 P.M. Upon arrival the resident was lying supine on the floor with a large amount of blood present on the floor approximately four feet to the right side of the resident and much of the blood was coagulated (thickened). CPR and ventilation (rescue breathing) with a bag valve mask (hand held device used for ventilation) was being performed by the fire department. The facility staff stated the resident was last seen at approximately 6:00 P.M. Staff found the resident with the laceration to his/her left antecubital and it was unknown who or what caused the laceration. The fire department had placed a bandage on the left antecubital. CPR and ventilation were continued. Due to continued bleeding, a tourniquet was placed on the resident's left arm above the laceration and it stopped the bleeding. Monitor pads were placed on the resident and an electrocardiogram (EKG) showed pulseless electrical activity (the monitor showed electrical activity in the heart, but the resident had no palpable pulse). An intraosseous infusion (used to administer medications) was placed in the left tibia (lower leg). Normal saline was administered with a pressure infuser (delivers medications quickly) and [MEDICATION NAME] (medication for blood pressure support) was administered. An airway was placed. The physician was notified and gave orders to discontinue resuscitation efforts. During an interview on [DATE], at 4:24 P.M., the resident's primary physician said he/she expected staff to call EMS and initiate CPR when a resident was not breathing or did not have a pulse. During an interview on [DATE], at 4:02 P.M., the resident's Family Nurse Practitioner (FNP) said he/she expected staff to get help, call 911, get supplies and start CPR after finding the resident. During an interview on [DATE], at 5:05 P.M., the Director of Nursing (DON) said if a resident did not show signs of life, she expected staff to go right to a resident's chart and check their code status, call EMS and start CPR if they were a full code. LPN A called her on [DATE], and said he/she found the resident deceased . She asked LPN A if he/she called 911 and LPN A said no. She told LPN A to call 911 and she was on her way to the facility. MO 5

Based on interview and record review, facility staff failed to clarify code status upon admission, failed to communicate the resident's Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) to nursing staff and nursing staff failed to follow an Advance Directive that showed the resident did not want cardiopulmonary resuscitation (CPR) for one resident (Resident #1) out of three sampled residents. Staff initiated CPR and transported the resident to the hospital where the family re-communicated the resident did not want life sustaining measures. The resident was removed from life support and passed away. The facility census was 92. Review of the facility's policy titled Notification of Advance Directives, dated [DATE], showed the healthcare center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive CPR, and the right to formulate an Advance Medical Directive such as a Living Will, Power of Attorney for Health Care Decision, or Health Care Surrogate according to state and federal law. The healthcare center recognizes each resident's right to establish advance legal choices concerning future medical care and treatment. The healthcare center recognizes the following medical orders for Advance Directives: - Do Not Resuscitate; - Living Will; - Durable Medical Power of Attorney for Health Care; - Health care surrogate directive as applicable. 1. Review of the resident's Durable Power of Attorney (DPOA) for Health Care Choices and Healthcare Choices Directive, dated [DATE] at 7:40 A.M., showed the resident appointed Family Member (FM) A to be his/her agent to make healthcare decisions when he/she could not make decisions or communicate what he/she wanted done. When speaking for him/her, he/she expected for his/her agent to be guided by his/her directions as stated in his/her health care choices. When he/she had a condition that would cause him/her to die soon or a condition so bad including serious brain damage or brain disease that there is no reasonable hope that he/she would regain a quality of life acceptable to him/her as described, he/she did not want CPR to restart his/her heart or breathing, breathing machine including a respirator or a ventilator, and all other life-prolonging medical treatments that were merely intended to keep him/her alive without reasonable hope of making him/her better. Review of the hospital transfer records, dated [DATE], showed a code status order (information that would let staff know if they should or should not start CPR if the resident stopped breathing or the resident's heart stopped beating) was not documented. Review of the resident's admission note, dated [DATE] at 4:07 P.M., showed Licensed Practical Nurse (LPN) A documented the resident was cooperative with care and was alert and oriented to person and time. The resident's breathing was non-labored. The resident denied pain and the resident's vital signs were within normal limits. The admission note did not include a code status. Review of the admission assessment, dated [DATE], showed LPN A documented the resident's [DIAGNOSES REDACTED]. The assessment did not include a code status. Review of the resident's admission checklist, dated [DATE], showed LPN A documented a code status order was received but did not indicate the code status. Review of the Physician order [REDACTED].>Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated [DATE], included the following: - Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. - [DIAGNOSES REDACTED]. - The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. During an interview on [DATE] at 9:52 A.M., LPN A said he/she received transfer orders from the hospital. The orders did not include a code status. When he/she received a telephone report from the nurse at the hospital, the nurse told him/her the resident was a full code (resident wants CPR). LPN B helped him/her with the admission and completed the POS. He/she told LPN B to add the full code status to the POS. LPN A did not know the resident had an Advance Directive and did not talk to the physician. During an interview on [DATE] at 2:00 P.M., LPN B said he/she did not remember if LPN A asked him/her to add the code status to the POS. Review of the Family Nurse Practitioner (FNP) assessment, dated [DATE], showed the resident was a full code. During an interview on [DATE] at 9:45 A.M., FNP A said when he/she completed the resident's assessment on [DATE], there was not an order for [REDACTED]. Review of the Social Service Director's (SSD) assessment, dated [DATE], showed the resident was a full code. DPOA, Health Care proxy and Living Will, were left blank on the form. The form instructed staff to check all that applied to the resident. During an interview on [DATE] at 3:30 P.M., the SSD said she completed an assessment on each resident after admission within the first 48 hours to seven days. Sometimes she was not able to meet that time frame. When she completed the social service assessments upon admission, she usually checked with the residents and/or their family to see if the residents had a DPOA and Health Care Directive. However, she did not do this with the resident. If residents had any of these documents, she made one copy for the business office and one copy to put on the residents' charts. If the document indicated the resident did not want CPR, she discussed it with the resident and/or family to ensure that was still their wish. If the resident and/or family still wanted the resident to be a Do Not Resuscitate (DNR), she initiated the purple sheet which is the outside the facility DNR form. She had the resident and/or family member sign the form and then she put the form in the physician folder at the nurses' desk to be signed by the physician when the physician came to the facility on Fridays. The physician signed the form and his/her nurse gave her a copy of the signed form. When she had the signed copy, she added the copy to the resident's chart and notified nursing staff. She completed the resident's assessment on [DATE]. She interviewed the resident during the assessment, but the resident was confused. She did not discuss code status or advance directives with the resident. The resident's family was not present during the assessment. Review of the resident's care conference summary, dated [DATE], showed staff documented topics discussed were advance directives, code status, and invoking the DPOA. Staff did not document specific information regarding these items. FM A, FM B, Physical Therapist, SSD and the MDS Coordinator attended the care conference. During an interview on [DATE] at 12:11 P.M., FM B said the family was told the resident was a DNR during the care plan meeting. They asked if the DPOA could be invoked and the SSD said she would work on it. The family brought a copy of the resident's Health Care Directive to the facility the day the resident was admitted to the facility to be kept on file, but could not remember who they gave it to. FM B said the family still had not heard from the facility about the status of the DPOA being invoked a few weeks after the care plan meeting. They asked the Director of Nursing (DON) if it had been invoked, but she could not find it on the chart and took them to talk with the Administrator. The Administrator said she would talk to the SSD and asked them to bring another copy of the advance directive to the facility. FM B said he/she was under the impression the facility knew the resident was a DNR all along. During an interview on [DATE] at 10:00 A.M., the Administrator said the family asked about the DPOA being invoked. She did not know anything about it and talked with the SSD who said she would obtain a copy from the family and get the doctor to invoke it. The family did not discuss the resident's code status with her. During an interview on [DATE] at 3:30 P.M., the SSD said the resident's family asked about invoking (physician gives the authority for the assigned person on the DPOA to make medical choices because the resident was unable to do so) the Health Care Directive during the care conference on [DATE]. She told the family she did not have a copy of the Health Care Directive and asked the family to bring a copy to her and she would work on getting it invoked. The family brought the copy in over the weekend and left it with nursing staff prior to having the DPOA invoked around [DATE] to [DATE]. She received a copy of the Health Care Directive when she returned to work on Monday, [DATE]. The physician invoked the DPOA on Friday, [DATE] while at the facility. He/she signed the Invoke DPOA form for the resident. After the DPOA for the Health Care Directive was invoked, she made a copy for the business office and put a copy on the resident's chart and added a new face sheet (summary of the resident's personal information kept on the front of the medical record) that reflected that the resident's DPOA was invoked. The SSD said she dropped the ball and did not initiate a purple sheet to obtain a physician order [REDACTED]. Review of the resident's Invoke Durable Power of Attorney document, dated [DATE], showed the resident was under the medical care of the physician. Due to the resident's impaired cognitive status, the resident was unable to make rational decisions regarding healthcare and financial status. This impairment showed no indication of being reversible in the future. The physician believed the DPOA previously appointed by the resident should go into effect immediately. The document was signed by the resident's attending physician. Review of the resident's nurses' notes, dated [DATE] at 12:40 P.M., showed staff documented the resident called out to staff and said he/she had trouble trying to make it to the restroom. Staff assisted the resident into a chair and noticed the resident acted out of character. Staff left the room to get supplies to check the resident's vital signs and when staff returned to the resident's room, the resident had stopped breathing. Emergency Medical Services (EMS) was called and CPR was initiated. EMS arrived and transported the resident to the hospital. Prior to leaving the facility the resident had a faint pulse. Staff notified the resident's family and physician of the transfer. Review of the resident's hospital records, dated [DATE], showed on arrival to the emergency room , the resident was intubated (tube inserted into the resident's airway to assist