Every finding on record at Appleton City Manor

Based on interview and record review, the facility failed to provide care that reflected the resident's wishes as expressed by the resident's advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of health care when the individual is incapacitated) when the facility failed to ensure one resident's (Resident #1) CPR order (CPR - a medical intervention used to restore circulatory and/or respiratory function) was clearly and consistently documented in the resident's chart resulting in staff failing to provide CPR when the resident was found unresponsive. The facility census was 35.The Administrator was notified on [DATE], at 5:10 P.M., of the Immediate Jeopardy (IJ) which occurred on [DATE]. The IJ was removed [DATE] as confirmed by surveyor on-site verification. Review of the facility's policy titled Advance Directives, revised [DATE], showed the following:-Advance directives will be respected in accordance with state law and facility policy;-Prior to or upon admission of a resident to the facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives;-Prior to or upon admission of a resident, the SSD will inquire of the resident, and/or his/her family members, about the existence of any written advance directives;-The facility has defined advanced directives as preferences regarding treatment options and include but are not limited to Do Not Resuscitate (DNR - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to used.) 1. Review of Resident #1's face sheet (a document that gives a residents' information at a quick glance) showed the following:-admission date of [DATE];-Page one of the resident's face sheet showed code status DNR;-Page two of the resident's face sheet showed advance directive field with code status of CPR;-Diagnoses included schizophrenia (a chronic, severe brain disorder characterized by a disconnection from reality through hallucinations, delusions, and disorganized thinking), bipolar disorder (a chronic mental illness characterized by extreme mood swings, ranging from high-energy mania/hypomania to deep depression), hypertension (high blood pressure), and type two diabetes (a chronic condition causing high blood sugar). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's care plan, dated [DATE], showed the resident had a guardian for all decision making. Review of the facility document titled Advance Directive Acknowledgement, dated [DATE], showed the following:-The resident's guardian did not select an option;-The guardian wrote and initialed, none at this time (indicating no advance directives at this time). Review of the facility document titled Health Care Directive, dated [DATE], showed the following:-Possible health care directive options included withholding CPR, surgery, artificially supplied nutrition, antibiotic, chemotherapy, radiation and all other life prolonging medical or surgical procedures; --The resident's guardian initialed the selection indicating he/she did not wish to make a health care directive at this time;-The document was signed by the resident's guardian. Review of the resident's current Physician's Order Sheet (POS) showed an order, dated [DATE], for CPR. Review of the resident's nursing progress note dated [DATE], at 8:53 A.M., showed Registered Nurse (RN) E documented the following:-Resident was found unresponsive at 7:50 A.M.;-Resident was found lying across the bed, face ashen (pale gray color), and lips purple with no respirations noted;-At 7:55 A.M., the resident was pronounced deceased with a second RN;-Placed call to Family Nurse Practitioner (FNP) and reported findings;-Staff notified guardian. During an interview on [DATE], at 2:30 P.M., certified nurse aide (CNA) F said the following:-He/she went and checked on the resident around 6:00 A.M., and the resident was sleeping;-He/she returned around 7:45 A.M., to start helping the resident's roommate when he/she noticed the resident was now laying across the bed;-He/she thought it looked like the resident was attempting to sit up and then slumped over;-He/she checked on the resident and he/she did not respond;-He/she yelled for the nurse and RN E responded to the room;-He/she left the room to check the emergency book and saw it indicated DNR. During interviews on [DATE], at 1:52 P.M. and 3:40 P.M., RN E said the following:-Yesterday morning ([DATE]) a CNA came and got him/her from the dining room to check on the resident;-The resident was laying across the bed and had no heartbeat or breath sounds;-The resident lips where blue and he/she had a gray appearance;-He/she went and notified the Administrator, and they returned to the room and pronounced the resident dead at 7:55 A.M.;-He/she and the Administrator did not start CPR;-The resident was listed as a DNR in the emergency book; -He/she would have started CPR if the resident was a full code;-If a resident was found unresponsive, staff were to call for help and check the code status;-Code statuses were kept in the emergency book and the computer;-If a resident was CPR, staff get the crash cart (a cart with emergency medical equipment) and begin CPR;-If there is no signed DNR staff should start CPR. During an interview on [DATE], at 2:27 P.M., CNA A said the following:-Staff should find the resident's code status on the resident's name tag on the door. A red sticker means DNR;-Facility staff should get the nurse if staff find a resident unresponsive;-The nurse checks the resident's code status. During an interview on [DATE], at 3:17 P.M., CNA B said the following:-Facility staff should find the code status in the binder located at the nurses' desk;-Facility staff should yell for help if they find a resident unresponsive;-Staff should initiate CPR if a resident code status is full code. During an interview on [DATE], at 3:50 P.M., Licensed Practical Nurse (LPN) C said the following:-Facility staff should stay with a resident if they are found unresponsive, call for help, and check for vital signs;-Facility staff should find the code status in the computer or the emergency binder which has the code status on the face sheet;-If a resident or representative did not sign a health care directive, it defaulted to full code status;-The resident's code status on the computer showed the profile section as a DNR code status. The physician orders showed CPR code status. The resident's health care directive was initialed to not make a directive which means full code status. During an interview on [DATE], at 3:49 P.M., LPN G said the following:-Resident code status was kept in the emergency book at the nurses' station;-If a resident was found unresponsive staff check pulse and breathing and start CPR if resident is a full code;-Once staff start CPR staff continue until emergency medical services arrive;-If staff are not sure of code status, the resident is a full code;-If there is conflicting information in the chart, the resident is a full code and staff should start CPR. During an interview on [DATE], at 3:54 P.M., the MDS Coordinator said the following:-He/she worked the floor sometimes and provided RN coverage for the facility;-If a resident was found unresponsive staff are to check pulse and breathing and start CPR if the resident is a full code;-Code status was kept in the emergency book. Also, there will be a red dot outside the door indicating DNR;-If code status does not match, staff should start CPR and continue until emergency medical services arrive;-Social Services was responsible for updating a resident's code status. During an interview on [DATE], at 2:40 P.M., the SSD said the following:-The resident's code status paperwork was completed upon admission with the responsible party and/or resident and explains the difference of code status;- The resident or representative signs the DNR form and she places it in the physician's box to sign;-The nursing staff give her the signed DNR form, she copies it onto purple paper, uploads it into the electronic medical record, and places it in the emergency book located at the nurses' station;-Nurses enter the orders into the computer;-She enters information on the face sheet and on the profile, section including emergency contacts and physicians, and she can enter the code status in the electronic medical record;-She informs the nurses of a resident's code status of a new admission, and the code status also populates on the computer;-She did not enter the resident's code status. The former SSD reviewed the resident's code status;-The resident's record showed the resident's code status as CPR and the physician's orders, dated [DATE], showed CPR;-The resident's profile page showed DNR. She did not see a signed DNR uploaded in the resident's electronic medical record;-The resident's health care directive showed the resident's representative initialed did not wish to make a health care directive dated [DATE], which means a full code status;-She was responsible for updating residents' code status if changes. During interviews on [DATE], at 1:39 P.M. and [DATE], at 1:04 P.M., the Director of Nursing (DON) said the following: -Resident DNR or CPR status is uploaded in the charts in the electronic chart;-Staff also have a red emergency binder at the nurses' station with all residents' code statuses;-The SSD reviews code status upon admission with residents and/or representative;-The resident/representative signs a DNR form which staff give to the physician to sign; -The SSD scans the signed DNR document into the miscellaneous tab in the computer. She or the MDS Coordinator can enter a resident's code status in the computer;- She is not sure what happened with the resident's code status when staff entered it on admission. The resident's profile page on the computer showed a DNR code status and the banner showed a full code status for the resident;-The resident's health care directive signed by his/her guardian indicated he/she was a full code (CPR to be started if found unresponsive);-She expected staff to perform CPR on the resident; -Staff must have removed the resident's face sheet after he/she passed away, as it is not in the binder at this time. During an interview on [DATE], at 4:10 P.M., the Nurse Practitioner (NP) said the following:-He/she expected all staff to follow advance care directives;-If code status is CPR, staff start chest compressions and call 911;-He/she finds code statuses in electronic medical record and staff also use a colored dot system;-He/she received a call from the Administrator stating the resident was blue from the head up and had no pulse;-Social services updates code statues;-If a resident or representative did not complete a health care directive, it would default to a full code status;-He/she did not ask if staff started CPR or instruct them to start CPR as staff reported the resident was already gone. During an interview on [DATE], at 12:52 P.M., the Medical Director said the following:-If a resident was found unresponsive staff on duty should report to the DON, Administrator, and NP, and call 911;-He expected staff to check a resident's code status to determine whether to perform CPR or if they had a DNR code status;-He expected a resident's code status to match throughout the medical record;-Facility staff should initiate CPR if a resident is a full code status immediately due to time matters;-If the resident was a full code status, staff should have initiated CPR. During an interview on [DATE], at 4:30 P.M., the Administrator said the following:-Staff were to check resident code status using the emergency binder and the nurses' station;-Social services updates code status on admission and any licensed staff can update or make changes after that;-The resident had DNR listed on the front page of his/her face sheet and the second page indicated CPR;-The resident's physician orders showed the resident was CPR;-Staff did not start CPR on the resident;-She and RN E did not perform CPR because the resident's face sheet showed a DNR code status and did not question it;-She did not find a signed uploaded DNR for the resident in the electronic medical record;-The resident's representative initialed a health care directive form stating did not wish to make one at this time which defaults to a full code status;-He/she called the NP who was on their way to the facility when this happened;-He/she did not question the code statuses on the face sheet;-He/she expected all code statues on face sheets to match the resident's actual code status;-She expected a resident's code status to match throughout the medical record;-The resident was a full code when he/she passed away;-Staff were to start CPR when a resident was a full code and found unresponsive. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. Complaint #2788657

Based on interviews and record review, the facility failed to keep residents free from accidents when one staff (Certified Nurse Aide (CNA) A) assisted one resident (Resident #1) in a hurried manner resulting in a fall from a wheelchair. The facility census was 31.Review of the facility's policy titled, Repositioning, dated 2001, showed staff to ask the resident's permission to reposition or assist in the resident in repositioning.Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 2001, showed the following: -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques;-Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 02/21/25;-Diagnoses included contracture of muscle, unspecified lower leg (a condition in which a muscle becomes permanently shortened and stiff, limiting its range of motion), dementia (a general term for a number of neurological conditions that cause a decline in cognitive abilities), and intracapsular fracture of right femur (a break in the femoral neck, the part of the femur (thigh bone) inside the hip joint capsule). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/25, showed the following: -The resident was cognitively intact;-The resident used a wheelchair for mobility.Review of the resident's care plan, revised 10/09/25, showed the following: -The resident was dependent on staff for meeting physical needs;-All staff should converse with resident while providing care;-The resident was dependent on staff for locomotion in wheelchair. He/she did not propel self.Review of the resident's October 2025 Physician Order Summary (POS) report showed the following: -An order, dated 04/03/25, for activity as tolerated, assist of two using Hoyer (mechanical lift used for non-weight bearing residents) for all transfers; -An order, dated 03/21/25, to admit to hospice services on 03/21/25; -An order, dated 04/29/25, for pain monitoring and staff to assess for pain and document every shift.Review of the Facility Incident Report, dated 10/09/25, showed the following: -When Certified Nurse Aide (CNA) A attempted to incline resident in the wheelchair, resident tipped forward in the wheelchair and fell to his/her knees;-Resident had blood noted to his/her mouth. Resident had bit his/her lip;-Range of motion and neurological checks were within normal limits (WNL) for this resident;-Resident unable to give description.During an interview on 10/16/25, at 2:16 P.M., CNA A said the following:-He/she had worked at the facility since July 2025;-He/she did not complete any skills competencies with staff from the facility;-CNA A had gone to the dining room to assist with lunch;-The resident was sitting in his/her Broda chair next to the table;-He/she approached the resident and announced him/herself;-CNA A told the resident that he/she was going to reposition his/her Broda chair;-The lever on the residents Broda chair was stuck. CNA A pushed on the lever which caused the resident to fall out of the chair;-CNA A had no intention to harm the resident. Review of CNA A's personnel record showed the following: -CNA A was hired on 06/30/25;-CNA A started work on 07/22/25;-Staff did not document trainings or skills competency reviews completed in the CNA A's file.Review of the resident's care plan, revised 10/09/25, showed on 10/09/25, staff added resident fell out of wheelchair while being repositioned and landed on the floor on his/her knees. Resident was sent to emergency room (ER) per resident and family's request. Fracture identified below right knee.During an interview on 10/15/25, at 11:07 A.M., the resident's Family Member A said he/she was told by another family member an aide had flipped the resident out of his/her wheelchair causing a hairline fracture of the resident's knee.During an interview on 10/15/25, at 11:36 A.M., the resident's Family Member B said the following: -The resident had been at the facility since January 2025;-The family member received a call on 10/09/25, that the resident had fallen out of his/her wheelchair while at the dining room table during lunch;-CNA B told the family member that the resident was being repositioned in his/her chair by CNA A when the resident was catapulted out of his/her chair;-The resident landed on his/her hands and knees and hit his/her mouth on a wooden chair causing a laceration to the resident's mouth.During an interview on 10/15/25, at 12:43 P.M., the Dietary Aide (DA) E said the following: -The DA was in the dining room preparing for lunch when he/she saw the resident sitting too far forward in his/her Broda chair (a specialized, high-durability seating system designed for individuals with mobility challenges, such as the elderly or those with chronic conditions);-While CNA A was repositioning the resident and he/she fell out of the chair and landed on his/her hands and knees, hitting his/her mouth on a wooden chair.During an interview on 10/15/25, at 12:50 P.M., CNA B said the following: -The resident was sitting at an angle at the table during lunch;-There was a wooden chair next to the resident for staff to sit in to assist the resident with eating;-CNA A came up behind the resident, without announcing himself/herself, and CNA A grabbed the lever on the Broda chair to reposition the resident;-CNA A pushed on the Broda chair causing the resident to fall out of the chair;-The resident fell on his/her hands and knees, hitting his/her mouth on the wooden chair causing the resident to bleed;-CNA B said the resident was startled and asked the CNA to help him/her;-CNA B stabilized the residents head while CNA A stood behind the resident still holding onto the chair;-When repositioning residents, staff were to announce themselves to the resident and explain to the resident what they were doing while doing it. CNA A did not do this with the resident.During an interview on 10/15/25, at 1:11 P.M., CNA D said staff were to announce themselves to residents and explain to them what they were doing before repositioning residents.During an interview on 10/16/25, at 2:44 P.M., LPN C said the day before the incident LPN C and the Assistant Director of Nursing (ADON) had re-educated CNA A on slowing down and being gentle when providing cares to residents.-No other staff had reported any concerns regarding the care that CNA A provided to During an interview on 10/15/25, at 1:20 P.M., Registered Nurse (RN) E said staff were to always announce themselves to residents before providing any care.During an interview on 10/15/25, at 1:26 P.M., the ADON said the following:-The day prior to the resident's fall it had been reported that CNA A moved too quick with residents;-On 10/08/25, the ADON and LPN C met with CNA A and re-educated CNA A on taking his/her time while providing cares to residents and all other tasks.During an interview on 10/15/25, at 3:07 P.M., the Administrator said the following: -Staff reported to her after the incident with the resident that CNA A worked too with residents;-The Administrator did not believe that the CNA intentionally meant to hurt the resident;-CNA A had not completed new employee training in the system and there were no documented skills competency reviews for CNA A. During an interview on 10/15/25, at 3:22 P.M., the Director of Nursing (DON) said the following: -The facility had a nurse educator that completed skills checks with employees;-The only concern regarding CNA A that the DON was aware of was that CNA A was unmotivated at times.During an interview on 10/15/25, at 4:55 P.M., the facility physician said the following:-The physician felt that CNA A had rushed with the resident;-The physician would expect staff to have training on properly repositioning residents.During an interview on 10/15/25, at 4:55 P.M., the Nurse Practitioner (NP) said staff should complete new employee training with management and the on-line system. The facility had a nurse educator who does skills competencies with employees.Complaint Number 2640366