with breathing), bagging (artificial ventilation) and CPR in progress. The nursing home staff had initiated CPR and when EMS arrived they cardioverted the resident (shock in an attempt to return the resident to a normal heart rhythm) and gave [MEDICATION NAME] (medication used to restore a normal heart rhythm). The resident was on a ventilator (machine that breathes for someone when they are unable to breath on their own). The family member stated the resident was a DNR and requested any artificial life support be shut off. The family member stated the resident did not want any of that and the nursing home should have never started it. The hospital staff explained the consequences of removing life support. The family member understood and requested hospital staff to immediately take the resident off life support. The resident passed away peacefully with his/her family member at the bedside. During an interview on [DATE] at 12:11 P.M., FM B said it was very painful for FM A to have the resident taken off life support to honor the resident's wishes as they had been together for over [AGE] years. The resident and FM A had a lengthy conversation after he/she was resuscitated in the hospital prior to his/her admission to the facility in July and said he/she did not want to be resuscitated again. During an interview on [DATE] at 10:45 A.M., the resident's physician/facility's medical director said he would not expect staff to initiate CPR on a resident who has a Health Care Directive and requested to be a DNR. He felt the discussion regarding health care directives should happen close to the time of the resident's admission. The discussion should be with the resident and/or family so the information was available to staff for them to follow the resident's wishes. During an interview on [DATE] at 11:15 A.M., the Administrator said she expected staff to verify the information on the resident's Health Care Directives as soon as they receive the information and initiate any orders needed to honor the resident's wishes. During the interview on [DATE] at 11:06 A.M., the DON said when a staff member received a resident's Health Care Directive that included a DNR, staff should verify the information with the resident and/or family member. If the resident still wanted to be a DNR, nursing should obtain a DNR order immediately from the physician and initiate the outside the facility DNR form. MO 2 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, record review, and interview completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. Resident #1 passed away at the hospital. During the onsite visit, the facility staff began on audit on [DATE] of charts for all residents currently residing in the facility to assure DPOA/Advance Directives were on the charts. They also verified residents' advance directives were accurately reflected on the residents' charts. The facility administration reviewed their system for obtaining and implementing code statuses. On each admission/readmission, the Administrator/DON or nurses (if the Administration is not available) will inform residents of advance directive choices. If the resident chooses to be a DNR, the staff will notify the physician to obtain a DNR order. The staff will put a red sheet in the front of the residents' charts if they are a DNR and it they choose to be a full code, a green sheet will be placed in the chart. Staff in-servicing was initiated on [DATE], and will continue until all staff have been in-serviced. They inserviced the nurses and CNA's on the facility's system 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 level was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address a Class I violation

Based on record review and interview, facility staff failed to provide personal attention and nursing care in accordance with the resident's condition for one (Resident #1) of five sampled residents. Facility staff failed to obtain a urine sample for a urinalysis (UA, a test which would indicate if the resident had a urinary tract infection, UTI) and failed to notify the resident's physician when staff did not obtain the UA specimen. Additionally, facility staff failed to notify the resident's physician of the resident's significant change in condition and increased pain. Facility staff failed to assess, document, and monitor the resident when a physical therapy assistant (PTA), certified nurse's aide (CNA), and certified medication technician (CMT) told the licensed facility staff of the resident's increased confusion, pain, and the need for increased assistance in transferring. Facility staff failed to act immediately when a CMT noticed the resident in a dazed state. The resident went to the emergency room (ER) on 10/25/15, was diagnosed with [REDACTED]. The facility census was 113. Review of the facility's Resident's Medication's Rights Policy, last updated 1/1/13, showed: - Facility staff should document when a resident refused medications. - The physician needed to be notified of the resident's refusal to take medications if refused within a 24 hour period or immediately if the medications could negatively impact the resident's overall health or safety. Review of the facility's undated Pain Management Policy showed: - The resident's pain will be controlled to maintain maximum comfort and enhanced quality of life. - If a resident said they had pain, they should be asked to rate it on a numerical scale. - If the resident was nonverbal, staff must assess by the resident's nonverbal expressions. - Pain and pain concerns needed to be added to the resident's care plan. - If new acute pain occurs, an evaluation will be conducted to determine the cause. - The staff must follow up on the effectiveness of the pain interventions used. - Non-pharmacological approaches may be used and staff needed to document the interventions and their effectiveness. Review of the facility's Change of Condition Policy, dated 8/1/12, showed: - The change of condition needed to be reported to the charge nurse immediately when they noticed it. - The resident's physician will be notified immediately of any change of the resident's physical or mental change of condition. - The notifications of the physician and/or responsible parties shall be documented in the clinical records as well as on the 24 hour report form. Status changes which are not significant enough to be reported must be documented in the medical record. - Advanced skin breakdown or recurrent UTI's can trigger a reassessment. Review of the facility's Notification of Change Policy, dated 8/1/12, showed: - The resident's family must be notified of a resident's change of condition. - The resident, their physician, and their family will be notified of a life-threatening condition or clinical complications, or need to significantly alter treatment or when an accident occurred. - Licensed nurse will notify the physician and responsible party/family of a change of condition. - Who the licensed nurse notified and when, should be in the nurse's notes with the time of notification(s). Review of the facility's physician's orders [REDACTED]. - Ensure the physicians maintain control of the overall plan of care for each resident and have the responsibility for decision making in regards to the plan of care. - All physicians' orders shall be followed as prescribed, and if not followed, shall be handled in accordance with Federal and State laws. - In the event the order cannot or is not followed, the licensed nurse shall document the reason in the medical record during that shift. - The physician must be informed that the orders had not been followed and the reasons why. - The instructions he/she gives needed to be documented as a telephone order and in the nurses' notes, and staff needed to follow through as required. Review of the facility's Laboratory Services Policy, dated 8/1/12, showed: - The facility will provide or obtain clinical laboratory services to meet the needs of the resident. - The licensed nurse will contact the laboratory to arrange test when the physician orders [REDACTED]. - The facility may obtain samples such as a stool sample or urine. - The licensed nurse will notify the resident of the impending laboratory test. 1. Review of Resident #1's Discharge Summary from a hospital admission, dated 10/3/15, showed: - Discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] can cause leg pain or swelling), chronic [MEDICAL CONDITIONS] (low red blood cells), and weakness; - Needed a follow up appointment with his/her primary care physician (PCP) in 72 hours of discharge; - Needed a follow up appointment with a [MEDICATION NAME] in two weeks due to [MEDICAL CONDITION]; - Chest x-ray: evidence of previous graulomatous (as small area of inflammation in the tissue, with the most common cause being from a fungal infection and can [MEDICAL CONDITION] on a chest x-ray) lung disease with no acute appearing abnormality of the chest; - Recent history of falls with a subdural hematoma (a pool of blood between the brain and its outer most covering) surgery and GI bleed; - At the emergency room (ER), found to have left lower extremity [MEDICAL CONDITION]; not a candidate for anticoagulation (use of blood thinning medications to treat blood clots); IVC filter (inferior vena cava filter, a type of vascular filter that is implanted into the inferior vena cava, a large vein carrying [MEDICATION NAME] blood into the heart, to presumably prevent life-threatening a [MEDICAL CONDITION] embolism, PE, an embolisation (blood clot, air bubble, or fatty tissue) of infectious particles into the lungs via the [MEDICAL CONDITION] arterial system (the system responsible for supplying [MEDICATION NAME] blood to the lungs, typically a blood clot in the lungs that can cause fatality)); - Anemic and refused a GI scope; advised to follow up as an outpatient; - Urinary tract infection treated with [MEDICATION NAME] (an antibiotic); - Alert and oriented with no acute distress; - Bilateral lower extremities with 1+ to 2+ [MEDICAL CONDITION] (swelling to the extremities where indentions are left when pushed with a finger). Review of the resident's face sheet, dated 10/3/15, showed the resident was admitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. Review of the nurse's note, dated 10/3/15 at 6:10 P.M., written by Licensed Practical Nurse (LPN) B, showed: - Resident admitted from hospital at 3:50 P.M.; - Blood pressure (BP) 130/72, pulse 66, oxygen 97% on room air, respirations 16; - Alert and oriented x3 (person, place and time) - 2+ [MEDICAL CONDITION]. Review of the Admission Clinical Health Status form, dated 10/3/15 at 7:37 P.M., showed: - Pain: no pain; never complains of pain; on a scale of 1-10, resident experienced no pain in the previous five days; - Cognitive status: alert; oriented to person, place and time; no obvious neurological problems; - Psychosocial well-being: staff did not check any areas of concern for mood; staff did not check any areas of concern for behaviors, which would have included hallucinations, rejection of care, or resistance to care; - Physical functioning: assistance of two staff for bed mobility, transfers, and toileting; dependent on staff for walking or moving about the facility; assistance of one staff for personal hygiene and bathing; used a wheelchair; - Fall risk factors: no impairment with gait or balance, ambulatory and incontinence, or lower extremity strength; - Did not take any of the following types of medications: [REDACTED] - Skin condition: no history of pressure ulcers; general condition of the skin dry and warm; - Did not check the box to indicate the resident had any [MEDICAL CONDITION] in his/her lower extremities; - No narrative notes entered by LPN B, who completed the form. Review of the physician's orders [REDACTED]. - [MEDICATION NAME] (used to treat high blood pressure) 12.5 milligrams (mg) once daily, order date of 10/3/15, and discontinued on 10/14/15; - [MEDICATION NAME] (used for depression) 120 mg once daily at 7:00 A.M., order date 10/3/15; - Levetiracetam (used for [MEDICAL CONDITION]) 500 mg BID at 7:00 A.M. and 5:00 P.M.; - [MEDICATION NAME] (used for [MEDICAL CONDITION]) 150 micrograms once daily at 6:00 A.M.; - [MEDICATION NAME] (Tylenol) 1,000 mg PRN every eight hours as needed for pain, ordered on [DATE]; - [MEDICATION NAME] (antibiotic) 250 mg once daily for 7 days at 7:00 P.M., ordered while the resident was inpatient at the hosptial just prior to admission to the facility on [DATE] for a UTI. Review of the nurses' note, dated 10/4/15, at 9:09 A.M., showed LPN C documented the resident: - Was alert and oriented to person, place, and time; - Denied pain or discomfort - Bilateral 2+ [MEDICAL CONDITION]. Review of the activity note, dated 10/4/15, at 3:55 P.M., showed activity staff documented: - He/she visited with resident a couple of times in activities; - The resident was very busy. Review of the nurses' notes, dated 10/5/15, at 1:24 A.M., LPN C documented the resident was: - Alert and oriented to person, place and time; - Heart rate regular; denied chest pain; - Skin intact, 2+ [MEDICAL CONDITION] bilateral lower extremities; denied pain and voiced no complaints; able to make needs known. Review of the social services notes, dated 10/6/15, at 3:43 P.M., showed: - Resident reports he/she needed to get out of here as soon as possible due to the expense; - Resident is to see physician on (10/12/15) and would request to go home then. Review of the nurses' notes showed staff documented: - 10/6/15 2:02 P.M.: Returned from physician appointment with follow up appointment with PCP on 10/12/15 at 11:10 A.M. - 10/6/15, 4:40 P.M. Medicare Part B Update: working with physical therapy (PT) on standing tolerance, muscle strengthening and transfers; also working with speech therapy (ST) on cognition including attention, judgment, memory, safety awareness, orientation, problem solving and swallowing precautions; - 10/7/15, at 8:12 P.M., LPN A wrote: call placed to Physician A due to resident complaining of pain in his/her feet; order for Tylenol 500 mg, may have two tablets every eight hours as needed for pain and temperature. Review of a telephone order sheet (TOS), dated 10/7/15, at 1:05 P.M., showed the physician gave an order for [REDACTED]. Review of the electronic Medication Administration Record [REDACTED] - Tylenol Extra-Strength, 500 mg caplet, may give two tablets every eight hours as needed for pain/temp; order date 10/7/15; - Administered on 10/7/15, at 11:46 P.M.; - 10/8/15 at 2:56 A.M., medication effective; - Staff did not document they administered the medication between 10/7/15 and 10/16/15. Review of the nurses' notes showed: - 10/8/15, at 1:41 P.M., LPN A wrote: voiced no complaints of pain this morning; off-going staff reported complaints of right side pain at liver vicinity; 2+ non-[MEDICAL CONDITION] to bilateral lower extremities; alert and oriented to person, place, and time, pleasant and cooperative; skin warm, dry and intact; - 10/11/15, at 12:23 P.M., Admission Assessment and Care Plan note: Alert and oriented; pain to lower back and both legs; as needed (PRN) pain medications; skin intact but some excoriation on the back on admission; transfers with two person assist and uses wheelchair for locomotion; continent of bowel and bladder; requires staff assistance with ADL's (activities of daily living); working with PT, occupational therapy (OT) five times a week for ADL's and therapeutic exercises; taking antidepressants with no adverse reactions noted; no plans to discharge to the community; will continue with the plan of care and updated as needed. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/11/15, showed staff assessed the resident as: - Cognitively intact; - Hallucinations; no rejection of care exhibited; - Required extensive assistance of two or more staff for transfers; limited assistance of one person to walk in his/her room and corridor; unsteady but could stand, walk, toilet, and move from surface-to-surface with staff assistance; no impairments to the lower or upper extremities; - Occasionally incontinent of urine; always continent of bowel; - Pain almost constantly at a level 4 (on a 1-10 scale, ten being excruciating); no scheduled pain medications; had not received any as needed (PRN) pain medications; did not receive any non-medication interventions for pain; did not limit his/her day-to-day activities; - Staff indicated his/her [DIAGNOSES REDACTED]. - Did not indicate [MEDICAL CONDITION] or UTI with in the last 30 days prior to assessment as diagnoses; - Resident did not have a condition or chronic disease which may have resulted in a life expectancy of less than six months; - Did not indicate any other problem conditions; - Unable to determine if the resident had any previous falls within the six months prior to admission; - admitted with an antibiotic; - Had an active discharge plan in place for him/her to return to the community; - Participated in therapy. Review of the nurses' notes showed on 10/11/15, at 7:34 P.M., LPN C documented: - Resident unsettled and stated there were people in his/her room; stated a man tried to tear up his/her wheelchair and people in the air conditioner (AC); - Explained to him/her the staff break area was located outside his/her window and he/she might be hearing staff. - Resident said No! I'm not hearing voices, I can see them just as plain as day! - Thorough investigation of AC and surrounding area revealed no people, attempts to redirect unsuccessful, getting more aggravated and began cursing at staff; - Called his/her friend who said the resident had a history of [REDACTED].>- Called on-call physician who said since not a new or emergent problem, he/she would let the primary care physician (PCP) address concerns at follow up appointment the following morning. Review of the social service notes, dated 10/12/15, at 3:57 P.M., showed social services documented: - Self-responsible and goal is to return home with home health when able; - No known behaviors at this time. Review of the nurses' notes showed: - 10/13/15 4:33 P.M., LPN B documented the resident has appointment with PCP on 10/14/15 at 11:10 A.M. (no documentation as to why appointment changed from 10/12/15 to 10/14/15, no documentation to indicate nursing staff contacted the PCP regarding the resident's hallucinations since he/she did not have an appointment on 10/12/15); - 10/13/15 4:49 P.M.: Skin tear to right upper forearm, contacted PCP's office and received new orders to treat (did not indicate they spoke with PCP's office regarding the resident's hallucinations); - 10/14/15 7:45 P.M., LPN A documented the resident was out to appointment with PCP, returned with orders for a supplement twice a day, an order to discontinue [MEDICATION NAME], labs to be drawn before next appointment on 10/28/15 (did not indicate any new orders to address the resident's recent hallucinations). Review of a fax sent to the PCP's office on 10/14/15 showed staff documented: - Resident had orders for [MEDICATION NAME] 60 mg, two capsules by mouth daily; - Staff asked for a [DIAGNOSES REDACTED]. - PCP wrote a [DIAGNOSES REDACTED]. Further review of the fax showed staff did not address the resident's recent hallucinations. Review of the Office/Clinic Note-physician progress notes [REDACTED].M., showed the resident's PCP documented: - Chief complaint: hospital follow up from left leg [MEDICAL CONDITION]; - Did not like living at facility and wanted to go back home; - Reviewed with resident his/her inability to provide self-care at home currently and he/she understood; - Cognitive Status: independent, decisions consistent/reasonable; - Pain: 4 out of 10, constant, aching; - Long discussion with resident regarding living situation; - Having some loose bowel movements, reviewed need to stop [MEDICATION NAME] twice a day; - Reviewed his/her mood; lengthy visit with resident, a lot of time spent consoling him/her. Further review of the Office/Clinic Note-physician progress notes [REDACTED]. During an interview on 11/16/15, at 10:35 A.M., the case manager from the PCP's office said: - Facilities send information to the office and list what they would like the PCP to address while in the office. - On 10/14/15, the PCP's progress notes indicated he/she documented the resident wanted to return home. - The resident did not like the food at the facility. - He/she encouraged the resident to remain at the facility and mostly consoled him/her. - The PCP's progress note did not mention the resident's state of mind or address hallucinations. During an interview on 11/5/15, at 12:26 P.M., Physician A (the resident's primary care physician) said the resident had a [DIAGNOSES REDACTED]. During a telephone interview on 11/2/15, at 1:40 P.M., Friend A said on 10/18/15, he/she took food to the resident with Friend B and the resident ate half of a double cheeseburger and some fries. The resident could communicate well and overall it was a good visit. During a telephone interview on 11/2/15, at 2:06 P.M., Friend B said on 10/18/15, he/she and Friend A entered the room and the resident slouched in his/her bed and would not eat his/her cheeseburger well. Review of the eMAR showed LPN A documented he/she administered Tylenol Extra Strength to the resident on 10/16/15, at 11:11 A.M. He/she did not indicate why he/she gave the medication. LPN A indicated the medication was effective at 12:23 P.M. Review of the nurses' notes, dated 10/16/15, showed LPN A did not document he/she gave the resident Tylenol Extra Strength, indicate why he/she administered the as needed Tylenol to the resident or the effectiveness of the medication. Review of the care plan, dated 10/18/15, showed: - Problem: needed staff assistance due to weakness and decreased mobility. Approaches included: transfer with two-person assistance, participate in therapy; - Problem: at risk for discomfort due to occasional pains in the feet. Approaches included: give PRN pain medications as ordered and observe for effectiveness; assess for pain at least every shift and as needed; notify PCP if pain not well controlled; - Problem: sometimes hears voices outside window and other noises. Approaches: when hearing voices and noises, please help find the source and remind resident the staff break area is outside the window; AC unit makes the voices louder and sometimes resident needed to be reminded of this; if startled please comfort the resident and be patient through the matter; did not direct staff to notify the PCP if voices get more frequent; - Did not address the resident's recent [MEDICAL CONDITION] or IVC filter placement; did not direct staff on what to look for if resident began to shows signs of complications because of the [MEDICAL CONDITION]; - Did not address the resident's history of a recent UTI upon admission; - Staff did not make any adjustments or corrections to the care plan as the resident's pain increased, he/she began having more frequent hallucinations, he/she needed more assistance from staff for activities of daily living and began having uncontrolled diarrhea. During an interview on 11/3/15, at 2:05 P.M., Physical Therapy Aide (PTA) A said: - One day (10/20/15) when he/she worked with the resident, he/she had multiple bowel movements (BMs) during the session. After the BMs the resident's buttocks appeared raw and red and nursing staff used cream on it. - The resident's physical abilities actually improved towards the end of his/her stay as they worked with him/her. The resident had some confusion, but could follow commands and was easily redirected. - The resident often had pain in his/her legs during transfers. - They worked with the resident five times a week and he/she displayed pain in his/her legs most days they worked with him/her since his/her admission into their program. - He/she came to the facility for rehabilitation services. Review of the nurse's notes, dated 10/20/15, at 4:41 P.M., LPN D wrote: - The resident had continuous incontinent stool seepage today, causing skin breakdown on the buttocks. - Therapy reported five loose incontinent stools in 45 minutes of working with him/her. - Buttocks are red and excoriated. - The physician notified and they had new orders to give the resident Immodium (anti-diarrheal) one tablet four times as needed for loose stools. - Continue to use house barrier cream; - Did not indicate if the resident had any [MEDICAL CONDITION] in his/her lower extremities. During an interview on 11/3/15, at 2:59 P.M., LPN D said he/she typically worked with the resident only twice a week. The resident declined in the past ten days LPN D worked with the resident. The resident was always alert and responsive when he/she saw him/her. The resident used a bed pan per his/her request. When he/she worked, he/she did not see the resident have bad diarrhea, but the resident's buttocks was red. Staff told him/her this was due to a diarrhea episode. During an interview on 11/3/15, at 2:05 P.M., PTA A said: - On 10/21/15, the resident's buttocks appeared sore. - The resident said it hurt to stand so they did activities in his/her chair because the resident could not tolerate the pain to stand. - They told nursing about the pain