Based on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #21), out of 8 sampled residents, who informed staff of past trauma. The facility census was 26.Review of the facility's policy entitled Behavior Health Services, undated, showed the following:-Residents in the community will receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan;-Identify the population of the following residents in the facility assessment. Those with mental disorders, psychosocial disorders, substance abuse, and those with a history of trauma and post traumatic stress disorder (PTSD);-Assess the resident upon admission, and at least quarterly, and with change in condition, utilizing the available readmission Screening and Resident Review (PASARR - a federal program mandated to ensure individuals are not inappropriately placed in nursing facilities for long-term care), the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) and other assessments;-Assess residents with mental or psychosocial adjustment difficulty, or have history of trauma and/or PTSD for necessary care and services, appropriate person centered care plan and individualized treatment to meet their needs;-Interview and evaluate the resident or representative for stressors or triggers and address on the care plan;-Evaluate the frequency, urgency, intensity, duration, and impact of the resident's expressions or indications of distress as well as the location, surrounding or situation in which they occurred.1. Review of Resident #21's face sheet (gives brief profile information) showed the following information:-admission date of 10/02/24;-Diagnoses included Williams syndrome (rare genetic disorder characterized by a distinctive set of physical features, and may also experience developmental delays), post-traumatic stress disorder (mental health condition that can develop after experiencing or witnessing trauma), anxiety disorder, and depression (feelings of sadness)Review of the resident's progress note, dated 01/02/25, showed the following:-Resident had a diagnosis of PTSD with status being acute;-Resident had a diagnosis of nightmares with status being chronic;-Resident began taking prazosin (used to treat high blood pressure but commonly used off label to manage symptoms of PTSD, especially nightmares). Review of the resident's progress note, dated 02/27/25, showed resident had PTSD and depression. Resident had childhood trauma that resulted in PTSD and depression which subsequently led to methamphetamine addiction. Review of the resident's quarterly MDS, dated [DATE], showed a diagnosis of PTSD. Review of the resident's care plan, revised on 06/09/25, showed the following:-Impaired cognitive function related to William's syndrome;-Resident has potential to be physically aggressive toward peers related to poor impulse control when he/she witnesses them yelling at staff or other resident's.(Staff did not care plan the resident's diagnosis for PTSD and related triggers or interventions.)Review of the resident's June 2025 Physician's Order Sheet, showed a diagnosis of PTSD. During interviews on 06/26/25, at 10:21 A.M. and 4:45 P.M., the MDS Coordinator said the following:-He/she reviewed progress notes that showed a diagnosis of PTSD related to childhood trauma that led to the use of drugs;-Resident had nightmares due to the PTSD;-He/she saw the diagnosis on the progress notes dated 02/27/25, but it is not on the care plan;-A trauma assessment was completed on admission and quarterly;-He/she had not completed a trauma assessment on the resident;-He/she and social services planned to review the diagnosis and complete a trauma assessment during the next review meeting in July;- The resident takes medications that assist with the PTSD;-He/she was not aware of any triggers for the resident or anything staff would need to be made aware. They do monitor the nightmares.During an interview on 06/26/25, at 1:43 P.M., Certified Nurse's Aide (CNA) A said the following:-He/she did not know when a resident had PTSD. The nurse would usually let the staff know;-He/she wouldn't know the triggers related to PTSD. The nurse would tell them;-If the resident was having new behaviors, he/she let the nurse know;-He/she didn't look at the care plans and didn't know if he/she had access. The nurse could pull the care plans up if he/she needed to see them;-The resident did have some issues such as getting overwhelmed easily and being stressed;-The resident was a private person, but had said he/she had nightmares;-He/she believed the nurse was aware of the nightmares.During an interview on 06/26/25, at 1:49 P.M., CNA B said the following:-He/she knew a resident had PTSD as the diagnosis if it was listed in their chart or he/she looked on the care plan;-He/she also talked to the residents and sometimes they shared things that's happened to them that had caused trauma;-If he/she was aware of the resident having PTSD;-If he/she witnessed new behaviors from residents, he/she passed that to the nurse;-He/she knew the resident had a hard past, but he/she hadn't noted any behaviors. During an interview on 06/26/25, at 1:57 P.M., Registered Nurse (RN E) said the following:-He/she looked through a resident's history upon admittance to see what diagnoses they might have and he/she talked to the resident;-He/she talked to the resident to understands the triggers, or things to avoid;-The resident gets emotional and has difficulty expressing things;-The resident will sometimes come to him/her and just needs to unload when he/she is in a rough spot;-The careplan should have PTSD listed in it as well as triggers. During an interview on 06/26/25, at 3:00 P.M., Certified Medication Technician (CMT) C said the following:-He/she didn't know when a resident had PTSD. He/she would ask other staff;-If a resident was having behaviors, he/she would ask the nurse if it would be related to PTSD;-He/she had access to the care plans, but wasn't sure if it listed PTSD or triggers related to PTSD;-The resident was usually happy and hadn't ever told him/her about past trauma. During an interview on 06/26/25, at 3:00 P.M., Certified Medication Tech (CMT) D said the following:-He/she did not know the signs of PTSD;-He/she was supposed to have access to care plans, but he/she didn't know for sure where they were at since going to the electronic records;-The care plans should list if a resident had PTSD and triggers;-He/she didn't know if the resident had PTSD. No other staff had said anything.During an interview on 06/27/25, at 8:48 A.M., the Assistant Director of Nursing (ADON) said the following:-If there was an active PTSD diagnosis, the staff should know what to look for in the resident. They might become more reclusive or have paranoid thoughts;-If staff are aware of behaviors related to PTSD, they should be relaying that to the nurses and passing it on to the next shift;-He/she didn't know if aides had access to the care plans;-The MDS Coordinator was responsible for making changes to the care plan and staff were supposed to relay changes in condition to the MDS Coordinator;-PTSD would be listed in the care plan as well as the triggers;-They do a trauma informed assessment if it triggers from the MDS assessment. During an interview on 06/27/25 at 10:50 A.M., the Director of Nursing (DON) said the following:-PTSD should typically be on the care plan;-If it's a new diagnosis, the staff should be communicating with one another and relaying information from shift to shift;-If the resident comes in with the diagnosis they would try to figure out the triggers by visiting with the resident and their family;-The electronic health record has a trauma assessment that's done on admit and quarterly;-PTSD should be listed on the care plan along with any triggers. During an interview on 06/27/25, at 9:49 A.M., the Administrator said the following:-He/she didn't know the resident had PTSD;-The staff speak to the residents about PTSD and the triggers;-According to the Nurse Practitioner they did not call it PTSD, it was called nightmares;-They do complete trauma assessments in the electronic records;-PTSD should be on the care plan and all staff have access to the care plans.

Based on record review and interview, the facility failed to ensure each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being when staff failed to provide adequate monitoring for one resident's (Resident #21) hypertensive (high blood pressure) medications when staff failed to obtain blood pressure readings prior to administering the medication. A sample of 8 residents was reviewed in a facility with a census of 26.Review of the facility's policy titled Administering Oral Medications, revised October 2010, showed the following:-Verify there is a physician's medication order for this procedure;-Perform any pre-administration assessments;-Allow the resident to swallow oral tables at his/her pace.1. Review of Resident #21's face sheet (gives brief profile information) showed the following information:-admission date of 10/02/24;-Diagnoses included high blood pressureReview of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 04/17/25, showed a diagnosis of hypertension (high blood pressure).Review of the resident's care plan, revised on 06/09/25, showed the following:-Impaired cognitive function;-Resident has a diagnosis of essential hypertension;-Resident will remain free of complications related to hypertension;-Staff will administer hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension (low blood pressure) and increased heart rate;-Monitor/record used/side effects of antihypertensive medications. Report to medical provider as necessary.Review of the resident's May 2025 and June 2025 Physician's Order Sheet (POS) showed the following:-An order, dated 04/20/25 with a start date of 05/01/25, for amlodipine (used to treat high blood pressure and chest pain) tablet 5 milligrams (mg), give one tablet by mouth in the A.M., one time per day, related to essential hypertension. The active order states under supply direction, give one tablet by mouth one time daily for hypertension, hold if systolic blood pressure is less than 100 mm/Hg or heart rate is less than 60 bpm;-An order, dated 04/20/25 with a start date of 05/01/25, for lisinopril (used to treat high blood pressure) tablet 20 mg one time per day in the A.M., for essential hypertension. The active order states give one tablet by mouth one time daily for hypertension, hold if pulse is less than 60 bpm or systolic blood pressure less than 100 mm/Hg;-An order dated 04/20/25, with a start date of 05/01/25, for prazosin (primarily used to treat high blood pressure) HCL cap 2 mg, give one capsule one time per day, at bedtime, related to essential hypertension;-An order, dated 05/20/25, to notify the provider if blood pressure was greater than 160/90 millimeters of Mercury (mm/Hg) or less than 90/50 mm/Hg, and/or the pulse is greater than 110 beats per minute (bpm) or less than 50 (bpm) if on blood pressure medication. Give meds and then recheck in one hour before notification of provider.Review of the resident's medical record and Medication Administration Record (MAR) for the month of May 2025, showed the following:-On 05/04/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/05/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/06/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/07/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/08/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/09/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/10/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/11/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/13/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/14/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/15/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/16/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/17/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/18/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/19/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/20/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/21/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/22/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/23/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/24/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/25/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/27/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/28/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/30/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 05/31/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin.Review of the resident's medical record and (MAR) for the month of June 2025, showed the following:-On 06/02/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/03/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/04/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/05/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/06/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/07/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/08/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/09/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/10/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;;-On 06/12/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/13/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/14/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/15/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/17/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/18/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/19/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/20/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/21/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/22/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/23/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/24/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/25/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/26/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin;-On 06/27/25, staff did not document a check of the resident's blood pressure. Staff administered the resident's amlodipine, lisinopril, and prazosin.During an interview on 06/26/25, at 1:57 P.M., Registered Nurse (RN) E said the following:-Residents are on a lot of blood pressure medications;-Staff are to take the blood pressure before administering the blood pressure medications;-The blood pressure should be taken as well if the resident is showing signs of blood pressure issues such as sweating or feeling anxious;-The facility has parameters to follow on blood pressure medications. If the blood pressure is not within the parameters, they are to hold the medication and notify the doctor;-The vitals are documented in the resident's electronic record and it would be documented if a resident refused to take the blood pressure.During an interview on 06/26/25, at 3:00 P.M., Certified Medication Technician (CMT) C said the following:-If a resident was taking blood pressure medications it would pop up to take the resident's blood pressure;-He/she will write it down on paper and gives it to the nurse to put into the record;-There were parameters to follow and they were listed on the computer. If the blood pressure was not within those parameters, he/she would tell the nurse;-He/she did take the resident's blood pressure before passing his/her hypertension medications in the morning;-If it was not within the parameters, he/she would mark that it's not given;-He/she looked in the computer and attempted to show the surveyor where the vitals would be documented, but there was no vitals documented for 06/26/25.During an interview on 06/26/25 at 3:00 P.M., CMT D said the following:-Blood pressure should be taken before administering the blood pressure medications;-If residents are not acting like their normal selves, he/she would take the blood pressure;-The blood pressures are charted under each resident on their weights;-He/she looked in the computer for the resident and seen only the vitals were taken three times in June. He/she said it should be done at least every morning before administering the blood pressure medications;-He/she said they have parameters to follow, if the systolic is below 100 or the pulse below 60, they hold the medication and notify the nurse.During an interview on 06/27/25, at 8:48 A.M., the Assistant Director of Nursing (ADON) said the following:-Blood pressure checks generally pop up in the resident's MAR for the CMTs;-There were instructions on parameters to follow with the blood pressure medications;-If the blood pressure was not within the parameters they were to recheck the blood pressure in an hour and notify the nurse;-Amlodipine and lisinopril would have blood pressure checks;-The staff should be documenting on the MAR the vitals and the CMTS have access to the weights/vitals tab to document;-He/she reviewed the resident's vitals and noted they were only taken on 06/01/25, 06/11/25, and 06/16/25 but should be taken daily.During an interview on 06/27/25, at 10:50 A.M., the Director of Nursing (DON) said the following:-All resident's have monthly vitals and if they're on blood pressure medications, the staff take the blood pressure prior to administering the medication;-He/she would expect the staff to follow the physician's orders on the parameters, notification, and administration;-He/she would expect staff to document the vitals in the electronic record.During an interview on 06/27/25, at 9:49 A.M., the Administrator said the following:-Blood pressure was taken depending on the medication order;-Some residents have it monthly and some have it more often;-The staff would need to check the blood pressure depending upon the orders and determine if it's within the parameters;-He/she would expect the blood pressure to be taken as ordered and documented in the electronic record.