in his/her buttocks that inhibited his/her ability to fully participate in all the therapy activities. - The resident needed to do only sitting activities because his/her pain did not subside during that day's session. Review of the nurses' notes, dated 10/21/15, at 1:06 P.M., showed LPN E documented: - He/she called family with an update on the resident's area on his/her buttocks. - He/she did not indicate he/she notified the resident's PCP of the areas on his/her buttocks. - He/she did not indicate he/she notified the resident's PCP of the increase in pain and the resident's inability to participate fully in therapy sessions. Review of the 24 hour report sheet (used by licensed nursing staff to communicate information between shifts) showed staff were directed to document the following on the report sheets: - Change in condition; - Falls; - New orders; - Physician appointments; - Problem/solution; - Antibiotics and diagnosis; - Physician and responsible party notified of any changes with a resident. Review of the resident's 24 hour report sheet, dated 10/22/15, showed staff documented: - On the 6:00 A.M. to 6:00 P.M. shift, the resident was OK; - On the 6:00 P.M. to 6:00 A.M. shift, the resident had excoriation to buttocks. During an interview on 11/3/15, at 2:05 P.M., PTA A said: - On 10/22/15, the resident could not stand with two therapy staff. - The resident needed full assistance, but could typically transfer with two person assistance. - They decided to transfer him/her using a mechanical lift, which they had not needed to use prior to that date. - They told nursing about the increased need in assistance the resident required for transfers. - The nursing staff usually transferred him/her with the mechanical lift. - Since therapy had never had the problem, they felt nursing needed to know about the weakness/pain in the resident's legs which caused them to make the decision to transfer him/her with the mechanical lift. Review of the telephone order, dated 10/22/15, showed the physician ordered a UA with culture and sensitivity if indicated at 3:40 P.M. Review of the nurses' notes, dated 10/22/15, at 3:47 P.M., showed LPN A wrote: - The resident had an increase in his/her complaint of pain, an increase in confusion, and hallucinations. - New orders to conduct a UA with culture and sensitivity (C&S, a test to determine which antibiotic will treat the infection and which will not) on the resident; - Notified the physician of the red area to the resident's buttocks. During an interview on 11/4/15, at 9:05 A.M., LPN A said: - He/she worked 10/21/15 (Wednesday), 10/22/15 (Thursday), and 10/24/15 (Saturday). - The resident's confusion appeared to be getting worse as that week progressed. - On the evening of 10/21/15, the resident talked to people in (his/her) air conditioning unit. - He/she could usually get the resident redirected, but that evening he/she could not. - He/she seemed to continue to have confusion from that point until the last time he/she saw him/her. - He/she called the physician for the UA on 10/22/15 due to the resident's increased confusion. Further review of the nurses' notes, dated 10/22/15, showed LPN A did not document: - What types of hallucinations the resident had; - If the resident had any [MEDICAL CONDITION] in his/her lower extremities; - If he/she assessed the resident for a possible [MEDICAL CONDITION]. During an interview on 11/2/15, at 10:26 A.M., Family Member (FM) A said: - On 10/22/15, the facility staff told him/her the resident was talking out of (his/her) head, which could be a sign of a UTI, so they contacted the physician to obtain an order a UA on 10/22/15. Review of the 24 hour report sheet, dated 10/22/15, showed: - On the 6:00 A.M. to 6 P.M. shift, UA C&S if indicated due to increased confusion, hallucinations, needs Mobile Wound Solutions (MWS) to see on 10/23/15; - On the 6:00 P.M. to 6:00 A.M., the resident stated he/she was unable to void. During an interview on 11/4/15, at 9:05 A.M., LPN A said: - The last week of the resident's stay in the facility he/she stopped getting out of bed. - The resident would cry in pain when staff moved his/her legs. - The resident had a PRN order for [MEDICATION NAME], which kept his/her pain controlled. - They looked for signs of a clot in his/her leg on 10/22/15 due to the pain but determined there was no concern or swelling. - He/she did not document this assessment since they did not find anything wrong with him/her other than his/her legs hurt and he/she ruled out a [MEDICAL CONDITION]. - The resident had an appointment scheduled with his/her doctor on 10/28/15, which was a follow up of the labs they drew on 10/11/15. He/she figured the physician wanted to see the resident before changing his/her orders. During an interview on 11/3/15, at 2:05 P.M., PTA A said: - On 10/23/15, the therapy staff only worked with him/her for 45 minutes in his/her bed because he/she was a little confused. - They did not attempt to transfer him/her at all that day. - Typically they worked with him/her for over an hour. - He/she was not lethargic and could follow commands in bed but needed more help than usual to do the therapy and staying focused. - The resident did not act like himself/herself that day. - They told nursing about the shortened therapy session and why they shortened it that day. During an interview on 11/4/15, at 9:05 P.M., LPN A said: - Staff attempted to collect the UA for the resident four times on 10/23/15. - They tried to collect the urine in a bed pan. - Every time they went to get the sample, they had a problem. - One time the resident had an incontinent episode; one time as they went to position him/her on the bedpan, he/she urinated and they could not collect it; one time they collected the urine and it spilled out, which contaminated it; and one time the resident had a bowel movement in the bedpan along with the urine, which they could not use for a UA. - He/she did not want to put a straight catheter into the resident (a method of using a temporary catheter to collect urine for a UA by inserting a tube directly into the resident's bladder) because the resident was urinating and he/she did not want to disrupt that. - He/she told the next shift they needed to collect the UA and did not tell the physician they could not collect the UA. Review of the nurses' notes showed staff did not document any notes regarding the resident on 10/23/15. Additionally, staff did not document they did not obtain a specimen for the UA, if they notified the physician of not obtaining the UA specimen, the resident's inability to participate in therapy longer than 45 minutes from his/her bed, or any [MEDICAL CONDITION] in the resident's lower extremities. Review of the 24 hour report sheet, dated 10/23/15, showed staff documented: - On the 6:00 A.M. to 6:00 P.M. shift, the resident was OK. - On the 6:00 P.M. to 6:00 A.M. shift, need UA. - Staff did not document they notified the physician they still had not yet obtained the UA specimen he ordered 24 hours prior or that PT did not transfer the resident out of bed for therapy. Review of the CNA documentation records showed: - On 10/23/15, at 9:42 A.M., the resident ate 75 percent (%) of his/he breakfast; - On 10/23/15, at 1:37 P.M., the resident ate 75% of his/her lunch; - On 10/23/15, at 11:47 P.M., the resident ate 0% of his/her dinner; - On 10/23/15, at 11:24 P.M., the resident refused a snack then accepted it; - When the resident refused to eat, staff documented they notified the nurse. Review of the Pain Assessment completed by LPN A on 10/24/15, at 10:03 A.M., showed: - A significant change; - Resident may not be able to verbalize pain due to cognitive impairment; - The resident is displaying a behavioral change, facial grimacing, protecting body, and groaning/crying; - The pain completely interfered with the resident's ability to ambulate, bathe, dress, pleasurable activities, mood, and sleeping; - The medication relieved 50 percent of his/her pain; - Intensity on a 10 point pain scale with 7-10 = Severe: 7-10; - Intensity scale for non-communicative residents with 3 = Horrible/Excruciating (withdrawal, crying, yelling, immobility): 3; triggered by movement of legs; - Both lower legs appeared red and warm, this started on 10/7/15; - The pain was described as aching, pin/needles, sharp, and stabbing; - This pain was severe, frequent, horrible/excruciating, and persistent; - [MEDICATION NAME] was ordered with noted relief. Review of the eMAR showed the licensed nurses did not document they administered any Tylenol Extra Strength to the resident at anytime on 10/24/15 for his/her increase in pain with movement. Review of the Situation, Background, Assessment and Request (SBAR) assessment (a tool used to facilitate prompt communication), completed by LPN A on 10/24/15 (Saturday) at 10:32 A.M., showed: - A blood pressure of 94/52 (120/80 is normal); - A temperature of 96 degrees Fahrenheit (°F, 98.6°F is normal body temperature); - Increase in confu

Based on observation, interview, and record review, the facility failed to assure staff ambulated one of 21 sampled residents (Resident #21) with a history of falls, in a safe manner to prevent a fall which resulted in multiple fractures and hospitalization . Staff did not instruct a Nurse's Aide in the resident's care planned interventions and failed to use a transfer/gait belt during a transfer to prevent the possibility of injury which affected one sampled resident (Resident #7); and failed to assure staff used techniques to reduce the possibility of injury during transfers for one resident (Resident #11) when they did not open the legs of the mechanical lift for stability. The facility census was 107. Review of the facility's undated Care System Guideline for Falls policy showed the following: - Purpose: To establish a process that identified risks and established interventions to reduce the occurrence of falls. - When a fall risk is evident from the assessment, the care plan and Certified Nurses' Aide (CNA) care card is updated with interventions to assist in the prevention of falls. - The fall preventions are initiated and physically in place. - When a fall occurs, a post fall evaluation is completed to find the causative factors and interventions to assist in prevention of future falls. Review of the facility's undated Tender Lift and Care, Using a Transfer Belt policy showed the following: - Used as a teaching tool and signed by new employees. - A transfer/gait belt is used to assist unsteady resident to transfer or walk. - Used with residents who required assistance in transferring including those who are weak, unsteady, or prone to falls. - Used when a resident assessed and approved appropriate for this type of transfer. - The resident should be able to ambulate but may be require support for balance, should bear weight on at least one leg, and be able to turn and pivot. - Should not be used to totally support a resident who is unable to stand. - Transfer belts are not used to stabilize the upper body. - Always communicate to the nurse if the resident did not meet guidelines. 1. Review of Resident #21's Departmental Note (DN) dated 11/14/14 showed Licensed Practical Nurse (LPN) C recorded the following: - admitted at 4:10 P.M. - [DIAGNOSES REDACTED]. Review of an Incident Report Sheet dated 11/16/14 at 4:10 A.M. showed Registered Nurse (RN) A recorded the following: - Resident found lying on back with his/her head under the end table in his/her room. - Laceration to head; complained of pain in shoulder, head, and neck. - Sent to hospital emergency room (ER) for evaluation. - Medical Risk Factors: Fall risk, previous fracture, confusion. Review of DN dated 11/16/15 at 7:38 A.M. showed RN A recorded the following: - admitted to hospital with [DIAGNOSES REDACTED]. Review of DN dated 11/21/15 at 9:58 P.M. showed RN A recorded the following: - readmitted to facility at 7:15 P.M. - Assisted by one staff from wheelchair to bed, resident difficult time staying on his/her feet. - Transfer status to be evaluated by physical therapy (PT). - Confused, immobilizer (cloth sling) to left arm. Review of the care plan dated 12/02/14 showed the following: - At risk for falls. - Will have no serious injury from falls over the next three months. - Assistance of on staff for walking. - Transfer/gait belt for transfers. - Wheel chair for mobility and staff to propel the wheelchair. - Fall risk assessment quarterly. - Wear shoes or non-skid socks when up. Review of the CNA care card dated 12/9/14 showed the following: - Oriented but confused at times. - Used wheelchair. - Assisted transfers. - Fall risk. - Did not address the use of a transfer/gait belt. Review of the PT Care Plan dated 1/5/15 showed the following: - Fall risk, balance: High risk; - Confused. - Gait, level surfaces: Moderate assistance, hand held by therapist. - Did not address the use of a transfer/gait belt. Review of the Incident Report Sheet dated 2/2/15 at 9:15 P.M. showed RN A recorded the following: - CNA D assisted resident to the bathroom; resident attempted to sit on the toilet and missed the toilet; - CNA D assisted the resident to the floor; no injuries. - Medical Risk Factors: Fall risk. Review of the Updated PT Care Plan dated 2/8/15 showed the following: - Improved standing balance, decreased fall risk. - Did not address the use of a transfer/gait belt. Review of the Incident Report Sheet dated 2/14/15 at 3:15 P.M. showed LPN C recorded the following: - Found on floor at foot of bed lying on left side. - Tipped over in wheelchair; bruising noted to right arm. - Medical Risk Factors: Fall history, inability to understand directions, fracture, confusion. Review of the DN dated 2/14/15 at 3:21 P.M. showed LPN C recorded the following: - Found on floor; wheelchair tipped over on side. - Confused; the resident said he/she was stuck between the bed and couch and the wheels turned on their own. - Held body alarm in his/her hand; alarm did not sound. - Bruising to right arm between shoulder and elbow. - No complaints of pain or non-verbal indicators of pain. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/15 showed the following: - Short- and long-term memory problem. - Moderately impaired cognition, supervision required for decision making. - Inattention and disorganized thinking. - Extensive assist of one staff for transfers, walk in room, and walk in corridor. - Total dependence on one staff for locomotion off the unit (600 hall). - Only able to stabilize with staff assistance with walking. - Used walker and wheelchair. - One non-injury fall. - Physical therapy. - [DIAGNOSES REDACTED]. Review of the DN dated 2/24/15 at 4:43 P.M. showed Social Service Designee (SSD) A recorded the following:- Care plan meeting with Family Member (FM) A. - FM A wanted to take resident home for five to seven days with 24 hour in-home care to see if memory would improve. - If not improved by end of stay, FM A would return the resident to the facility. - Continued confusion discussed. Review of the PT Discharge Summary sheet dated 2/26/15 showed PT A recorded the following: - Low risk for falls. - Did not address transfer/gait belt use. Review of the Therapy to Restorative Nursing Recommendations sheet dated 2/26/15 showed PT A recorded the following: - Walking/gait assistance of one staff; - Walk 200 feet; - No equipment used. - Did not address use of transfer/gait belt. Review of the DN dated 3/2/15 at 2:51 P.M., the MDS Coordinator recorded the following: - Care plan note for 2/20/15: Continued to work with physical therapy, occupational therapy, and speech therapy. - Low risk for falls. - Able to stand upright in proper alignment for 10 minutes. - Nursing staff provided minimal assist with activities of daily living and mobility. - At risk for falls; continued to need cuing due to confusion. Review of the resident's Admission Clinical Health Status dated 3/7/15 showed the following: - Fall risk factors: Impairment of gait or balance, history of falls, diminished awareness of safety, anti-psychotic medications, displays restlessness, lethargy, and wandering. - No previous fall risk assessments available. Review of the DN dated 3/7/15 at 12:19 P.M. showed LPN D recorded the following: - Resident returned to the facility with FM A. - Confusion noted. - Transferred with assist of one and a transfer/gait belt. - Gait and balance steady. Review of the DN dated 3/8/15 at 6:19 P.M. showed LPN D recorded the following: - Ambulated back to room from evening meal; approximately three to five feet from his/her room doorway lost his/her balance and fell to the floor. - Observed with front of body on floor (face down). - Small laceration to right side of nose with skin tear beneath the nostril. - Nose bleed lasted 10 minutes; nasal packing placed to assist with cessation of nose bleed. - Upper lip bruised and swollen. - Resident's partial plate removed by the resident along with his/her own permanent front tooth. - Frontal area of partial plate cracked. - Moderate amount of blood from mouth and lip. - Vital signs: Blood pressure 146/86, Pulse 70, Respirations 18, Temperature 98.2. - Neurological checks (pupils, grip, alertness) within normal limits. - Grips equal, pupils equal and react to light. - Bruising and discomfort noted to the left thumb with swelling to the joint. - On call physician notified. - Family member notified. Review of the facility Investigation for Fall dated 3/8/15 at 6:25 P.M. showed the Director of Nursing (DON) recorded the following interviews: - Nurses' Aide (NA, staff not yet certified as a CNA, not yet completed training) B was assigned to the 100 and 300 halls as a float (could be sent to any floor to work) staff under the supervision of RN A and CNA E. - CNA F walked the resident from his/her room on the 600 hall to the dining room by standing beside him/her. - CNA F asked NA B to walk the resident back to his/her room after completion of the evening meal. - NA B said he/she was asked by CNA F to walk the resident back to the resident's room. - NA B said the resident walked without problems to his/her doorway to his/her room. - The resident asked NA B to get the wheelchair located in his/her room. - NA B went in to get the wheelchair and when he/she came out of the room he/she found the resident on the floor. - LPN D responded to the fall about 6:15 P.M. when NA B came to the desk to report that the resident fell . - LPN D found the resident three to five feet from the resident's doorway; the resident sustained [REDACTED]. plate and a permanent tooth came out during the fall, vital signs and neurological checks within normal limits, swelling, discomfort, and bruising of the left thumb, the on call physician and FM B were notified along with the DON, the Assistant DON (ADON) and the on call nurse which was also the MDS Coordinator. - NA B was suspended until the investigation of the fall was completed. - LPN E notified the DON that the hospital admitted the resident for observation and pain control. Review of the DN dated 3/8/15 at 7:15 P.M. showed LPN E recorded the following: - Transported to the hospital ER for evaluation. Review of the hospital ER record dated 3/8/15 at 7:48 P.M. showed the following:- fell at nursing facility. - Symptoms: Facial pain, nose bleed, right shoulder pain, right hand pain, and neck pain. - Resident walked with one staff at the facility and fell on his/her face. - Family said the resident should not have been walking. - The resident lost one permanent tooth during the fall. - The Emergency Medical System (EMS) personnel placed the resident in a Cervical (C) collar because of facial injury and neck pain. - Surgical history: Surgical repair of fractured left humerus on 11/18/14; left shoulder replacement on 11/11/14. - diagnosed included: Closed fracture of the finger, nasal bone fracture, nasal septum (nose) fracture, fracture of the maxilla (upper jaw), and left thumb fracture. Review of the DN dated 3/9/15 at 12:26 A.M. showed LPN E recorded the following: - Resident admitted to the hospital for pain control and observation. - [DIAGNOSES REDACTED]. Review of an Educational Note dated 3/10/15 at 2:30 P.M., the Corporate Nurse (CN) recorded the following: - NA B educated on CNA care card assignment sheets, where the sheets were located, and what information was on the cards. - NA B verbalized understanding of where the sheets were kept and how to interpret the information. - Explained that NA B should not care for any resident without knowing how to care for them properly and he/she verbalized understanding. - Explained the facility was responsible for the safety of the residents. - Educated on cell phone use; staff should not use cell phones while on the clock taking care of residents. - Explained that he/she needed to follow the CNA care card for transfers, transfer/gait belts, assistive devices and other pertinent information. During an interview on 3/11/15 at 3:15 P.M., FM A said the following: - The resident fell on [DATE] around 6:00 P.M. - The resident lived here for four months and fell four times. - The resident should not walk long distances and should not walk alone. - He/she walked with CNA F from his/her room to the dining room without a transfer/gait belt. - He/she said staff reported to him/her the resident walked with NA B from the dining room to his/her room without a transfer/gait belt and fell face first onto the floor. - He/she suffered a broken nose, jaw, and thumb. During an interview on 3/12/15 at 10:15 A.M., CNA F said the following: - He/she found the resident walking independently down the 600 hall, just past the nurse's station, headed to the dining room for the evening meal. - The resident wore his/her shoes. - The care plan said to use a gait belt with the assist of one staff when the resident ambulated. - CNA F said he/she did not think to get a transfer/gait belt or ask anyone to get a transfer/gait belt to use on the resident. - There was no other staff on the floor to get a transfer/gait belt at the time. - There was three staff assigned to the 500/600 halls. - One staff was a float and was in the dining room assisting residents to eat and the other staff transported another resident to the dining room. - CNA F did not want to leave the resident alone so he/she grabbed the resident's pants and walked the resident to the dining room. - The resident walked slow and steady, and walked fine. - CNA F noticed the resident finished eating and tried to get up from his/her chair. - CNA F was delivering trays to residents who ate in their rooms and he/she asked NA B to walk the resident back to his/her room. - CNA F did not tell NA B to get a transfer/gait belt to assist the resident to walk; - CNA F did not think about telling NA B to get a transfer/gait belt. - NA B was new to the facility, was a float staff that worked on the 100/300 halls the evening of the resident's fall, and did not know the resident. - CNA F did not see the resident fall or see NA B assist the resident to walk up the hall to his/her room. During an interview on 3/12/15 at 10:30 A.M., LPN D said the following: - He/she sat at the 500/600 hall nurse's station desk and gave report to LPN E and could not see over the desk to see which resident NA B assisted to walk up the 600 hall. - LPN D did not know NA B walked the resident without a transfer/gait belt until after the fall. - LPN D said NA B came to the desk and said the resident fell outside his/her room. - LPN E responded to the fall first and neither LPN saw or knew how the fall occurred. - LPN D saw the resident sitting up in the hallway three to five feet from his/her doorway and sat away from the wall. - LPN D said the resident sustained [REDACTED]. - LPN D obtained 4x4 gauze pads and wash cloths to clean the resident. - The resident's mouth bled and the resident handed LPN D his/her partial plate and permanent tooth that was knocked out with the fall. - The resident's mouth was bruised and swollen. - The resident sustained [REDACTED]. - Neurological checks and vital signs were within normal limits and he/she was alert and oriented to person and place. - Staff assisted the resident to bed and LPN E notified the family and physician. - The EMS transported the resident to the ER around 7:15 P.M. - FM A took the resident home for a few days the week prior to his/her fall. - The resident had dementia and could have been confused about his/her surroundings. - LPN D knew CNA F walked the resident to the dining room but did not know he/she did not use a transfer/gait belt. - Resident #21's care plan showed a one person assist with a transfer/gait belt to walk. - CNA F should have yelled for someone to get a transfer/gait belt before he/she walked the resident to the dining room. - If LPN D saw the resident being assisted without a transfer/gait belt, he/she would tell the staff to obtain a transfer/gait belt immediately. - Staff usually transported the resident by wheelchair to the dining room. - The resident fell several times since his/her admission to the facility in November, 2014. During an interview on 3/12/15 at 12:25 P.M., the Physical Therapist (PT) A said the following: - The resident started PT on 11/16/14 and PT staff worked on his/her gait, lower extremity strength and balance. - The resident's level of functioning showed limitations in standing balance and standing tolerance during standing activities. - PT staff walked the resident with stand by assist around the facility with one rest break, approximately 700 feet. - Nursing staff should use a transfer/gait belt to ambulate the resident because the resident continued to have problems with balance, or ideally transported the resident by wheelchair to the dining room. - The resident should not walk alone in the hall. - Staff should not leave the resident standing alone in the hallway. - Because family took the resident home for a short stay, PT A did not write a transfer status for walking for the resident in the facility prior to discharge. During an interview on 3/12/15 at 2:00 P.M., the DON said the following: - NA B did not know Resident #21 because he/she worked on the 100/300 halls and was new to the facility. - CNA F asked NA B to walk the resident back to his/her room and should have told NA B to use a transfer/gait belt. - NA B did not know the resident should not stand alone. - The DON thought the change of environment from home to facility may have caused the resident to be confused and that was why the resident walked independently in the hall the evening of the fall. - She expected any staff that saw NA B walking the resident to tell NA B to use a gait belt to ambulate the resident, but no staff told him/her. - NA B needed more direction in caring for the resident; it was his/her third day of orientation to the facility. During an interview on 3/12/15 at 3:30 P.M., NA B said the following: - He/she worked one week as a NA. - He/she never worked with or knew the resident. - No one instructed him/her to use a transfer/gait belt or wheelchair when he/she assisted the resident to his/her room. - The resident walked without difficulty but at a slow pace. - NA B left the resident to stand alone when he/she asked NA B to get the wheelchair from his/her room. - He/she knew after the fact that the resident should not have been left standing alone outside his/her room. - He/she found the resident face down on the floor when he/she came out of the room with the wheelchair. - He/she asked the resident if he/she was okay, and the resident said he/she was alright and turned over onto his/her back. - NA B went for help at the nurse's desk. - The resident sustained [REDACTED]. - The resident removed his/her partial plate from his/her mouth. - CNA F asked me to walk the resident back to his/her room but did not tell me to use a transfer/gait belt or a wheelchair. - It was "rush hour", the evening meal, and everyone was busy; no staff told him/her to use a transfer/gait belt or wheelchair to take the resident back to his/her room. - He/she learned after the fall that the care plan showed to use a transfer/gait belt on the resident. During an interview on 3/12/15 at 3:45 P.M., LPN E said the following: - Sometime after 6:00 P.M. on 3/8/15 he/she sat at the nurses' desk on the 500/600 hall and received report from LPN D. - He/she did not notice staff ambulated the resident to his/her room because the nurse's desk was tall and difficult to see over when sitting down. - NA C reported to LPN E the resident fell in the hallway outside of his/her room. - LPN E observed the resident sitting in the middle of the hallway with his/her legs out in front; the resident bled profusely from his/her right nostril and a sustained a small laceration on the bridge of his/her nose. - The resident's dental partial plate became dislodged in his/her mouth and a tooth lay on the floor next to him/her. - There was no gait belt fastened around the resident; - LPN D attempted to stop the resident's bleeding by applying 4x4 gauze pads. - The resident talked and apologized for falling. - NA C stayed with the resident while LPN E notified the family and the physician. - LPN D notified the DON. - The physician ordered the resident to be sent to the emergency room . - LPN E did not know why staff ambulated the resident back to his/her room because usually residents were transported in wheelchairs. - He/she did not notice if there was a gait belt in the resident's room, but the resident should not have been ambulated without a gait belt. -The resident did not have an alarm attached to his/her clothing, but should have. During an interview on 3/12/15 at 4:10 P.M., NA A said the following: - He/she worked at the facility for three weeks. - He/she worked with the resident after readmission on 3/7/15; - The resident was confused. - The resident did not walk independently on 3/7/15 and NA A used a wheelchair to transport the resident to the dining room. - Staff did not tell him/her how to transfer the resident but the care plan said to use a wheelchair to transport to the dining room. - NA A saw CNA F walk the resident to the dining room without a transfer/gait belt and asked him/her about it. - CNA F said he/she would get a wheelchair but NA A did not know if CNA F got a wheelchair for the resident. - He/she did not see NA B walk the resident to his/her room after the evening meal. - NA A said he/she knew to look at the care plan to determine type of transfer for the resident. During an interview on 3/12/15 at 4:15 P.M., RN A said: - On the evening of 3/8/15, he/she worked on the 100/300 halls, the area closest to the dining room, and assisted staff to transport residents after the evening meal from the dining room to their rooms. - He/she did not pay attention to how staff transported the residents. - He/she did not notice how newly hired NA B transported the residents. - Staff should have used a transfer/gait belt to ambulate Resident #21 but did not. - Staff always transported the resident in a wheel chair and he/she did not know why staff ambulated him/her the long distance from the dining room to the resident's room. - He/she asked LPN D what occurred when the resident fell and was told that some "newbie" was on his/her cell phone while he/she ambulated the resident. During an interview on 3/12/15 at 4:25 P.M., LPN D said the following: - LPN D saw NA B using his/her cell phone as he/she rounded the corner of the 100 hall to walk up the 600 hall with a resident. - LPN D told NA B to put away his/her phone, he/she could not be on the phone while caring for residents. - LPN D saw NA B remove the phone from his/her ear and believed he/she placed the phone in his/her pocket. - LPN D saw NA B continue to walk a resident up the 600 hall. - LPN D did not tell NA B he/she needed to use a transfer/gait belt on the resident because LPN D did not realize NA B did not use a gait belt prior to the resident's fall. During an interview on 3/12/15 at 4:25 P.M., the DON said the following: - Staff told her NA B used his/her cell phone while he/she walked the resident to his/her room. - LPN D did not tell NA B he/she needed to use a transfer/gait belt on the resident. During an interview on 3/12/15 at 4:25 P.M., the CN said the following: - NA B said he did not know he/she could not be on the phone while working and he/she put the phone away immediately when told to do so. - The CN did not believe cell phone usage caused the fall. 2. Review of Resident #7's quarterly MDS dated [DATE] showed the following: - Moderate cognitive impairment - Assistance by one for transfers and ADL's. - History of falls. - [DIAGNOSES REDACTED]. Review of the resident's care plan reviewed by staff on 1/21/15 showed the following: - Assistance of one staff with a transfer belt for transfers. - At risk for falls related to unsteady gait, weakness, and noncompliance with transfer status and unsafe practices. Observation on 3/11/15 at 9:20 A.M. showed the following: - CNA B leaned the residents electric recliner forward and CNA B and CNA C assisted resident in grabbing a hold of walker. - Staff did not apply a gait belt. - CNA C held the back of residents shirt while ambulating to bathroom with resident leaning forward over his/her walker with shortness of breath. - Upon standing he/she leaned forward over walker and the walker moved forward. - CNA C grabbed a hold of the walker to a stop it; - Both CNA's walked the resident back to the chair with stand by assist and no transfer belt. During an interview on 3/11/15 at 9:35 A.M. CNA B said the following: - He/she normally has a transfer belt on resident. - He/she had gotten another CNA to assist with transfer due to resident not feeling well and unsteady. - A transfer belt is kept in residents room. During an interview on 3/12/15 at 3:10 P.M. DON said the following: - Staff are expected to use transfer belts when ambulating residents. 3. Review of Resident #11's quarterly MDS, dated [DATE] showed: - Cognitively intact; - Assistance of two for transfers, dressing, hygiene, and bathing; - Weight 301 pounds; - One fall with injury; - Range of motion limitations to lower extremities, bilaterally. Review of the resident's care plan updated 2/2/15 showed: - Transferred with mechanical lift; - At risk for falls. Observation on 3/10/15 at 6:40 A.M. showed: -The resident lay in bed, CNA G and CNA H placed mechanical lift pad under the resident and attached it to the mechanical lift. - CNA H transferred the resident with the mechanical lift from the bed to the wheelchair which was positioned about 5 feet away from the bed. CNA H did not spread the legs of the mechanical lift as he/she moved the lift away from the bed, then turned it in a half circle and positioned the resident near the wheelchair. CNA H then spread the legs of the mechanical lift to position the resident directly over the wheel chair. During an interview on 3/10/15 at 6:50 A.M. CNA H said he/she should have spread the mechanical lift legs sooner to stabilize it. During an interview on 3/12/15 at 3:00 P.M. the DON said the mechanical lift's legs should be opened when staff transfers a resident. MO 4

Based on interview and record review, the facility failed to assure staff notified the physician for three days after one of twelve sampled resident's (Resident #1's) pressure ulcer developed an odor and purulent (pus) drainage. When the facility staff notified the physician, he/she ordered a wound culture (technique used to remove bacteria from a wound to determine a type of infection) as soon as possible. Staff failed to obtain the wound culture. The resident went to the hospital two days later with an infected Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling)/Stage IV (full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer. The facility census was 109. 1. Review of the facility's skin policy and procedure revised 7/27/10, included the following: - The policy was all nurses will use the following procedures for assessing, managing tissue loads (the distribution of pressure, friction, and shear on tissue), decubitus ulcer (pressure ulcer) care and managing bacterial colonization (presence of bacteria on the surface or in the tissue of a wound without indications of infection) and infection. - The purpose was to ensure accurate and ongoing assessment for resident's skin and to provide guidelines, based on the best available scientific evidence and clinical expertise, for wound care. - Any wound that has more the 75% slough (necrotic, dead tissue in the process of separating from viable portions of the body) or eschar (thick, leathery, necrotic, devitalized tissue) in wound bed, the wound is unstageable (inability to see the wound bed to determine the stage of the wound). - If a wound has an odorous discharge or drainage the facility has a standing Infection Control order from our medical director to obtain a culture, i.e., wound culture with culture and sensitivity if indicated per infection control policy and signed physician order: T.O. (telephone order) Medical Director/Your name. Notify the medical director you wrote a standing order under his name. - After the initial assessment, each pressure ulcer is to be reassessed, at least weekly, but deterioration either in the resident's overall condition or in the pressure ulcer itself, mandates more immediate reassessment as well as a reevaluation of the treatment plan. 2. Review of Resident #1's Braden scale (an assessment tool used for predicting pressure ulcer risk) dated 3/9/11, showed the resident's score was 13. A total score of 12 or less represents a high risk for developing pressure ulcers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/11, showed the following: - No speech. - Able to understand, had clear comprehension. - Totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. - No