Based on interview and record review, the facility failed to ensure all residents were free from significant medication errors when staff failed to administer a controlled medication (Klonopin - medication that enhances the activity of chemical messengers to transmit signals to other nerve cells in the brain, used to treat seizures and panic disorder in adults, regulated by the government due to its potential for abuse and addiction) as order for two residents (Resident #24 and Resident #22) out of a sample of 15 residents in a facility with a census of 26.Review of the facility's policy titled Administering Oral Medications, revised October 2010, showed the following information:-Verify there is a physician's medication order for the procedure;-Select the drug from the unit dose drawer or stock supply;-Check the label on the medication and confirm the medication name and dose with the Medication Administrator Record (MAR);-Check the expiration date on the medication;-Check the medication dose;-Prepare the correct dose of medication;-Confirm the identify of the resident;-Notify the supervisor if the resident refuses the procedure;-Report other information in accordance with the facility policy and professional standards of practice.1. Review of Resident #24's face sheet (brief resident profile sheet), showed the following information:-admission date of 05/30/25;-Diagnoses included toxic encephalopathy (neurological disorder that occurs when the brain is exposed to toxic substances, such as heavy metals), bipolar disorder with psychotic features (mental illness that involves experiencing both the mood swings characteristic of bipolar disorder and symptoms like hallucinations (sensory experiences that appear real but are created by the mind) or delusions (belief of altered reality that is persistently held despite evidence to the contrary)), anxiety disorder, hallucinations, unintentional poisoning by amphetamines (mood altering drug, used illegally as a stimulant), and unintentional poisoning by ecstasy (recreational drug that can induce intense euphoric and ecstatic feelings).Review of the resident's Baseline Care Plan, dated 05/30/25, showed the following information:-Cognitively intact;-Resident took psychotropic medications.Review of the resident's progress note dated 06/09/25, at 4:07 P.M., showed the resident complained of increased depression and wanting to add something to his/her Zoloft (antidepressant medication). The resident said he/she felt he/she needed additional medication to aide with reducing signs and symptoms of depression. Staff spoke with the nurse practitioner related to the resident's concerns. Review of the resident's progress note, dated 06/10/25, showed staff received a fax from the nurse practitioner related to the resident's complaints of increased depression. The nurse practitioner to speak with the physician on 06/12/25 for further recommendations. Staff to monitor closely for homicidal/suicidal ideations.Review of the resident's Physician Order Sheet (POS) and order details for active orders, as of 06/26/25, showed the following information:-An order, dated 06/12/25, for Klonopin 1 milligram (mg) by mouth at bedtime for anxiety.-Prescriber directly entered the order for Klonopin into the computer software system;-Klonopin was a controlled drug level 4 (feasible medical use and low probability of use or misuse).-Medication class was anticonvulsants;-Licensed Practical Nurse (LPN) I confirmed the order.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/12/25, showed the following information:-Cognitively intact;-Exhibited hallucinations;-Staff documented use and indication for antipsychotic medication;-Staff documented use and indication for antidepressant medication.Review of the resident's MAR and Order Administration Notes, dated 06/01/25 to 06/30/25, showed the following information:-An order, dated 06/12/25, for Klonopin 1 mg tablet for staff to administer by mouth at bedtime;-The chart definition of codes showed 9 indicated other/see progress notes;-On 06/12/25 to 06/15/25, staff documented 9 and staff initials;-On 06/12/25, at 11:37 P.M., staff documented medication not available;-On 06/13/25, at 8:57 P.M., staff documented medication not available;-On 06/14/25, at 8:19 P.M., staff documented medication not available;-On 06/15/25, at 8:30 P.M., staff documented medication not available.Review of the resident's progress note dated 06/16/25, at 1:55 A.M., showed the resident said the last couple nights, he/she had been waking up about 1:00 A.M. due to having nightmares. Review of the resident's MAR and Order Administration Notes, dated 06/01/25 to 06/30/25, showed the following information:-An order, dated 06/12/25, for Klonopin 1 mg tablet for staff to administer by mouth at bedtime;-On 06/16/25 to 06/19/25, staff documented 9 and staff initials;-On 06/16/25, at 8:08 P.M., staff documented medication not available;-On 06/17/25, at 8:31 P.M., staff documented medication not available;-On 06/18/25, at 9:19 P.M., staff documented medication not available;-On 06/19/25, at 9:03 P.M., staff documented medication not available;-On 06/20/25, LPN I documented a checkmark and initials;-On 06/21/25 to 06/24/25, staff documented 9 and staff initials;-On 06/21/25, at 7:31 P.M., staff documented medication not available;-On 06/22/25, at 7:27 P.M., staff documented medication not available;-On 06/23/25, at 7:13 P.M., staff documented medication not available;-On 06/24/25, at 8:20 P.M., staff documented medication not available.Review of the resident's comprehensive care plan, revised on 06/24/25, showed the following: -The resident had hallucinations; -Resident used psychotropic medications related to hallucinations;-Administer psychotropic medications as ordered by the physician;-Monitor for side effects and effectiveness every shift.Review of the resident's MAR and Order Administration Notes, dated 06/01/25 to 06/30/25 showed the following information:-An order, dated 06/12/25, for Klonopin 1 mg tablet for staff to administer by mouth at bedtime;-On 06/25/25, LPN I documented a checkmark and initials.During an interview on 06/26/25, at 8:51 A.M., Certified Medication Technician (CMT) C said the resident should have had Klonopin last night. He/she looked on the MAR and said it showed it was given last night on 06/25/25, and it showed it was given on 06/20/25. The other night staff documented 9- other/progress note. There was not a medication card in the drawer for Klonopin. He/she was not told anything about the medication. The Director of Nursing (DON) could pull up medications administered from the emergency kit (e-kit) medications/administrations of medications. During interviews on 06/26/25, the Director of Nursing (DON) said the following: -At 9:00 A.M., she did not have access to pull the report from the emergency kit. She would check with the pharmacy and have them pull a report; -At 9:15 A.M., Klonopin was not in the emergency kit. The facility did not have Klonopin in the emergency kit, so there is no way it would have been given through it. -The Klonopin had not been given when staff documented it was not available. Review of the resident's progress notes dated 06/26/25, at 10:25 A.M., showed the DON documented she was notified about a medication error on this resident. The resident's physician ordered the resident's Klonopin on 06/12/25. The medication was a controlled medication and had to be faxed to the pharmacy. The pharmacy never received a fax, so they never sent the medication to the facility. The nurses did not follow up on the ordering of the medication and did not notify nursing management of the medication not being received. During an interview on 06/26/25, at 2:15 P.M., CMT C said he/she did not know why Klonopin was ordered for the resident. He/she did not know who ordered his/her medication. The CMT assumed he/she did not work the day it was ordered. He/she called pharmacy yesterday to check on the resident's Klonopin. The CMT assumed they would have given the Klonopin from the e-kit and given it from there for those two days it showed it had been administered to the resident. During an interview on 06/26/25, at 6:40 P.M., LPN I said he/she did not take the order for the resident's Klonopin. It came directly from the physician. He/She did not know who put in the order. The nurse looked in the computer in the orders and said if staff click on the order, it will show who ordered it and what staff entered/confirmed the order. The nurse did not remember if he/she worked that night or not, but he/she did not put in the order. The nurse looked further and said the physician put the order in himself. He/She confirmed the order. The nurse did not know if the medication had ever been delivered because it needed a physician signature. The nurse documented in the progress notes the medication was not available. The nurse did not know what the 9 code meant on the MAR. There was no other place to get the medication. It is not one that would be in the e-kit. He/she assumed a checkmark and initials meant staff administered the medication. The nurse did not give it last night. There were problems with the computer last night and he/she could not get back in and correct it. On 06/20/25, the medication was also not available, and he/she did not give it on 06/20/25. That night the computer also had problems, and he/she could not go back in and correct it.During an interview on 06/26/25, at 3:58 P.M., Registered Nurse (RN) E said the resident's Klonopin was ordered on his/her day off. Staff called pharmacy several times to follow up. He/she remembered on a weekend a CMT tried to talk to the pharmacy about the resident's Klonopin and the phone kept disconnecting. Staff did not document those calls/follow-ups to pharmacy anywhere. The resident was having night terrors, bad dreams and the physician ordered Klonopin to help. He/she found out today the resident never received his/her medication (Klonopin). The nurse did not think Klonopin was in the e-kit.During an interview on 06/26/25, at 4:47 P.M., the MDS/Care Plan Coordinator said the resident stays in his/her room a lot. They monitor the resident for depression. The resident came to staff about two weeks ago, right before the medication change for the antidepressant. The resident thought his/her depression was worse. Staff monitor his/her interactions and ability to get back into the community. The resident's physician started him/her on Klonopin due to the resident's social anxiety after talking to the resident. The resident has been out of his/her room a lot more the last couple weeks and out in the community more. They monitor the resident's hallucinations. The resident will occasionally see snakes/worms. The resident said it has been that way since childhood. He/she has learned to verify and ask other staff if they see it. The resident thought the amphetamines help ed with the hallucinations. When the resident first left the facility for day trips/errands, the nurse was concerned how he/she would do. The resident has done well so far. During an interview on 06/27/25, at 10:55 A.M., the DON said the resident's Klonopin was ordered but not sent to the pharmacy. If a medication was not available, staff document 9 which meant other/progress note. Staff document the medication is not available in the progress note. That would be the appropriate place to document it. She would expect to be notified about it. The DON's morning report does not include the medication progress notes. The resident had taken Klonopin before he/she came to the facility. The hospital discontinued it prior to his/her admission to the facility. The resident had expressed he/she was a little more anxious and so the physician went back to the medication he/she had been on prior to admission to the facility. During an interview on 06/27/25, at 11:27 A.M., the Administrator said the DON told her the Klonopin did not get flipped because it was a narcotic. They did not know narcotics did not automatically send to the pharmacy. The Administrator said they did not get the Klonopin medication. She knew the staff documented it was not given. Staff faxed the form to the pharmacy yesterday for Klonopin to be added to the e-kit today. 2. Review of Resident #22's face sheet showed the following:-admission date of 02/21/25;-Diagnoses included moderate vascular dementia with behavioral disturbance, and mood disorder with depressive features.Review of the resident's quarterly MDS dated [DATE], showed the following:-Cognition was intact;-Verbal behavioral symptoms directed toward others occurred 1 to 3 days;-Other behavioral symptoms not directed toward others such as hitting/scratching self, verbal/vocal symptoms like screaming, and disruptive sounds;-On antianxiety and antidepressant medications.Review of the resident's Care Plan, dated 05/16/25, showed the following:-Administer medications as ordered; -Staff to monitor/document for side effects and effectiveness;-Review medications and record possible causes of cognitive deficit. -Potential to be verbally aggressive towards staff and other residents related to ineffective coping skills;-Monitor behaviors every shift and document observed behavior and attempted interventions;-When agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response was aggressive, staff to walk calmly away, and approach later.Review of the resident's Physician's Progress Note, dated 06/18/25, showed the following:-Patient on hospice care and presents with chronic pain and anxiety;-Patient expressed the pain significantly impacts quality of life, mentioning suicidal ideation due to the severity of the discomfort;-In addition to pain, the patient is experiencing anxiety and had previously been prescribed Xanax (for anxiety) and was discontinued before coming to the facility;-The patient reports ongoing anxiety symptoms, which appear to be causing obsessive thoughts and behavioral issues;-Currently, the patient was on a pain management regimen and for anxiety, the patient was prescribed lorazepam (or Ativan - used to treat anxiety) 0.5 mg every 8 hours as needed;-Despite the medication regimen, the resident continued to experience significant pain and anxiety symptoms;-Plan to discontinue lorazepam and start clonazepam (Klonopin) 0.5 mg po (by mouth) at bedtime.Review of the resident's Physician's Order Summary Report showed an order, dated 06/18/25, for clonazepam oral tablet 0.5 mg to give one tablet by mouth at bedtime for anxiety.Review of the resident's MAR showed the following:-An order, dated 06/18/25, for clonazepam oral table 0.5 mg to give one tablet by mouth at bedtime for anxiety;-On 06/19/25, 06/20/25, 06/21/25, 06/22/25, 06/23/25, 06/25/25, and 06/26/25, staff put a number 9 with their initials to indicate the medication was unavailable.Review of the resident's progress note, dated 6/24/25, showed the resident had been complaining of increased anxiety sine the as needed Ativan was discontinued a month ago. The nurse left a message for the nurse practitioner at this time.Review of the resident's progress notes, dated 06/26/25, showed the Assistant Director of Nursing (ADON) contacted the physician to make him/her aware the clonazepam was not available and the script for the clonazepam was sent by the physician to the pharmacy (eight days after the physician had ordered the clonazepam).Observation on 06/26/25, at 2:40 P.M., of the medication room and medication cart showed there was no clonazepam 0.5 mg tablets in roll pack or on a card for the resident. During interview on 06/26/25, at 3:10 P.M., CMT C said the pharmacy did come nightly but he/she did not order the resident's medications.During interview on 6/26/25, at 7:00 P.M., LPN I said the physician put the resident on the clonazepam 0.5 mg one at bedtime and he/she didn't know if the physician sent in a signed prescription for the clonazepam since it was a narcotic medication. He/she did not know who was to follow up with a new prescription such as a narcotic with the physician and the pharmacy. Usually, they can get the nurse practitioner (NP) who can get a hold of the physician. They do not have a number to call the physician since they work the evenings and nights. The DON can get a hold of the physician in the day. The resident's medications pop up on the medication sheet in the electronic medical record. He/she did report this to the day shift nurse a few times about the resident's medication not there at the facility, but did not tell the DON. They can print out a script and send it to the physician for him to sign and get to the pharmacy but did not know if he/she was do this at night when it was ordered by the physician. He/she thought the DON or ADON was responsible for the new prescription orders to get to the physician. When they order narcotics, they don't print out the order to sign but sometimes the physician can do an electronic signature.During interview on 06/27/25, at 10: 50 A.M., the DON said the following:-The order from the electronic medical record for a controlled medication was not sent to the pharmacy;-They have to send this to the pharmacy. A controlled drug has to have a written script or electronic prescription or e-script or they send an actual hard copy script. She just found this out;-Clonazepam 0.5 mg one tablet was not a part of the emergency kit, but it was now;-The night nurse documented 9 to see progress note that the medication was not available. She would have expected the nurse to notify her that they did not have the medication;-She was not aware the clonazepam had not been ordered for the resident.During interview on 06/27/25, at 11:26 A.M., the Administrator said the following:-For the resident, they were unaware the clonazepam 0.5 mg medication had not come in until yesterday. The resident's progress notes said it was not available;-She would expect the nurse to put in a note when they did not administer the medication;-Would have expected the night nurse to contact the DON or ADON about the unavailable medication. 3. During an interview on 06/26/25, at 2:15 P.M., CMT C said the following: -Getting the medication on the MAR and physician order sheet is completed by the nurse; -The CMTs or the nurse calls the pharmacy to let them know of the new order and faxes the order over to the pharmacy. It should be faxed within the same day. -Staff call and check on it at least twice on their shift, once to see if the pharmacy got the fax, and the second time to ensure when the medication is coming. Medications do not come in until 3:00 A.M. to 5:00 A.M. That is the normal delivery time. -If the medication doesn't come in, the CMT lets the nurse know and they call the pharmacy and check on it. Usually then, it is something that needed a signature, prior authorization, or something like that causing the delay. Sometimes it is delayed a day or two for those types of things. Staff call the physician or nurse practitioner within the day. -Medications should be given by that night or the next morning. There should not be a delay of more than a day before a routine medication is administered from when it was ordered. If not given, he/she tells the nurse and enters a note regarding what medication was not administered and why the medication did not get administered. The CMT would explain why it was not given and steps he/she had taken to correct it. Then, he/she would call and talk to the pharmacy also and include that in his/her note. -If not given on the day ordered, then the CMT or the nurse would call the physician and notify them of the delay in giving the medication. CMT's pass medications on the day shift (6:00 A.M.-6:00 P.M.). -Nurses pass medications on the night shift (6:00 P.M.-6:00 A.M.), Sometimes, the medication technician stays over and helps. During an interview on 06/26/25, at 3:58 P.M., RN E said the following: -Sometimes, the order is received as a verbal order or sometimes the nurse will send a written order for a medication. If a verbal order, he/she reads it back, puts it in the medication order system, including what type of order, telephone or verbal. The order is placed and sent to the pharmacy; -If not a stock medication, the order auto uploads to the pharmacy; -If it is a new admission, staff send the resident's whole medication list and face sheet. If it is just a new medication order, then he/she enters a progress note in the medical record and begin their change of medication charting to ensure there is no reaction to the new medication. -Since the system is new, the nurse will call the pharmacy and doublecheck to make they got the order. He/she only documents if there is a problem with the order received, or if the order is not received; -If the medication is ordered during the day, it should be available for staff to administer that night. But it should be available and administered usually within 24 hours; -If it is a routine order, it will auto populate to the MAR. If it is a timed order, staff enter the start date/time on the MAR. If staff cannot pull it from the e kit and there is a delay, staff are calling pharmacy to see what is needed; -If the medication is not available, staff can document right under the medication. Staff should check to see if the medication is available in the e kit. If not, staff should document the medication not administered. When they document that, they system provides a drop-down menu of choices, including one that shows medication not available; -Staff should call the physician if a medication is not received within the 24 hours and discuss it with the physician regarding an over-the-counter option, alternative medication, or if the pharmacy cannot get the medication. During an interview on 06/26/25, at 4:47 P.M., the MDS/Care Plan Coordinator said if a resident started a new psychotropic medication, she ran a new orders report. If any new orders, she tried to flow it over to the care plan and add monitoring for any behaviors. It should be added to the care plan within 48 hours. Staff will also notify her if something needs added to the resident's care plan. During an interview on 06/26/25, at 6:40 P.M., LPN I said the following: -When staff obtain an order, it is put in the electronic medical records system. The order goes directly onto the MAR. Sometimes, the physician inputs the order directly or the nurse inputs the order in from the physician; -Pharmacy usually delivers medications from 11:00 P.M.-1:00 A.M. The medication is usually available and able to be administered by the next day; -When staff enters the order in the electronic records, it automatically sends the order to the pharmacy. If a new order is obtained in the evening, it would not get there by the same night. It would be the next night. The nurse would notify the day shift of the new order pending; -The medication should be delivered/administered within 24 hours of being ordered. If not delivered within the 24 hours, he/she would call the pharmacy. If a medication is not delivered/administered within that 24 hours, he/she would notify the DON. The nurse would text the DON or leave a note. It would not be something he/she would document in the medical records. When he/she calls the pharmacy, he/she would not officially document that in the resident's medical record. The nurse would document it on a communication sheet that is in the medication room. That is where the calls and follow-up would be documented; -The only problem that usually causes a delay is orders that require the physician to be notified, such as a narcotic medication. It requires a physician signature. The nurse would notify the DON that a physician signature is needed. During interviews on 06/27/25, at 8:47 A.M., 9:05 A.M., and 10:55 A.M., the DON said the following: -Communication sheets are in the medication room for the CMTs. She looked but could not find the June 2025 communication sheets in the medication room or her office; -Nurses are the only ones who can input orders. The physician can enter their own orders in. There is an icon that shows when the physician entered the order; -The order from the electronic record that transfers to the pharmacy does not automatically send to pharmacy if it is a controlled drug. The physician needs to either do an electronic prescription (e-script) or send the actual hard copy prescription. She just found that out yesterday; -The physician put the order into the electronic record. The pharmacy did not get the order; -They have instructed night shift about when they have a controlled medication, they have to reach out to the physician to get the signature; -She was not made aware some of these medications were not actually sent to the pharmacy; -The ones they are not getting, staff should be reaching out to the DON. The DON is the one who deals with the pharmacy; -When a medication is ordered, if it is after noon, they won't get it that night. It would go into effect the next night for current residents; -If a new admission, the pharmacy has to get the orders by 5:00 P.M. for the facility to get them that night; -A new order should be administered within 24 hours of being ordered. If not administered within those 24 hours, she would expect staff to notify the DON or the ordering provider (physician or nurse practitioner). During an interview on 06/27/25, at 11:27 A.M., the Administrator said the following: -She would expect the charge nurse to enter the order into the electronic medical records. The nurse practitioner can put the orders in the electronic medical records also. They have to activate the order to get it to send to pharmacy; -They discovered the glitch. If it a narcotic, it does not automatically send the order to pharmacy; -She would expect staff to print the prescription off and get it to the physician for a signature; -She would expect a new order to be administered, depending on the medication, anywhere from the next medication pass to the next day, within 24 hours; -If unable to give a medication, they would document if as not given in electronic medical records and explain why it was not administered. After that, they should notify the DON or ADON and let them know. They should reach out to the physician and see if the medication can be changed to something else or just to let them know; -If staff don't administer a medication one time for whatever reason, they should notify the charge nurse, who should notify the DON, who would then reach out to the physician.

Based on record review and interview, the facility failed to maintain a complete infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when staff did not complete admission tuberculin (TB - an infectious disease caused by bacteria that most often affects the lungs) testing/screening (also known as Mantoux test or tuberculin skin test (TST)) for two residents (Residents #179 and #24) who did not have their first TB test completed or documented in a timely manner. The facility had a census of 26.Review of the facility's policy entitled Tuberculosis, Screening Residents for F880, undated, showed the following:-This facility shall screen all residents for TB infection and disease; -The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of, TB and will check results of recent (within 12 months) tuberculin skin tests (TST) or chest X-rays (CXR);-Any resident without documented negative TST or CXR within the previous 12 months will receive a baseline (two-step) TST or one step upon admission. If the first TST is negative, a follow-up TST will be administered 1 to 3 weeks after the initial test is read. The BAMT (blood assay for mycobacterium tuberculosis) is a one-step test;-Asymptomatic (showing no signs/symptoms) residents who have a known positive skin test or a past history of TB, and who have not had a CXR in the past six (6) months, will receive a CXR before, or soon after, admission;-The physician will screen each new admission for possible signs and symptoms of TB, including: coughing for greater than three weeks, loss of appetite, fatigue, weight loss, night sweats, bloody sputum or coughing up blood, hoarseness, fever, and/or chest pain.(The policy did not give specifications regarding the reading and documentation of the TST's.)1. Review of Resident #179's face sheet (shows basic profile information at a glance) showed an admission date of 06/18/25.Review of the resident's June 2025 Physician Order Sheet (POS) showed an order, dated 06/26/25, for a Tuberculin PPD (purified protein derivative) intradermal (under the skin) solution 5 units/0.1 ml (Tuberculin PPD); inject 0.1 ml intradermally every night shift for TB Screening for 1 day until finished; read within 48 to 72 hours; and document results on separate order.Review of the resident's June 2025 electronic Treatment Administration Record (eTAR) showed the following:-Staff documented administration of a TB PPD to the right arm on 06/27/25 (nine days after admission);-The TB PPD administered on 06/27/25 was scheduled to be read on 06/29/25.Review of the resident's nurses' notes for showed staff did not document information pertaining to TB screening. During an interview on 06/27/25, at 10:35 A.M., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said the resident was admitted on [DATE], but staff did not enter the order for initial TB testing until 06/26/25. 2. Review of Resident #24's face sheet showed an admission date of 05/30/25.Review of the resident's May 2025 and June 2025 POS showed the following:-An order dated 05/30/25 for Tuberculin PPD intradermal solution 5 units/0.1 ml; inject 0.1 ml intradermally every night shift for TB Screening for 1 day until finished; read within 48 to 72 hours; and document results on separate order;-An order, dated 05/30/25, for Tuberculin PPD intradermal solution 5 unit/0.1 ml (Tuberculin PPD); inject 0.1 ml intradermally every night shift for TB Screening for 1 day until finished; schedule 7-10 days from first administration; read within 48-72 hours; document results on separate order.Review of the resident's May 2025 MAR showed on 05/31/25, start date 6:00 P.M., staff documented a checkmark and staff initials for Tuberculin PPD intradermal solution 5 unit/0.1 ml inject 0.1 ml intradermally every night shift for TB screening for 1 day until finished. Read within 48 to 72 hours. Document results on separate order.Review of the resident's June 2025 MAR showed on 06/01/25, staff documented a 9 and staff initials for Tuberculin PPD intradermal solution 5 unit/0.1 ml inject 0.1 ml intradermally every night shift for TB screening for 1 day until finished. Read within 48-72 hours. Document results on separate order.Review of the resident's administration progress note dated 06/01/25, at 7:57 P.M., showed staff documented TB test done 05/31/25. Review of the resident's medical record showed staff did not document the result of the 05/31/25, TB test. Review of the resident's June 2025 MAR showed on 06/06/25, staff documented a checkmark and staff initials for Tuberculin PPD intradermal solution 5 unit/0.1 ml inject 0.1 ml intradermally every night shift for TB screening for 1 day until finished. Read within 48 to 72 hours. Document results on separate order.Review of the resident's June 2025 eTAR showed the following:-Start date 06/14/25, 6:00 A.M.: admission 2-step PPD; read every day shift for TB Screening for 1 day; read PPD and record; -On 06/14/25, staff documented a negative TB result (8 days after the TB test was administered). Review of the resident's nurse's note dated 06/15/25, at 10:00 A.M., showed staff documented as a late entry; visualized resident's right forearm for evaluation of the first TB skin test. Results were 0 mm (millimeters) (negative). Resident will be given 2nd TB skin test later in the week.Review of the resident's June 2026 TAR showed start date of 06/21/25, 6:00 A.M.: admission 2-step PPD; read every day shift for TB Screening for 1 day; read PPD and record. On 06/21/25 staff documented Other/See Progress Notes.Review of resident's nurses' notes dated 06/22/25, at 3:14 P.M., staff documented as a late entry; TB test was read on the resident's left arm as negative. During an interview on 06/27/25, at 10:34 A.M., the ADON said the resident admitted to the facility on [DATE]. Staff administered his/her 1st step TB test on 5/31/25 but didn't read it until 06/06/25. Staff did not document it in the immunizations report. So, she did not know what arm it was given in or the results of that first test. Staff administered another 1st step TB test on 06/13/25. She can only see the result as negative on 06/19/25. She reviewed the TAR and said it looks like they read it a day too early on 06/14/25. But it was actually read on 06/15/25 per the late entry in the progress notes. The second TB skin test was read on 6/21/25 for TB skin test administered on 06/19/25. RN E had marked it as too early because he/she thought it was due 06/22/25. But it wasn't too early. So, it was read on 06/21/25 for the administration on 06/19/25. She did not know what the 06/06/25 checkmark on the MAR means. It should be on the nurse MAR or TAR. She is trying to get them all on the TAR. It should be documented/transferred over to the Immunizations on the electronic medical records screen. During an interview on 06/27/25, at 9:05 A.M., the Director of Nursing (DON) said the actual read date for the resident's first TB skin test was 06/15/25, at 10:00 A.M. The second TB test was read on 06/22/25, at 3:14 P.M.3. During an interview on 06/27/25, at 10:35 A.M., the ADON/Infection Preventionist (IP) said the admitting nurse should enter orders for TB 2-step testing for all newly admitted residents. Separate orders should be entered for the administration of the skin test and for the reading/test result. The nurse should administer the 1st step within 24 hours of admission, and the test should be read in 48 to 72 hours. The 2nd step should be administered about 10 days later. During interviews on 06/27/25, at 9:07 A.M. and 11:40 A.M., the Administrator said all residents should have the first of a 2-step TB test done on admission, unless there was documentation of a recent chest x-ray. The 2nd step should be administered in one to two weeks. Staff had informed her about the missed admission TB testing for Residents #179 and #24. The ADON/IP would be responsible for ensuring the residents' admission TB testing was administered, with results read and documented in the appropriate time frame.

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when the facility did not report one resident's (Resident #1) statement threatening physical violence towards other residents. The facility census was 28. Review of facility policy titled, Abuse Prohibition, Prevention, Investigation, Reporting and Response, updated 09/26/16, showed the following: -It is the policy of the facility to take all reasonable and responsible measurements to prevent the occurrence of abuse, including mental abuse, neglect, injuries of unknown sources, and misappropriation of resident property, and to ensure that all alleged, reported, and suspected violations of Federal or State laws which involve mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are reported to State agencies within twenty-four (24) hours after receiving said report. The facility will investigate each alleged violation thoroughly and report the results of all investigations to the appropriate State agency or individuals within five working days of the alleged violation; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulted in physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain, or maintain, physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents cause physical harm or pain or mental anguish; -Mental abuse includes, but is not limited to verbal or nonverbal humiliation, harassment, threats or punishment or deprivation. This includes conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Verbal abuse is any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), suicidal ideation's, and hypomagnesemia (condition in which the level of magnesium in the blood is lower than normal). Review of the Resident Incident Report dated 11/16/24, at 7:00 P.M., and completed by LPN E showed the following: -Certified nurse aide (CNA) reported resident out at smoke break at 7:00 P.M. The resident became verbally aggressive with peers and stated you're in my fucking spot. Staff immediately intervened and redirected, when resident came in from smoke he/she stated I'm gonna bash somebody's fucking head with a hammer. Staff redirected resident immediately, all parties separated, staff assisted resident to room and to bed. No harm to any parties. Staff notified Medical Director, interim Director of Nursing (DON). Staff completed 72 hour incident report and 15-minute checks initiated. Medical Director issued new orders for labs. Review of the resident's nurses' notes showed Licensed Practical Nurse (LPN) E wrote the following: -On 11/16/24, at 8:00 P.M., the resident was outside for smoke break at 7:00 P.M. with staff and other residents. The resident became aggressive and stated to peer you're sitting in my fucking spot. Staff immediately intervened. Resident continued cussing and yelling at two peers. The resident mumbled as residents were coming back inside, I'm gonna bash somebody fucking head with a hammer. Staff redirected and immediately residents were separated and taken to room away from other residents. Staff assisted the resident to bed. No harm done to any of residents involved. Staff notified Interim DON notified and Medical Director called at 8:10 P.M. with new orders for labs. Resident is his/her own responsible part and aware of new orders. (Staff did not document reporting the allegation of possible abuse to DHSS.) Review of a witness statement provided by CNA F, dated 11/16/24, showed the following: -At approximately 7:00 P.M., CNA F took the residents out to smoke for their scheduled smoke break. The resident stated, Resident #3 do not sit in my spot! Resident #3 began to switch seats, but the other CNA and CNA F told Resident #3 that he/she did not have to move. Resident #3 remained seated and Resident #1 began cussing. Resident #2 began to stick up for Resident #3. Resident #2 and Resident #1 began a heated verbal dispute. The other CNA spoke up and stated that if the arguing did not stop, the smoke break would not occur. The resident calmed down and smoke break ensued with no further arguing. -Upon entering the facility, post smoke break Resident #1 was asked by CNA F if he/she wanted to get ready for bed. Resident #1 stated that he wanted to bash somebody's fucking head in with a hammer. -Resident #1 was taken to his room and put to bed. Charge nurse notified immediately. No further occurrences at the time of this statement, involving resident. Review of a witness statement by CNA G, dated 11/16/24, showed the following: -At approximately 7:00 P.M., CNA G, another CNA and three residents outside to smoke. Resident #1 said Resident #3, Do no sit in my spot. Resident #3 began to get up, but CNA G told him/her that he/she could sit back down and CNA G directed Resident #1 to the opposite end of the table, where he/she had sat at every other smoke break that day; -Resident #2 and Resident #1 began to argue and CNA G stated that if the arguing continued, the smoke break would be over. Residents stopped arguing. Review of a witness statement by CNA H, dated 11/16/24, showed the following: -At around 7:00 P.M., when the residents came inside from smoke break CNA H heard Resident #1 say I'm gonna bash somebody's fucking head in with a hammer. The other CNA's and CNA H immediately redirected, and the resident went in room and went to bed. The resident continued to be hateful and completely disrespectful. The patient's room was searched for any kind of hammer or weapon. The patient is getting checked every 15-minutes. During an interview on 11/18/24, at 1:37 P.M., Resident #1 said the following: -Resident #1 was involved in an incident over the weekend with Resident #2; -Resident #1 said there was a confrontation with another smoker in the smoking area that was verbal and nearly physical; -Resident #1 said staff calmed them down and there have been no other issues since; -Resident #1 said he/she only sees Resident #2 when smoking. Record review of DHSS records showed the facility did not complete a self-report to DHSS regarding the allegation of possible abuse. 2. Review of Resident #2's face sheet showed admitted [DATE]. Review of the resident's care plan, updated 11/12/24, showed the resident was a smoker. Review of the resident's nurse's note dated 11/16/24, at 3:00 P.M., showed LPN E wrote the resident was out at smoke break with other residents. Resident #1 was aggressive and cussing at Resident #3. The resident intervened and asked Resident #1 to stop yelling at Resident #3. Resident #1 said to the resident fuck you. The resident said no fuck you. Resident #1 said to the resident he/she would kick his/her ass and the resident replied bring it. Staff immediately redirected both residents and separated them. No further issues this shift. (Staff did not document reporting the allegation of possible abuse to DHSS.) During an interview on 11/18/24 at 1:21 P.M., Resident #2 said the following: -Resident #2 said Resident #1 was being mean to Resident #3. Resident #1 thinks he/she owns the bench and started cussing and calling Resident #3 names. Resident #2 told Resident #1 that he/she needed to leave Resident #3 alone and quit being mean; -Resident #2 said that was the first time he/she had any issue with Resident #1; -Resident #2 said that he and Resident #1 have talked since the incident on Saturday; -Resident #2 said staff intervened in the incident and told both residents to quit arguing and staff wrote a report on it; -Resident #2 said staff told Resident #1 if he didn't stop the cops would be called. Record review of DHSS records showed the facility did not complete a self-report to DHSS regarding the allegation of possible abuse. 3. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included COPD, major depressive disorder (mood disorder that is characterized by a low mood and negative emotions), and hypokalemia (a condition where the level of potassium in your blood is lower than normal). Review of the residents' nurses notes show no documentation on 11/16/24 by staff. 4. During interviews on 11/18/24, at 12:35 P.M. and 3:15 P.M., the Social Services Director (SSD) said the following: -The social service worker from hospice contacted the police department today (11/18/24) regarding the incident over the weekend with Resident #1 and a police report was made; -He/she did not know what occurred over the weekend, but he/she had a note taped to her door this morning. The note was from LPN E and said the following: Resident #1 needs cigarettes ASAP - completely out. Please get ASAP. Resident has been having behaviors this weekend, is on 72 hour charting and 15-minute checks per interim DON due to this. Don't want to add to it with no cigs. -The SSD said he/she talked with the hospice nurse about the situation and the hospice social worker called the police. -If staff received an allegation of abuse, staff should call her and the Administrator. The Administrator would conduct the investigation. -She found out about the incident today (11/18/24) and did not call the police or DHSS because she thought everyone else took care of it. 5. During an interview on 11/18/24, at 2:24 P.M., CNA A said the following: -CNA A said Resident #1 can get loud and cuss at staff when he/she doesn't get what he/she wants or if he/she misses a smoke break; -CNA A said that verbal abuse and threats is a form of abuse and should be investigated by the facility; -The state required allegations of abuse, neglect, or misappropriation to be reported to the state within two hours. 6. During an interview on 11/18/24, at 4:40 P.M., LPN I said if he/she witnessed a resident to resident altercation, he/she separated the residents first, then talked to them about the events that led to the altercation. He/she contacted the DON and completed an incident report. He/she thought the DON contacted the state agency to report abuse allegations. If a resident threatened another resident, he/she would consider that abuse. 7. During an interview conducted on 11/20/24, at 12:30 P.M., LPN C said if someone reported to him/her an allegation of abuse, he/she would investigate the situation, document what happened in the nurses' notes, and notify the DON who would report the allegation to the state agency within two hours. The DON would complete the investigation. A resident threatening another resident was an allegation of abuse. 8. During an interview on 11/18/24, at 2:25 P.M., the Assistant Director of Nursing (ADON) said if she observed a resident-to-resident altercation, she would separate the residents, then ask the residents what happened, obtain vital signs and complete a physical, if applicable and emotional assessment. She would also interview and obtain staff/witness statements, document the altercation/incident in the residents' nurses' notes, complete an incident report, notify the DON, physician, and resident's family. The DON notified the state agency. The ADON said she heard from the DON this morning, that Resident #1 and Resident #2 got into an argument around smoke break, sometime this last weekend. Resident #2 said Resident #1 was verbally aggressive because he/she did not have any cigarettes. Staff thought the weekend charge nurse notified hospice of the incident but hospice staff did not know about it until they visited the facility today. They called the police. 9. During an interview on 11/20/24, at 12:35 P.M., the DON said the following: -The incident over the weekend between Resident #1 and Resident #2 was not an allegation of abuse; -The residents were separated, put on 15-minute checks, the doctor was notified and new orders were given.

Based on observation, interview, and record review, the facility failed to ensure an environment that remained as free of possible hazards as possible when one resident (Resident #4) was found to have marijuana and unknown pills on their person and in their room. The facility also failed to educate staff and implement interventions to prevent future occurrences for the resident. The facility census was 28. Review of the facility's policy titled Incident/Accident Policy, dated 07/15/99, showed the following: -Document any incident occurring out of the normal, to any resident, employee, or visitor. When an incident occurs with a resident, employee or visitor, there should be an incident report made out as to name, what occurred, and if any injury was noted. If the incident occurred with a resident, be sure to put on the incident report exactly how staff found the resident, what injury staff found on the resident, and who staff notified such as physician, family, or any other responsible party; -Take the white copy to the Director of Nursing (DON) and the yellow copy to the Administrator's desk; -Note incident on charge sheet and pass it on to the other shifts; -Notify physician and family within 24 hours unless life threatening injury, then notify immediately. Review of the facility's policy titled Smoking Policy, dated 03/21/22, showed the following: -All residents who smoke must sign an agreement with the facility stating that they understand the risk and agree with this policy; -Staff are to report any unsafe practices by the resident; -If smoking materials are found in the resident's room, they will be placed behind the nurses' station. Explaining the importance of following these policies that are set out for their safety at this time; -These policies are a guideline to keep the staff and the residents in a safe environment and reduce the number of harmful outcomes. Residents may have a care plan meeting with staff to accommodate their needs and wants. Review of the facility's policy titled Storage of Medications, undated, showed it was the policy of the facility that drugs and biologicals be stored in a safe, secure, and orderly manner. 1. Review of Resident #4's face sheet (resident's information at a quick glance) showed the following: -admitted to facility on 8/20/24; -Diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer), secondary malignant neoplasm of brain (a brain tumor that occurs when cancer cells spread from another part of the body to the brain), chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe). Review of the resident's admission plan of care, dated 8/20/24, showed staff did not document the resident was a smoker. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 08/26/24, showed the resident was cognitively intact. Review of the resident's care plan, updated 10/07/24, showed staff did not document the resident was a smoker. Review of a facility investigation, dated 11/12/24, showed the following: -The Social Service Director's (SSD) handwritten statement showed the resident was found with marijuana on his/her person and in his/her room. State was notified. Please see statements for complete details. -The SSD provided the following statement: The resident said that he/she had never smoked marijuana with another resident, but he/she did smoke marijuana by himself/herself outside of the facility (but still on facility grounds). When the resident was asked where he/she got the marijuana from, the resident said he/she brought it from his/her house. The Administrator and SSD asked the resident if they could search the resident's person for any contraband and resident agreed. Several contraband items as well as medication pills were discovered during the search. The confiscated items found were given to the Administrator. SSD then asked the resident if she could search his/her room and consent was given. Upon search with SSD and Business Office Manager (BOM), there was other contraband found and removed from the resident's room and placed in the Administrators' office. -Statement from the resident, undated, showed I have smoked marijuana a few times here. I smoked it today. I got from my house. I got vape pens. I have cancer and you're only giving me Tylenol. I smoked a joint. I used the vape today. I haven't smoked it with anyone else. Review of the resident's nurses' notes, dated 11/12/24, showed the following: -The DON spoke with the Nurse Practitioner (NP) about the resident smoking marijuana and having vape pen. The NP stated she knew for a while the resident had been smoking. The NP said no medications needed to be held. -The DON educated the resident on the risk of smoking marijuana. (Staff did not document finding medication pills on the resident's person.) Review of a Medication Destruction Record, dated 11/12/24, showed the following: -Two THC vape pens, belonging to the resident, destroyed using drug buster by the DON and Licensed Practical Nurse (LPN) D; -One THC vape liquid refill, belonging to the resident, destroyed using drug buster by the DON and LPN D. During an interview on 11/18/24, at 1:21 P.M., Resident #2 said the following: -Resident #2 saw the resident smoking a marijuana joint a couple of times at the corner of the building; -Resident #2 said he had been outside and could smell marijuana on the resident. During interviews on 11/18/24, at 3:15 P.M., and 11/20/24, at 12:03 P.M., the SSD said the following: -During a facility investigation, the resident told the SSD and former Administrator he/she did smoke marijuana while a resident at the facility. He/She did not smoke inside his/her room. -The BOM searched the resident's room, with the resident's permission, and found an inhaler, two vape pens, one bottle of marijuana concentrate, and baggie that contained unmarked pills. -The resident said he/she did not smoke in the facility. Staff let him/her outside, where he/she smoked the marijuana. The SSD said she never saw the resident go outside. -The resident said he/she brought the vape cartridges and bottle from home. She knew the vape pen contained marijuana because it smelled like marijuana. She never smelled marijuana on the resident or in his/her room. -The staff told the resident he/she could not have these items in his/her room and took the items from the resident and gave them to the former Administrator. -The SSD did not know what pills were in the baggie or where the baggie came from. She did not ask the resident. -The SSD said the word contraband in her written statement dated 11/12/24 meant pills. During an interview on 11/18/24, at 3:34 P.M., the resident said the following: -The resident allowed administration to search his/her person, which included his/her purse; -The resident said that he/she had three marijuana vape pens and a couple of marijuana roaches (the remains of a joint after most of it has been smoked); -The resident said that he/she would smoke the marijuana joints behind the building; -The resident said she smoked marijuana to help with pain relief because of her cancer; -The resident said that he/she had two Ziploc bags of pills in his/her purse when he/she was searched; -The resident said one small Ziploc bag had pills the facility had given him/her when he/she went on a leave of absence with his/her family. The resident said he/she for got to take the medicine and was going to keep the medication for the next time he/she went out; -The resident forgot to tell staff that he/she had the pills; -The resident said the other bag contained Tylenol and Tylenol PM pills; -The resident said that he/she got the Tylenol while he/she was on a leave of absence. During an interview on 11/20/24, at 10:44 A.M., Certified Nurse Assistant (CNA) A said the following: -The resident doesn't vape or smoke; -The resident went outside with the smokers three weeks ago and was smoking a marijuana joint, staff smelt it; -Any medication found on a resident's person or in a resident's room should be turned over to the charge nurse; -No residents should have over the counter medication in the their room; -He/she was not aware of the resident having any medication on his/her person; -The residents were not allowed to have marijuana at the facility; -The residents were not allowed to have vape pens on their person or in their rooms. During an interview on 11/20/24, at 10:58 A.M., Nurse Assistant (NA) B said the following: -The resident vaped nicotine every now and then; -He/she would turn any pills found on a resident to the nurse; -He/she was not aware of any medication or marijuana being found on the resident. During an interview on 11/20/24, at 12:15 P.M., Licensed Practical Nurse (LPN) C said the following: -Residents are not allowed to have marijuana at the facility; -He/she was not aware of any residents being found with marijuana on their person or in their room; -No residents should have medications in their rooms; -Medication found in a resident's room or on their person should be turned over to nursing; -He/she did not know that the resident had any medication on her person. During an interview on 11/20/24, at 12:35 P.M., the Director of Nursing (DON) said the following: -The DON was not fully involved in the facility investigation when medication was found on the resident; -He/she destroyed two marijuana vape pens and liquid marijuana refill in drug buster; -The vape pens and refill belonged to the resident; -If any staff or residents found/smelt marijuana they should report to the registered nurse (RN) or DON immediately; -He/she identified the medication found on resident as Tylenol and Advil; -Information regarding the resident having medication/marijuana on his/her person should have been shared with the staff. MO00245077

Based on observation, interview, and record review, the facility failed ensure each resident received needed behavioral health care when the facility failed to develop and implement resident specific nonpharmalogical interventions for one resident (Resident #1) who exhibited signs and symptoms of psychosocial distress. The facility's census was 28. Review of the facility's Treatment/Services for Mental/Psychosocial Concerns Policy, undated, showed the following: -The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. -The facility will ensure that, a resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable. -The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Review of the facility's policy Behavior and Psychoactive Management Program, undated, showed the following: -The facility believes that all resident behavior has meaning. It is the pledge of the facility to work to identify the cause and meaning of behaviors that are distressing and affect negatively on the resident's quality of life. The facility will work diligently to minimize the use of psychoactive medications in its resident population. -The facility's behavior monitoring management program will consist of: an effective lnterdisciplinary Behavior Management Committee; ensuring a thorough and comprehensive assessment of the resident's needs, behaviors, and prior medication and medical history; monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency, and Identifying the specific (targeted) behavior(s) that are distressing to the resident which are decreasing the resident's quality of life. -Planning and implementing appropriate Interventions into the resident's plan of care. -Evaluating the effectiveness of pharmacological and non-pharmacological Interventions. -Purpose was to implement the most desirable and effective interventions that meet both the known and unknown needs of the resident, to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or Impacting on the resident's quality of life. -The Behavior Management Committee will ensure that the facility staff provide effective monitoring to include evaluating resident's progress towards achieving therapeutic goals and recognizing when adverse consequences may be may be or have already emerged. -The Behavior Management Committee will consist of at least the following: Director of Nursing (DON)/designee, social services, consulting pharmacist, nurse manager(s), activity department representative, and dietary representative (As determined by committee). The committee chair will be the Director of Social Services (SSD). 1. Review of Resident #1's face sheet (a brief summary of the resident's history) showed the following: -Readmitted [DATE]; -Diagnoses included anxiety disorder, dysthymic disorder (a mild, but long-lasting form of depression; also called persistent depressive disorder), depression, history of suicidal ideation, and insomnia. Review of the resident's November 2024 physician order sheet showed the following: -An order, dated 06/07/22, for buspirone (an antianxiety/sedative medication), 10 milligrams (mg), one tablet two times a day for anxiety disorder; -An order, dated 11/16/23, for escitalopram (an antidepressant), 20 mg, one tablet every day for anxiety disorder. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/10/24, showed the following: -Usually understood others; -Moderately impaired vision; -Cognitively intact; -Little interest or pleasure in doing things: Yes. Symptom frequency: 12-14 days (nearly every day); -Felt down, depressed, or hopeless: Yes. Symptom frequency: 2-6 days (several days); -Trouble falling or staying asleep, or sleeping too much: Yes. Symptom frequency: 12-14 days (nearly every day); -Feeling tired or having little energy: Yes. Symptom frequency: 12-14 days (nearly every day); -Poor appetite or overeating: Yes. Symptom frequency: 12-14 days (nearly every day); -Feeling bad about yourself-or that you are a failure or have let yourself or your family down: Yes. Symptom frequency: 12-14 days (nearly every day); -Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual: Yes. Symptom frequency: 2-6 days (several days); -Patient Health Questionnaire (PHQ-9- a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) total severity score equaled 17 which indicated moderately severe depression; -No behavioral symptoms; -No rejection of care; -Took antidepressant medication; -Took antianxiety medication. Review of the resident's submitted MDSs showed no MDS after 7/10/24. Review of the resident's nurse progress notes showed a nurse documented the following: -On 07/12/24, at 7:45 P.M., the resident went to the nurses' station yelling and demanding to go to bed. He/she did not want staff waiting or assisting someone else. Staff tried to be appropriate with the resident, but he/she kept pushing and getting louder. The resident told staff that when he/she needed them, they should come on his/her command. Staff attempted to explain that there were multiple residents to care for, and they could not come on his/her demand. Staff said that he/she needed to stop being disrespectful to staff, and they were there to assist him/her. The resident said he/she would keep doing it as it gets him/her what he/she wanted. -On 07/13/24, at 8:00 P.M., the resident yelled that he/she wanted up. At 6:00 P.M., the resident went out to smoke and yelled that he/she wanted to go to bed. -On 07/14/24, at 11:00 A.M., the resident was up for smoke breaks, but otherwise spent the day in his/her room. The resident had not yelled at staff that shift. The resident remained quiet and continue to refuse oxygen. -On 07/14/24, at 8:30 P.M., the resident was totally angry at the world. He/she was angry, rude, and disrespectful with no empathy for anyone around. He/she was mean and had a cursed response to everything. The resident was uncooperative with staff when they attempted to assist him/her to transfer. -On 07/16/24, at 3:40 A.M., the resident was up at the beginning of the shift being rude because nobody would assist him/her to bed. He/she kept saying staff were doing it on purpose. -On 07/19/24 at 9:00 P.M., the resident exhibited no physical behaviors, just putting peers down. The resident was nice to some staff at times, and at times was quiet. -On 07/20/24, at 2:30 P.M., the resident had been verbally abusive to staff. Resident wanted someone to take him/her out to smoke. -On 07/20/24, untimed, the resident laid in bed at screaming for help, when staff answered he/she said he/she wanted to get up to smoke. Staff assisted the resident and took him/her outside for a smoke break. The resident refused his dinner tray. -On 07/23/24, at 9:40 P.M., the resident yelled because staff did not put him/her into bed quickly after his/her request. Staff did their best, but the resident was still unhappy at times. Review of the resident's November 2024 Physician Order Sheet (POS) showed an order, dated 07/24/24, for lorazepam (a sedative/hypnotic/antianxiety medication), 0.5 mg, one tablet three times a day for anxiety/agitation. Review of the resident's nurse progress notes showed a nurse documented the following: -On 07/24/24, at 10:30 A.M., the physician wrote an order to increase the resident's lorazepam to three times a day. -On 07/25/24, at 6:30 P.M., the resident transferred himself/herself into a wheelchair and went out to smoke. The resident yelled wanting staff to assist him/her into bed, although he/she could transfer himself/herself. -On 07/31/24, at 8:00 P.M., the resident yelled out if staff did not get him/her up or down immediately. He/she cursed at staff as well. He/she went out to smoke breaks. Review of the resident's November 2024 POS showed an order, dated 8/1/24, for trazodone (an antidepressant medication), 50 mg, one tablet at bedtime for insomnia. Review of the resident's nurse progress notes showed a nurse documented the following: -On 08/01/24, at 9:30 P.M., the nurse practitioner saw the resident and wrote an order to decrease his/her trazodone to 50 mg at bedtime due to increased sleeping. -On 08/03/24, at 10:00 A.M., while smoking, staff heard the resident say nobody liked him/her and he/she might as well commit suicide. Staff assisted the resident to the nurses' station and he/she requested to go to his/her room. Staff initiated 15-minute checks for 24 hours for suicide precautions, notified the DON and hospice, and faxed the information to the clinic. Hospice staff and hospice said they would visit the resident. -On 08/03/24, at 2:00 P.M., staff found the resident on the floor. The resident said he/she tried to get up to his/her wheelchair unassisted. The nurse told the resident previously to use the call light and not to get up without help. The nurse also talked to the resident about his/her thoughts of suicide and asked if he/she had a plan. The resident said his/her plan. The nurse reminded the resident if he/she continued to speak of suicide, that he/she would possibly be moved to a locked unit and explained that for his/her safety, staff checked on him/her every 15-minute checks and would monitor his/her behavior. -On 08/03/24, at 4:00 P.M., the hospice nurse visited the resident. The resident told the hospice nurse that he/she was no longer suicidal. -On 08/05/24, at 11:00 A.M., a hospice social worker notified the DON that the resident made homicidal statements. The DON, facility social worker, and hospice nurse entered the resident's room. The resident said he/she wanted to hurt others with the intent to kill them. Affidavits were completed and notarized. Staff notified the physician and called 911. Staff placed the resident on one-on-one observations. -On 08/05/24, at 1:00 P.M., emergency services and police arrived at the facility. The resident went with EMS voluntarily to the hospital for evaluation. The notarized affidavits were sent with them. -On 08/05/24, at 8:00 P.M., the nurse from the hospital called the facility said they completed a psych evaluation and decided they had no grounds to admit the resident and he/she would return to the facility. Staff notified the DON who told staff to initiate 15-minute checks and behavioral charting. -On 08/14/24, at 11:00 A.M., the resident was very rude to staff with inappropriate and demanding behavior. He/she said the facility was the worst place he/she had ever been. -On 08/15/24, at 12:50 A.M., staff reported to the nurse that on 08/13/24 the resident made inappropriate comments to the staff. They finished assisting the resident and left the room. Review of the resident's social service progress notes, dated 8/26/24, showed the previous SSD documented following: -On 8/26/24, no time documented, the resident expressed his/her unhappiness with the SSD. The SSD asked the resident if he/she wanted to move to another city as previously discussed, and the resident said yes, he/she was tired living at the (current) facility. -On 8/27/24, no time documented, the SSD reviewed a list of facilities in the area of the state the resident preferred, and submitted packets to two facilities for review. (The SSD did not document any information regarding the resident's behaviors or further information regarding the referrals.) Review of the resident's nurse progress notes showed a nurse documented the following: -On 09/03/24, at 8:15 P.M., the resident was verbally abusive to staff when staff attempted to meet his/her needs. Staff assisted the resident to bed multiple times. Staff reported the resident called him/her a name when he/she tried to explain that he/she was assisting other residents and that they just assisted him/her to bed. The resident turned on his/her call light several times to get staff to come to his/her room to assist him/her and then became agitated and rude when staff attempted to explain, there was more than just him/her who needed attention. On 09/04/24, at 9:00 P.M., the resident sat at the front of the facility being negative to staff. The resident said he/she did not know why everybody was so sensitive. The nurse explained that some words are hurtful to some people and that was why we should be careful how we speak to others. The resident was more understanding but remained negative. -On 09/05/24, at 11:00 P.M., staff reported the resident was rude when they entered his/her room to assist him/her. The resident pushed against staff when they tried to turn him/her. He/she would put his hands against the wall then say staff did it. Staff tried to explain that when he/she pushed against them, it made it difficult for them to move him/her. He/she accused staff of not knowing how to do their job. Review of the resident's physician progress note, dated 9/11/24, included the following information: -The resident was seen for a routine 90-day physician visit. -Since the last visit, the resident continued to lose weight, developed ascites (a condition that occurs when fluid collects in spaces in the belly (abdomen)), refused baths and supplemental Oxygen despite Oxygen saturation (the measure of how much oxygen is traveling through the body in red blood cells. Normal oxygen saturation for healthy adults is usually between 95% and 100%) around 87%. -Reports are that he/she did not wish to know about his/her physical condition. -The resident had a 25-pound weight loss over the past several months. ` -Staff reported the resident exhibited excessive sleeping and not getting up for some meals. -The resident continued to go outside for smoke breaks. -Depression: The resident appeared to have worsening depressive symptoms related to his/her vision loss due to glaucoma (a term for diseases that cause eye pressure to increase, leading to permanent vision loss), and decline in overall health. -The resident received hospice services. -The resident exhibited irritable mood and affect. Review of the resident's nurse progress notes showed a nurse documented the following: -On 09/16/24, at 7:50 P.M., staff assisted the resident to bed, but he/she refused to allow staff to change his/her clothes. -On 09/21/24, at 5:00 A.M., the resident refused to allow staff to check him/her for incontinence. -On 10/01/24, at 4:00 P.M., at the beginning of the shift, the resident sat in his/her wheelchair. The resident asked to smoke before the scheduled time and started to yell. -On 10/03/24, at 10:30 P.M., the resident yelled at staff while he/she attempted to assist him/her to bed. The resident told the staff member to get out of the room. The staff reported the behaviors to the nurse. The resident told the nurse the staff member refused to help him/her. The staff again attempted to assist the resident to bed, and he/she refused. At the time of the note, the resident sat in his/her wheelchair in his/her room. -On 10/08/24, at 3:20 P.M., the resident yelled and cursed at staff. Staff offered to assist the resident and he/she refused while yelling, calling staff names, and yelling for staff to get out of his/her room. The resident said he/she would rather be incontinent and make staff clean him/her. -On 10/08/24, at 4:30 P.M., the resident yelled at nursing staff and said he/she would kill them, would punch them, and he/she hated them. The resident said he/she would call the police. Staff continued to assist the resident into bed per his/her request and left the room. Review of the resident's care plan, last reviewed on 10/8/24, showed the following: -The resident used antidepressant and antianxiety medication related to depression, anxiety and insomnia. -Administer antidepressant medications as ordered. -Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc). -Monitor/record/report to the physician as needed, acute (short term) episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns. -Monitor/record/report to physician as needed, signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. -Monitor/document/report as needed, any signs and symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health related complaints, tearfulness. -Consult with pastoral care, social services, psych services, etc. as needed. -When conflict arises, remove residents to a calm, safe environment and allow to vent/share feelings. -The resident had a terminal prognosis. -Assess the resident's coping strategies and respect the resident's wishes. -Encourage the resident to express feelings, listen with non-judgmental acceptance and compassion. Review of the resident's nurse progress notes showed a nurse documented the following: -On 10/23/24, at 8:30 P.M., the resident yelled while in his/her room. Staff entered the room and found the resident on the floor. Staff assisted the resident to bed. The resident refused to stand for staff. The resident was uncooperative and cursed and yelled at staff upon assessment. -On 10/24/24, at 9:00 P.M., the resident refused to allow staff to change his/her wet clothes. The resident was very rude to staff this shift. The resident laid in bed with soaked pants. -On 10/26/24, at 9:00 P.M., the resident yelled a lot and called staff names. -On 10/29/24, at 4:15 A.M., the resident was incontinent and refused for staff to clean him/her or place clean linens on his/her bed. The resident told staff to get out of his/her room and leave him/her alone. -On 11/02/24, at 12:30 A.M., the hospice nurse came to the desk and asked the nurse if the previous shift reported the resident had a fall. -On 11/02/24, at 1:30 A.M., staff said the charge nurse did not report the fall because that nurse thought the fall was a behavior. -On 11/04/24, at 9:00 P.M., the resident often refused to change clothes or receive incontinent care. -On 11/05/24, at 9:30 P.M., the resident refused to have staff change his/her clothes unless they applied a new a brief and pants. -On 11/08/24, at 9:00 P.M., the resident refused to allow staff to check him/her for incontinence. -On 11/08/24, at 11:00 P.M., the resident refused to allow staff to change his/her clothing. They would attempt later. -On 11/10/24, at 4:00 A.M., staff was finally able to change the resident after several attempts through the night. However, the resident yelled and cursed the entire time the aide was in the room. -On 11/12/24, at 2:00 A.M., the resident refused to allow staff to change him/her. -On 11/12/24, at 5:00 A.M., the resident continued to refuse staff changing him/her, multiple attempts were made. -On 11/16/24, at 8:00 P.M., the resident went outside for a smoke break at 7:00 P.M. The resident became aggressive and told another resident he/she was sitting in his/her spot. Staff intervened but the resident continued to curse and yell at two other residents. The resident mumbled, as a staff assisted the resident back inside, that he/she was going to bash someone's head with a hammer. Staff redirected the resident, and the residents were separated. Staff assisted the resident to bed. No harm was done to any residents involved. Staff notified the DON and Medical Director who gave orders for labs. Staff initiated 15-minute checks as well as 72 hour incident charting for verbal aggression. Staff searched the resident's room and found no hammer. Review of the resident's November 2024 POS showed an order, dated 11/16/24, for a urinalysis (a test of the urine to check for infection), complete blood count (a blood test that measures the number and types of cells), basic metabolic panel (a group of blood tests that provides information about your body's metabolism), ammonia level and a urine drug screen due to aggressive behaviors. Review of the resident's care plan showed on 11/16/24, staff added the resident was verbally aggressive, cursing, threatening peer, and staff redirected. Fifteen-minute checks were initiated and a new order received by physician. Review of the resident's nurse progress notes showed a nurse documented the following: -On 11/17/24, at 9:00 A.M., a nurse documented that at 8:30 A.M., the resident was outside on smoke break, and was verbally aggressive and instigating other residents. Staff immediately intervened. Residents were moved to opposite ends of the smoking area and supervised by staff. The resident remained on 15-minute checks and 72-hour charting for aggressive behaviors. After smoking, the staff brought the residents inside and assisted the resident to bed per his/her request. -On 11/17/24, at 1:00 P.M., while the resident waited at the nurses' station for smoke break, the resident started an argument with another resident. A second resident intervened and told Resident #1 to stop and leave the other resident alone. Staff immediately intervened and redirected all parties. When staff took the residents to smoke, Resident #1 told the first resident to hurry up and the second resident again said to stop. Resident #1 then cursed at the second resident. Staff separated the residents in the smoking area and educated Resident #1 on appropriate behaviors. Resident #1 stopped after staff redirected him/her two times. -On 11/17/24, at 1:40 P.M., staff attempted to draw blood for the ordered laboratory test. The resident cursed at staff and said that he/she would never allow staff to draw blood again. He/she was fine. The nurse discussed with the resident the importance of the laboratory tests. The resident refused at first, but then allowed staff to draw his/her blood. The resident cursed while staff drew the blood saying he/she did not need it. -On 11/17/24, at 2:20 P.M., the nurse notified the physician's clinic at 2:00 P.M. and left a message for the nurse practitioner to address the resident's behaviors as the behaviors were progressing. The nurse called the Medical Director regarding the resident's continued behaviors, escalation, and threats. The physician ordered Depakote (a mood stabilizer medication that works in the brain), 250 mg two times a day for agitation and behaviors. The physician also said if the resident continued to exhibit behaviors, staff should call the police to have the resident removed. The nurse notified the interim DON of the resident's behaviors and physician orders. The nurse notified the resident of the new orders. The resident said he/she would not take the (new) medication. The nurse educated the resident on the right to refuse, but they (the staff) had to notify him/her of any new orders since he/she was his/her own responsible party. The resident became agitated and said he/she hated the facility and the person in the front office. Staff educated the resident on the right to leave the facility or an option to speak with a social worker to arrange for discharge and transportation. Resident also educated on appropriate behaviors at smoke breaks and the physician order that if his/her behaviors and threats continued, staff should call the police to remove him/her from the facility. The resident placed his/her right pointer finger in the air and moved it in a circle and said oh well. Educated the resident to not make threats to other residents to maintain all residents' safety. Resident said oh yeah, they sent you and the other staff member to do their job. Educated the resident that the staff educating the resident was their job. The resident continued to curse and said who told you that and made a derogatory term towards another resident. Again, the nurse educated the resident that staff reported his/her behaviors at smoke break. Resident said oh well and again pointed his/her finger in the air and moved it in a circular motion. The nurse talked again with resident regarding appropriate behaviors and of not threatening others. -On 11/17/24, at 2:40 P.M., the resident turned on his/her call light wanting to go smoke. Staff noted the resident was out of cigarettes. Staff notified the resident that he/she was out, and the resident began cursing and said the staff just kept coming into his/her room and giving him/her bad news. The nurse educated the resident that they just wanted to let him/her know that he/she did not have any cigarettes before he/she went to the nurses' station and exhibited behaviors. The resident again yelled he/she hated this place and that he/she may leave tonight. The nurse educated the resident and notified the social worker that the resident was out of cigarettes via a note on her office door. The resident said someone would give him/her cigarettes, or else. Discussed with resident appropriate behavior and threats and reminded him/her of the physician orders. The resident said he/she did not care, and staff better get him/her a cigarette. The nurse again reminded the resident of appropriate behavior. The resident continued to yell and curse. The nurse asked the resident to calm down. -On 11/17/24, at 2:50 P.M., the nurse reminded the resident of appropriate behavior prior to smoking and gave the resident two cigarettes. -On 11/17/24, at 6:00 P.M., the resident went to the kitchen door and asked dietary staff for cigarettes. Dietary staff said they did not smoke, and the resident yelled and cursed at the staff. Dietary staff notified the charge nurse of the resident's cursing. The resident continued to ask staff for cigarettes. -On 11/17/24, at 6:45 P.M., the resident sat at the nurses' station asking the resident from a previous incident, for a cigarette. The other resident said no, you treated me terribly and walked away. Resident cursed and sat in his/her wheelchair at the nurses' station. Review of the resident's November 2024 physician order sheet showed the following: -An order, dated 11/17/24, for Depakote (a mood stabilizer medication that works in the brain), 250 mg, two times a day for increased agitation/behaviors. -An order, dated 11/17/24, if behaviors continue, call the police to have the resident removed. Review of the resident's care plan showed on 11/17/24, staff added to the care plan, the resident exhibited increased behaviors and agitation with threats to peers. The physician ordered Depakote 250 mg, two times a day and to call the police to have the resident removed if behaviors continued. Review of the resident social services progress notes on 11/18/24 showed no progress notes documented after 08/27/24. During an interview conducted on 11/18/24, at 2:10 P.M., Nurse Aide (NA) J said if he/she observed residents arguing, he/she would defuse and deflect the situation. He/she would separate the residents and notify the nurse. The resident was vocal and vulgar. He/she was inappropriate, at times, towards female staff. The resident verbally assaulted him/her (the aide) several times. It seemed that as the resident's abilities decreased, his/her behaviors increased. His/her behaviors were constant. Sometimes his/her outbursts were directed towards other residents. He/she tended to become upset around smoking time. He/she cursed at staff, would say he/she hated this place, and got loud. When staff took him/her to smoke, he/she stopped. The staff assisted the residents outside to smoke eight times a day. The resident did not normally get upset with the other two residents who smoked with him/her. The aide did not know of any verbal altercations between residents which occurred over the weekend. During an interview conducted on 11/18/24, at 2:25 P.M., the Assistant Director of Nursing (ADON) said the following: -If she observed a resident-to-resident altercation, she would separate the residents, ask the residents what happened, obtain vital signs, complete a physical, if applicable, and emotional assessment. She would also interview and obtain staff/witness statements, document the altercation/incident in the residents' nurses' notes, complete an incident report, and notify the DON, physician and residents' family. The DON notified the state agency. -The ADON heard from the DON this morning, that sometime this last weekend, Resident #1 and Resident #2 got into an argument around smoke break. Resident #2 said Resident #1 was verbally aggressive because he/she did not have any cigarettes. The ADON thought there was only one incident between the two residents. -About six months ago, staff called the police per physician instructions, and took the resident to the hospital for an evaluation and 96-hour hold due to statements of wanting to hurt others. The hospital did not keep the resident because the resident was alert and oriented and refused services. When the resident returned, staff placed him/her on 15-minute checks and the physician changed his/her medication. -The resident had a history of verbal altercations, outbursts, and being hateful. His/her anger generally started when he/she ran out of cigarettes. The Business Office Manager (BOM) or SSD bought residents' cigarettes. The resident ran out of cigarettes weekly. And when asked about why he/she ran out, the resident would blame running out on someone else. -Not all of the resident's anger came from no cigarettes, sometimes he/she yelled at staff and would say staff refused to assist him/her even when staff did not. The resident's behaviors were consistent and did not occur on any specific shift or with any specific staff member. -The physician recently changed the resident's medications. -The ADON did not think the resident spoke with or had psychological services. The facility did not have a contract with any psychologists, and none visited the facility. -If a resident asked to speak to a psychologist, the nurse contacted the physician and obtained an order for a referral for services. The facility and/or physician did not have a specific clinic they referred to. During an interview on 11/18/24, at 3:15 P.M., the SSD said the following: -She worked at the facility as the SSD for about two months. Her duties included resident discharges and discharge planning, admissions, assisting with grievances, assisting with the MDS and care plans, contacting the ombudsman as needed, and talking to residents per their request. -Whether or not the SSD assisted with behavior management depended on the situation. -If a resident exhibited any type of behaviors, the nurses documented the behaviors in the nurses' notes. The SSD talked to residents if they seemed upset. -Staff should tell the SSD if a resident exhibited behaviors. If staff told the SSD of behavioral issues, he/she would talk to the resident. -Recently (unknown time), she asked the resident about his/her edginess. The resident told her that staff did not listen to him/her and he/she hated the facility. The resident did not tell the SSD he/she wanted to leave therefore she did not send referral to any other facilities. The SSD did not ask the resident if he/she wanted to leave after he/she said he/she hated the facility. Most of the time the SSD documented conversations she had with residents, but t

Based on observation, interview, and record review, the facility failed to provide appropriate medically related social services for one resident (Resident #1) who had a history of depression, when the Social Services Designee (SSD) did not address or assist with finding the root cause of the resident's yelling and cursing behaviors, refusal of cares, and general unhappiness living at the facility. The facility census was 28. Review of the facility's Treatment/Services for Mental/Psychosocial Concerns Policy, undated, showed the following: -The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; -The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Review of the facility's policy Behavior and Psychoactive Management Program, undated, showed the following: -The facility believes that all resident behavior has meaning. It is the pledge of the facility to work to identify the cause and meaning of behaviors that are distressing and affect negatively on the resident's quality of life. -The facility's behavior monitoring management program will consist of an effective Interdisciplinary Behavior Management Committee; ensuring a thorough and comprehensive assessment of the resident's needs, behaviors, and prior medication and medical history; monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency; and identifying the specific (targeted) behavior(s) that are distressing to the resident which are decreasing the resident's quality of life. -Planning and implementing appropriate interventions into the resident's plan of care. -Purpose to implement the most desirable and effective interventions that meet both the known and unknown needs of the resident, to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or Impacting on the residents' quality of life. -The Behavior Management Committee will ensure that the facility staff provide effective monitoring to include evaluating resident's progress towards achieving therapeutic goals and recognizing when adverse consequences may be may be or have already emerged. -The Behavior Management Committee will consist of at least the following: Director of Nursing (DON)/designee, social services, consulting pharmacist, nurse manager(s), activity department representative, and dietary representative (as determined by committee). The committee chair will be the SSD. 1. Review of Resident #1's face sheet (a brief summary of the resident's history) showed the following: -Readmitted [DATE]; -Diagnoses included anxiety disorder, dysthymic disorder (a mild, but long-lasting form of depression; also called persistent depressive disorder), depression, history of suicidal ideation, and insomnia. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/10/24, showed the following: -Usually understood others; -Moderately impaired vision; -Cognitively intact; -Little interest or pleasure in doing things: Yes. Symptom frequency: 12-14 days (nearly every day); -Felt down, depressed, or hopeless: Yes. Symptom frequency: 2-6 days (several days); -Trouble falling or staying asleep, or sleeping too much: Yes. Symptom frequency: 12-14 days (nearly every day); -Feeling tired or having little energy: Yes. Symptom frequency: 12-14 days (nearly every day); -Poor appetite or overeating: Yes. Symptom frequency: 12-14 days (nearly every day); -Feeling bad about yourself-or that you are a failure or have let yourself or your family down: Yes. Symptom frequency: 12-14 days (nearly every day); -Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual: Yes. Symptom frequency: 2-6 days (several days); -Patient Health Questionnaire (PHQ-9- a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) total severity score equaled 17 which indicated moderately severe depression; -Took antidepressant medication; -Took antianxiety medication. Review of the resident's submitted MDSs showed no MDS after 07/10/24. Review of the resident's social service progress notes, dated 8/26/24, showed the previous Social Services Designee (SSD) documented following: -On 08/26/24, no time documented, the resident expressed his/her unhappiness with the SSD. The SSD asked the resident if he/she wanted to move to another city as previously discussed, and the resident said yes, he/she was tired living at the (current) facility. -On 08/27/24, no time documented, the SSD reviewed a list of facilities in the area of the state the resident preferred, and submitted packets to two facilities for review. (The SSD did not document any information regarding the resident's behaviors or further information regarding the referrals.) Review of the resident's nurse progress notes showed a nurse documented the following: -On 09/16/24, at 7:50 P.M., staff assisted the resident to bed, but he/she refused to allow staff to change his/her clothes. -On 09/21/24, at 5:00 A.M., the resident refused to allow staff to check him/her for incontinence. -On 10/01/24, at 4:00 P.M., at the beginning of the shift, the resident sat in his/her wheelchair. The resident asked to smoke before the scheduled time and started to yell. -On 10/03/24, at 10:30 P.M., the resident yelled at staff while they attempted to assist him/her to bed. The resident told the staff member to get out of the room. The staff reported the behaviors to the nurse. The resident told the nurse the staff member refused to help him/her. The staff again attempted to assist the resident to bed, and he/she refused. At the time of the note, the resident sat in his/her wheelchair in his/her room. -On 10/08/24, at 3:20 P.M., the resident yelled and cursed at staff. Staff offered to assist the resident and he/she refused while yelling, calling staff names, and yelling for staff to get out of his/her room. The resident said he/she would rather be incontinent and make staff clean him/her. -On 10/08/24, at 4:30 P.M., the resident yelled at nursing staff and said he/she would kill them, would punch them, and he/she hated them. The resident said he/she would call the police. Staff continued to assist the resident into bed per his/her request and left the room. Review of the resident's care plan, last reviewed on 10/8/24, showed the following: -The resident used antidepressant and antianxiety medication related to depression, anxiety and insomnia. -Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc); -Monitor/record/report to physician as needed, signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. -Monitor/document/report as needed, any signs and symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health related complaints, tearfulness. -Consult with pastoral care, social services, psych services, etc. as needed. -When conflict arises, remove residents to a calm, safe environment and allow to vent/share feelings. -The resident had a terminal prognosis. -Assess the resident's coping strategies and respect the resident's wishes. -Encourage the resident to express feelings, listen with non-judgmental acceptance and compassion. Review of the resident's nurse progress notes showed a nurse documented the following: -On 10/23/24, at 8:30 P.M., the resident yelled while in his/her room. Staff entered the room and found the resident on the floor. Staff assisted the resident to bed. The resident refused to stand for staff. The resident was uncooperative and cursed and yelled at staff upon assessment. -On 10/24/24, at 9:00 P.M., the resident refused to allow staff to change his/her wet clothes. The resident was very rude to staff this shift. The resident laid in bed with soaked pants. -On 10/26/24, at 9:00 P.M., the resident yelled a lot and called staff names. -On 10/29/24 at 4:15 A.M., the resident was incontinent and refused for staff to clean him/her or place clean linens on his/her bed. The resident told staff to get out of his/her room and leave him/her alone. -On 11/4/24, at 9:00 P.M., the resident often refused to change clothes or receive incontinent care. -On 11/5/24, at 9:30 P.M., the resident refused to have staff change his/her clothes unless they applied a new a brief and pants. -On 11/8/24, at 9:00 P.M., the resident refused to allow staff to check him/her for incontinence. -On 11/8/24, at 11:00 P.M., the resident refused to allow staff to change his/her clothing. They would attempt later. -On 11/10/24, at 4:00 A.M., staff was finally able to change the resident after several attempts through the night. However, the resident yelled and cursed the entire time the aide was in the room. -On 11/12/24, at 2:00 A.M., the resident refused to allow staff to change him/her. -On 11/12/24, at 5:00 A.M., the resident continued to refuse staff changing him/her, multiple attempts were made. -On 11/16/24, at 8:00 P.M., the resident went outside for a smoke break at 7:00 P.M. The resident became aggressive and told another resident he/she was sitting in his/her spot. Staff intervened but the resident continued to curse and yell at two other residents. The resident mumbled, as a staff assisted the resident back inside, that he/she was going to bash someone's head with a hammer. Staff redirected the resident, and the residents were separated. Staff assisted Resident #1 to bed. Staff notified the DON and medical director who ordered laboratory tests. Staff initiated 15-minute checks as well as 72 hour incident charting for verbal aggression. Staff searched the resident's room and found no hammer. Review of the resident's care plan showed on 11/16/24, staff added the resident was verbally aggressive, cursing, threatening peer, staff redirected. Fifteen-minute checks were initiated, and a new order received by physician. Review of the resident's nurse progress notes showed a nurse documented the following: -On 11/17/24, at 9:00 A.M., a nurse documented that at 8:30 A.M., the resident was outside on smoke break, and was verbally aggressive and instigating other residents. Staff immediately intervened. Residents were moved to opposite ends of the smoking area and supervised by staff. The resident remained on 15-minute checks and 72-hour charting for aggressive behaviors. After smoking, the staff brought the residents inside and assisted Resident #1 to bed per his/her request. -On 11/17/24, at 1:00 P.M., while the resident waited at the nurses' station for smoke break, the resident started an argument with another resident. A second resident intervened and told Resident #1 to stop and leave the other resident alone. Staff immediately intervened and redirected all parties. When staff took the residents to smoke, Resident #1 told the first resident to hurry up and the second resident again said to stop. Resident #1 then cursed at the second resident. Staff separated the residents in the smoking area and educated Resident #1 on appropriate behaviors. Resident #1 stopped after staff redirected him/her two times. -On 11/17/24, at 1:40 P.M., staff attempted to draw blood for the ordered laboratory test. The resident cursed at staff and said that he/she would never allow staff to draw blood again. He/she was fine. The nurse discussed with the resident the importance of the laboratory tests. The resident refused at first, but then allowed staff to draw his/her blood. The resident cursed while staff drew the blood saying he/she did not need it. -On 11/17/24, at 2:20 P.M., the nurse notified the physician's clinic at 2:00 P.M. and left a message for the nurse practitioner to address the resident's behaviors as the behaviors were progressing. The nurse called the medical director regarding the resident's continued behaviors, escalation, and threats. The physician ordered a mood stabilization medication for agitation and behaviors. The physician also said if the resident continued to exhibit behaviors, staff should call the police to have the resident removed. The nurse notified the resident of the new orders. The resident said he/she would not take the (new) medication. The nurse educated the resident on the right to refuse, but they (the staff) had to notify him/her of any new orders since h/she was his/her own responsible party. The resident became agitated and said he/she hated the facility and the person in the front office. Staff educated the resident on the right to leave the facility or an option to speak with a social worker to arrange for discharge and transportation. Resident also educated on appropriate behaviors at smoke breaks and the physician order that if his/her behaviors and threats continued, staff should call the police to remove him/her from the facility. The resident placed his/her right pointer finger in the air and moved it in a circle and said oh well. Educated the resident to not make threats to other residents to maintain all residents' safety. Resident said oh yeah, they sent you and the other staff member to do their job. Educated the resident that the staff educating the resident was their job. The resident continued to curse and said who told you that and made a derogatory term towards another resident. Again, the nurse educated the resident that staff reported his/her behaviors at smoke break. Resident said oh well and again pointed his/her finger in the air and moved it in a circular motion. The nurse talked again with resident regarding appropriate behaviors and of not threatening others. -On 11/17/24, at 2:40 P.M., the resident turned on his/her call light wanting to go smoke. Staff noted the resident was out of cigarettes. Staff notified the resident that he/she was out, and the resident began cursing and said the staff just kept coming into his/her room and giving him/her bad news. The nurse educated the resident that they just wanted to let him/her know that he/she did not have any cigarettes before he/she went to the nurses' station and exhibited behaviors. The resident again yelled he/she hated this place and that he/she may leave tonight. The nurse educated the resident and notified the social worker that the resident was out of cigarettes via a note on her office door. The resident said someone would give him/her cigarettes, or else. Discussed with resident appropriate behavior and threats and reminded him/her of the physician orders. The resident said he/she did not care, and staff better get him/her a cigarette. The nurse again reminded the resident of appropriate behavior. The resident continued to yell and curse. The nurse asked the resident to calm down. -On 11/17/24, at 2:50 P.M., the nurse reminded the resident of appropriate behavior prior to smoking and gave the resident two cigarettes. -On 11/17/24, at 6:00 P.M., the resident went to the kitchen door and asked dietary staff for cigarettes. Dietary staff said they did not smoke, and the resident yelled and cursed at the staff. Dietary staff notified the charge nurse of the resident's cursing. The resident continued to ask staff for cigarettes. -On 11/17/24, at 6:45 P.M., the resident sat at the nurses' station asking the resident from a previous incident, for a cigarette. The other resident said no, you treated me terribly and walked away. Resident cursed and sat in his/her wheelchair at the nurses' station. Review of the resident's care plan showed on 11/17/24, staff added to the care plan, the resident exhibited increased behaviors and agitation with threats to peers. Review of the resident social services progress notes on 11/18/24 showed no progress notes documented after 08/27/24. During an interview conducted on 11/18/24, at 2:25 P.M., the Assistant Director of Nursing (ADON) said the following: -Sometime this last weekend, Resident #1 and Resident #2 got into an argument around smoke break, Resident #2 said Resident #1 was verbally aggressive because he/she did not have any cigarettes. -About six months ago, staff called the police per physician instructions, and took the resident to the hospital for an evaluation and 96-hour hold due to statements of hurting others. The hospital did not keep the resident because the resident was alert and oriented and refused services. When the resident returned, staff placed him/her on 15-minute checks and the physician changed his/her medication. -Resident #1 had a history of verbal altercations, outbursts, and being hateful. His/her anger generally started when he/she ran out of cigarettes. The business office manager or social services designee (SSD) bought residents' cigarettes. The resident ran out of cigarettes weekly. And when asked, he/she would blame running out on someone else. -Not all of Resident #1's anger came from no cigarettes, sometimes he/she yelled at staff and would say staff refused to assist him/her. The resident's behaviors were consistent and did not occur on any specific shift or with any specific staff member. The ADON did not think the resident spoke with or had psychological services. The facility did not have a contract with any psychologists, and none visited the facility. During an interview conducted on 11/18/24, at 3:15 P.M., the SSD said the following: -She worked at the facility as the SSD for about two months. Her duties included discharges and discharge planning, admissions, grievances, assisting with the MDS and care plans, contacting the ombudsman as needed, and talking to residents per their request. -Whether or not the SSD assisted with behavior management depended on the situation. -If a resident exhibited any type of behaviors, the nurses documented the behaviors in the nurses' notes. The SSD talked to residents if they seemed upset. -Staff should tell the SSD if a resident exhibited behaviors and he/she would talk to that resident. -Recently (unknown time), she asked Resident #1 about his/her edginess. The resident told her that staff did not listen to him/her and he/she hated the facility. The resident did not tell the SSD he/she wanted to leave therefore she did not send referral to any other facilities. The SSD did not ask the resident if he/she wanted to leave after he/she said he/she hated the facility. Most of the time the SSD documented conversations she had with residents, but that time, when she spoke to the resident, it was a just a normal conversation and she did not document it. -Resident #1 issues tended to be related to smoking. He/she would get loud at the nurses' station when it was time to smoke. The BOM bought residents' cigarettes. Resident #1 was friendly with other residents. -This weekend, Resident #1 argued and became loud with another resident. That was out of character for Resident #1. -The SSD did not talk to Resident #1 or Resident #2 about the incident this weekend. She thought someone else took care of it. -The SSD wanted staff to call her if there was a resident-to-resident altercation. No one called her, she found out about it during morning meeting today (11/18/24). The SSD did not know if the policy instructed staff to call her, she had not read the policy. -The resident did not run out of cigarettes that she knew of and did not refuse cares. -The SSD did not review