ambulation. - Always incontinent of bowel and bladder. - [DIAGNOSES REDACTED]. - Resident at risk for developing pressure ulcers. - Does not have one or more unhealed pressure ulcers at Stage I ( an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persisten red, blue or purple hues) or higher. - Skin care treatments included a pressure reducing device for the chair and bed and a turning/repositioning program. Review of the resident's current care plan, dated 3/23/11, showed the resident had a problem with skin. The goal was the resident would have decreased risk of skin breakdown over the next three months. The approaches included: - Staff to assess skin daily with care, twice weekly by shower aide and weekly and as needed by nurse. - Nylex mattress (a foam-core mattress that helps prevent pressure ulcers) to bed as a preventative measure - Assist with turning and repositioning every two hours and as needed. Review of nurses' notes, dated 3/23/11 (Wednesday), at 10:00 P.M., showed Licensed Practical Nurse (LPN) E noted an open area on the resident's coccyx (tail bone). The area was "roughly circular in shape." The area measured four centimeters (cm). The nurse faxed the physician for treatment orders. The resident already received wound protocol of vitamins and laboratory tests. Review of the medical record showed a fax dated 3/23/11, to the physician with the information about the open area on the resident's coccyx. LPN E requested a wound treatment. Review of the resident's shower sheet the shower aide completed and dated 3/24/11, showed a diagram of a person. The aide circled the buttocks area and wrote beside it, "open area." A nurse signed the shower sheet. Review of nurses' notes, dated 3/24/11, 6:00 P.M. to 6:00 A.M., shift showed staff received faxed physician orders [REDACTED]. Review of the faxed physician orders [REDACTED].M. showed the order for Solosite to the wound, cover with Combiderm, change every three days and as needed until the wound was healed. During an interview on 4/18/11, at 1:30 P.M., Certified Nurse Aide (CNA) C said he/she first reported the resident's wound on the resident's bottom but was not sure of the date. The wound was about the size of a pea and not deep. It was red around the wound and the middle of the wound was pink. During an interview on 4/18/11, at 2:10 P.M., LPN C said he/she saw Resident #1's wound for the first time on 3/25/11. The area was on the coccyx and it was about the size of a quarter if not a little bigger. The wound had a "glaze" over it that was shiny and gray in color. Review of the care plan showed staff updated the care plan on 3/25/11, directing staff to lay resident down between meals. It showed the resident received [MEDICATION NAME] (wound gel used to help dry wounds and is effective against a broad spectrum of bacteria and fungi) and Combiderm (sterile dressing with super-absorbant pad to manage moderate to heavy draining wounds) to coccyx, change daily and as needed. Review of a fax LPN B sent to the resident's physician dated 3/25/11 showed the resident had an open area mid-coccyx with yellow tissue. Measured two cm. by 0.8 cm. with depth unmeasurable, less than 0.2 cm. Current treatment order was Combiderm and Solosite, changed every three days. The fax showed the resident had the wound protocol (multivitamin, Vitamin C 500 milligrams, and zinc 30 milligrams) already in place. LPN B requested to discontinue the current treatment order and to change the treatment to [MEDICATION NAME], cover with Combiderm, with adhesive removed, and secure with [MEDICATION NAME]. He/she also requested an order to obtain laboratory tests now and every two months and to continue the multivitamin, zinc and vitamin C. At the bottom of the fax, the physician marked yes to all order request. There was no date when the physician responded to the fax. Review of nurses' notes by LPN A, dated 3/25/11, at 4:00 P.M., showed the resident's physician saw the resident this day. The note did not show the physician checked the resident's wound. The physician gave the order to change treatments to the coccyx and ordered laboratory tests. Review of the laboratory test results dated 3/28/11 showed the resident's hemoglobin was 10.9 grams/deciliter (g/dl), normal range 12.0 to 15.5. The resident's hematocrit level was 33.3%, normal range 36 through 46. The resident's total protein level was 6.2 g/dl, normal range 6.0 through 8.0. The [MEDICATION NAME] level was 2.7 g/dl, normal range was 3.4 through 5.0. Review of nurses' notes, dated 3/25/11 and not timed, showed LPN B documented an open area on the resident's mid-coccyx. The tissue was yellow. It measured 2 cm. by 0.8 cm. with a depth less than 0.2 cm. The nurse documented, per the assistant director of nursing (ADON), use [MEDICATION NAME], with Combiderm with the adhesive removed and secure with [MEDICATION NAME]. Laboratory tests ordered now and every two months. The resident was currently on multivitamins, Vitamin C and Zinc. During an interview on 4/18/11, at 1:25 P.M., LPN B said he/she did a dressing change on the resident's wound on 3/25/11, when he/she received new treatment orders. At that time, the wound was a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer. The wound bed had yellow slough. Review of the resident's shower sheet the shower aide completed and dated 3/28/11, showed the shower aide circled the buttocks on the diagram and wrote "dressing" beside it. LPN D signed the shower sheet. During an interview on 4/18/11, at 2:10 P.M., LPN C said he/she worked the night shift on 3/29/11, and the resident's wound looked the same as on 3/25/11. The wound still had the gray, slimy substance over the wound. It did have some drainage on the old dressing that was the same gray color. He/she said the wound also had an odor. He/she did not notify the physician of the wound condition. Review of nurses' notes, dated for the night shift on 3/29/11, showed LPN C didn't document any information about the condition of the resident wound. Review of resident's wound care documentation (weekly wound report) dated 3/30/11, showed the ADON documented the resident had a Stage II pressure ulcer on the coccyx. The area measured 2.5 cm. by 1 cm. with less than or equal to 0.2 cm depth. 50% pink/50% yellow wound bed with smooth edges, no drainage, no odor noted. The ADON faxed the report to the physician on 3/30/11 at 4:11 P.M. Review of orders at the bottom of the 3/30/11 fax showed on 3/31/11 the facility received a physician order [REDACTED]. Review of the resident's shower sheet the shower aide completed and dated 3/31/11, showed the shower aide circled the buttocks on the diagram and wrote "dressing" beside it. A nurse signed the shower sheet. During an interview on 4/18/11, at 1:50 P.M., CNA D said he/she worked 4/1/11. He/she never saw Resident #1's wound but he/she did remember the wound had a distinct odor. The wound smelled horrible. He/she told the charge nurse (CNA D wasn't sure which nurse it was) about the wound odor. During an interview on 4/18/11, at 2:00 P.M., LPN A said he/she worked as the day shift charge nurse on 4/2/11, and 4/3/11. He/she did not see the resident's wound on those days. The night shift staff did the wound treatments. He/she did not receive anything in report from the night shift regarding the resident's wound. During an interview on 4/18/11, at 2:10 P.M., LPN C said he/she worked the night shift on 4/2/11 and 4/3/11. Resident #1's wound looked the same on 4/2/11, as it did on 3/29/11. There was more drainage from the wound on 4/2/11, and the odor was stronger. When LPN C came back to work on 4/3/11, he/she noticed the wound started to have tunneling (a passageway under the surface of the skin that is generally open at the skin level; however, most of the tunneling is not visible). There was a hole in the center of the gray substance on the wound. When the surveyor asked the LPN how the wound bed looked, LPN C asked what the wound bed was. LPN C said the odor and drainage was about the same on 4/3/11. LPN C said he/she notified the house supervisor but the supervisor did not look at the wound. He/she reported to the day shift nurse (LPN C didn't remember which nurse it was for sure) on 4/4/11, how the wound looked. He/she did not notify the physician of the condition of the resident's wound. Review of the employee written warning for LPN C dated 4/7/11, showed the write-up was for unsatisfactory work. The explanation of the offense showed the nurse documented the following on the 4/2/11, 24-hour report sheet, "coccyx appears to be worse." No further documentation on assessment. The night shift administrative nurse was in the building but she was not notified. The administration nurse on call or physician not notified for further orders. On 4/3/11, the nurse documented on 24-hour report sheet "coccyx treatment was not done on day shift. Wound is open." Again night administrative nurse not notified and the administration nurse on call and physician not notified for further orders. During an interview on 4/18/11, at 2:35 P.M., the DON said she expected LPN C to notify the administrative nurse on duty and the physician when the status of the wound declined. Staff should notify the physician by fax or telephone so they could get new treatment orders. During an interview on 4/19/11, at 9:45 P.M., Physician A said he/she expected staff to notify him/her if a resident had a significant change in his/her wound. If the wound was foul smelling and full of pus, he/she would expect staff to notify him/her. During an interview on 4/18/11, at 1:30 P.M., CNA C said he/she had not seen Resident #1's wound for about two weeks. He/she worked 4/2/11, and 4/3/11. During report on 4/2/11, the night shift staff said the resident had a sore on his/her bottom and they were putting cream on it. When he/she first saw the wound on 4/2/11, it was bigger than the first time he/she saw it and it was deeper. There was some yellow on the wound bed and the aide thought it was from the cream. He/she did not notice any odor. CNA C said he/she remembered thinking he/she was surprised all they were doing was putting cream on a wound like this. The wound did not have a dressing on it all day on 4/2/11. He/she did not know there was supposed to be a dressing on the wound. He/she kept cream on the wound every time he/she cleaned and changed the resident. Review of nurses' notes and the treatment administration notes from 3/31 until 4/4/11 showed no documentation regarding the condition of the resident's pressure ulcer. Review of nurses' notes by the ADON dated 4/4/11, at 10:25 A.M., showed staff received an order from the resident's physician for an air mattress when available. The note did not show if staff placed an air mattress on the resident's bed. During an interview on 4/14/11, at 9:30 A.M., LPN D said he/she worked the day shift on 4/4/11. This was the first day he/she saw Resident #1's wound. The night shift staff did the resident's dressing changes. LPN C (night shift nurse) told LPN D during report the resident's wound opened up over the weekend. LPN D and the ADON looked at the wound. The wound was approximately dime sized and a couple of centimeters deep. The wound had an odor but he/she did not notice any drainage. LPN D said staff put the resident on an air mattress that day. Review of physician orders [REDACTED]. The physician discontinued the previous treatment orders and ordered 1/4" Iodaform gauze packing (small strips of sterile gauze used to pack wounds to prevent closure on the outside when drainage from the inside is needed) to coccyx wound, cover with gauze and adhere with [MEDICATION NAME] tape (fabric tape), change twice daily and as needed. During an interview on 4/14/11, at 9:30 A.M., LPN D said he/she did not obtain the wound culture. During an interview on 4/11/11, at 3:35 P.M., the director of nursing (DON) said staff did not do the wound culture the physician ordered on [DATE]. She did not know why staff did not obtain a culture, other than staff were busy that day getting the air mattress on and the treatments changed. Review of nurses' notes dated 4/4/11, at 2:50 P.M., showed the ADON documented the resident's coccyx pressure ulcer measured three cm. by three cm. and three cm. deep with tan-thick drainage noted. The wound was dark brown with an open area over most of wound. The ADON documented he/she was able to measure depth at that area. Staff notified the physician's office nurse and orders received for a wound clinic consult, culture wound, and change wound treatment. Charge nurse notified of new orders. Review of nurses' notes dated 4/4/11, at 3:00 P.M., showed the DON documented she contacted the physician's office after visualizing the coccyx wound with the ADON. She discussed options for wound treatment along with trying to prevent stress to the resident by being sent out of the facility for wound care. The DON and physician decided to try Iodaform packing and more frequent dressing changes with report to the physician at the end of the week. During an interview on 4/11/11, at 3:35 P.M., the DON said she saw the resident's wound on 4/4/11, and it "looked bad." That was when the treatment orders got changed to the Iodaform packing. Review of the care plan showed staff updated the care plan on 4/4/11, to include air mattress on low boy bed (a bed that lowers to the floor to help prevent falls) with mats on the floor and changed the treatment to Iodaform gauze packing to coccyx wound, cover with gauze, adhere with [MEDICATION NAME] tape, change twice daily and as needed. During an interview on 4/18/11, at 1:25 P.M., LPN B said he/she worked 4/5/11. He/she helped the night shift nurse do the wound treatment when he/she got to work that day. The resident's wound was deep and tunneling. It had an odor. He/she did not see the old dressing so did not notice the drainage. Review of nurses' notes dated 4/5/11, showed LPN B didn't document any information regarding the condition of the resident's pressure ulcer after helping the night nurse with the wound treatment. During an interview on 4/12/11, at 2:30 P.M., Certified Nurse Aide (CNA) B said he/she worked 4/5/11, on the day shift. He/she provided care for Resident #1. He/she helped the nurse with the resident's dressing change. The resident had the wound on his/her bottom. The first thing he/she noticed about the wound was the odor. It was so strong, the aide said he/she could smell it out into the hall. During an interview on 4/18/11, at 2:10 P.M., LPN C said he/she worked 4/5/11, on the night shift. They were packing the wound with Iodaform gauze. The wound looked like a big hole. The circumference of the wound was not any bigger but it was a lot deeper. Review of the wound care documentation by the ADON dated 4/6/11, showed the resident had a Stage II pressure ulcer on the coccyx. The area measured 3 cm. by 3 cm. and was 3 cm deep. 100% brownish gray wound bed with moderate amount of thick, tan, odorous drainage noted. Peri-wound (skin around the wound) slightly darker than surrounding skin. Area larger with measurable depth this week. During an interview on 4/12/11, at 8:00 A.M., the ADON said he/she did not have the title of the wound nurse. He/she measured the wounds weekly and got treatment orders as needed. The floor nurses did the actual wound treatments. The ADON is a registered nurse. During an interview on 4/18/11, at 2:35 P.M., the ADON said the wound care documentation dated 4/6/11, actually reflected measurements taken on 4/4/11. The ADON said he/she looked at the wound also on 4/5/11, but did not take measurements. The wound looked the same as on 4/4/11, but the skin around it was getting darker. The ADON said she knew the wound was probably a Stage IV on Monday, but she did not know she could "upstage" a wound without physician approval. The DON said she thought the wound was a Stage III on Monday. Review of the registered dietician's note dated 4/6/11, showed the resident had a Stage II area on coccyx. During an interview on 4/11/11, at 3:35 P.M., the DON said she did not see the wound on 4/5/11 or 4/6/11. LPN A told the DON the wound looked much better on 4/6/11 and the Iodaform gauze packing really cleaned the wound out. The DON said the hospital contacted the facility and told her how bad the resident's wound looked. The DON said she believed her staff when they told her the wound looked better when the resident left the facility. Review of the resident's treatment notes dated 4/12/11, at 11:30 A.M., showed LPN A made a late entry for 4/6/11. The note showed treatment to coccyx wound changed after the resident's shower. The wound bed was pink and healthy with moderate amount of serosanguinous (clear, blood tinged) drainage noted to the old dressing. Wound bed packed with Iodaform gauze and covered and secured as ordered. Tolerated well. During an interview on 4/12/11, at 11:10 A.M., LPN A said he/she worked as a day charge nurse. He/she was familiar with Resident #1. Nurses did the wound treatments for their assigned halls. Resident #1's daily wound treatments were scheduled for the night shift. The only time the nurses documented on wounds was if there was a change in them. Otherwise the wounds were measured weekly. The aides document any skin issues on the shower sheets and the charge nurses sign off on the sheets. The first time he/she ever saw Resident #1's wound was on 4/6/11. He/she removed the resident's dressing and packing before the resident's shower. There was serosanguinous drainage on the old dressing. He/she did not notice any odor or tan/yellow drainage. He/she did not see any redness around the wound. He/she did the wound treatment on 4/6/11, after the resident's shower. The wound bed was pretty clean and there was not any eschar or slough that day. There was a hole about the size of a nickel. There was some tunneling or maybe it was undermining (a closed passageway under the surface of the skin that is open only at the skin surface; generally it appears as an area of skin ulceration at the margins of the ulcer with skin overlying the area; undermining often develops from shearing forces). He/she repacked the wound with the Iodaform gauze. He/she thought he/she used about eight inches of the packing. The resident seemed fine when he/she did the wound treatment. During an interview on 4/12/11, at 2:05 P.M., CNA A said the first time he/she saw the resident's wound was on 4/6/11. He/she helped LPN A change the resident's dressing that day. The CNA said he/she was shocked at how bad the wound looked. He/she was surprised the resident had a wound on his/her coccyx because he/she always lay on his/her side. When the CNA saw the wound, he/she thought it looked infected because it was greenish in color. It had yellowish pus. The wound had a really strong odor when the nurse removed the old dressing. During an interview on 4/12/11, at 2:05 P.M., CNA A said he/she went to get the resident up for lunch on 4/6/11, and found the resident unresponsive. The resident felt cold and clammy. He/she called for the nurse to come to the room and after the nurse checked on him/her, the resident went out to the hospital. During an interview on 4/12/11, at 11:10 A.M., LPN A said on 4/6/11, about 11:30 A.M., the CNAs went to get the resident up for lunch. The resident was not responding to them so they called him/her to the room. The resident responded some to the sternal rub. LPN B notified the physician and received orders to send the resident to the hospital for evaluation and treatment. Review of nurses' notes dated 4/6/11, at 12:00 P.M., showed the CNA's called LPN B to the resident's room because the resident was not responding. LPN B documented the resident was non-responsive to verbal stimuli but moved when the nurse did a sternal rub (rubbing the mid-chest area to elicit a pain response). Resident's temperature was 101? axillary (under the arm), pulse 116, respirations 24 and blood pressure less than 60. The resident's blood sugar was 164. Order received to send the resident to the emergency room for evaluation and treatment. Resident transported by ambulance at 12:25 P.M. During an interview on 4/13/11, at 11:50 A.M., Physician A said he/she did not remember seeing Resident #1's wound when he/she made rounds on 3/23 or 3/24/11. The physician said he/she did not realize staff did not obtain the wound culture ordered on [DATE]. Physician A said he/she expected staff to follow his/her orders and they should have done the wound culture. He/she ordered the wound culture because anytime there is pus, you need to know what it is. He/she spoke with the surgeon who debrided (removal of devitalized tissue and foreign matter from a wound) the wound and after the debridement, the physician determined it was a Stage III pressure ulcer. Physician A was not aware the resident had osteo[DIAGNOSES REDACTED] (inflammation of the bone marrow and adjacent bone, often due to infection) in the sacrum/coccyx. Review of the resident's ER report dated 4/6/11, showed the resident admitted to the ER with altered mental status. The resident was septic (severe illness in which the bloodstream is overwhelmed by bacteria) and severely dehydrated. The resident had a sacral (bottom vertebrae) decubitus (pressure ulcer). Review of the hospital physician's consultation for critical care services showed the physician consulted on 4/6/11. The consultation showed the resident had a "nasty looking" wound in the sacral area with drainage. A picture of the wound was on the chart. Review of the surgical consultation on 4/7/11, showed the surgeon documented during the course of admission, hospital staff noted the resident had a deep penetrating malodorous (having an unpleasant or offensive odor; smelling bad) coccygeal pressure ulceration which appeared to be Stage IV deep into the pelvis with undermining and tunneling. There is a large amount of brownish, necrotic (dead tissue), foul-smelling drainage from the wound base. The surgeon recommended surgical debridement to remove the necrotic tissue which the surgeon felt was likely contributing to the resident's infected state [MEDICAL CONDITION]. Review of the operative report dated 4/9/11, showed the preoperative [DIAGNOSES REDACTED]. The postoperative report was a large necrotic decubitus ulcer, Stage III. The surgeon debrided the ulcer. Review of the results of the hospital wound culture dated 4/12/11, showed the wound infected with Proteus mirabilis (a cause of bacterial infections of wounds and urinary tract infections). Review of the results on the resident's bone scan dated 4/12/11of the pelvis showed the resident had osteo[DIAGNOSES REDACTED] of the lower sacrum and coccyx. During an interview on 4/18/11, at 1:10 P.M., the DON said she updated the facility's wound care policy after Resident #1's wound issues. Prior to 4/6/11, staff were to document on the wounds any time there was a change in the wound. Since then, staff are supposed document something on the treatment notes every time they do a wound treatment. They began re-educating staff on this policy on the evening of 4/6/11. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level, "J". Based on record review and interviews completed during the onsite visit, it was determined the facility had implemented corrective actions to address and lower the violation at the time. During the onsite visit, the Department of Health And Senior Services (DHSS) surveyor determined the facility immediately re-educated their nursing staff currently on duty on the facility's skin care policy and procedure including skin assessment, documentation of skin conditions, and notification of physician of skin/wound conditions. All other staff will be re-educated on this policy and procedure prior to working their next shift. This addressed the risk for all resident's currently residing in the facility who have pressure ulcers/wounds or who are at risk for developing pressure ulcers. The facility has entered into an agreement with Mobile Wound Solutions that will result in a physician specializing in wound care to visit the facility weekly who will observe, measure, and made recommendations in writing for care of any residents who have primary care physicians order and written consent for treatment of [REDACTED]. The facility has scheduled an in-service for all licensed nursing staff on identifying skin issues which will include the basic premisis of wound healing, proper identification and pressure ulcer staging. They will also re-educate staff on wound documentation. Interviews and record review confirmed the DON completed this staff re-education for each staff person currently on duty and will re-educate all other staff prior to working working their next shift. Facility staff will monitor to assure interventions are effective and appropriate. 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. The facility had not completed inservicing of all staff, and had not had sufficient time to monitor interventions to assure staff adequately monitored, identified, and documented skin conditions including pressure ulcers and physician notification. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO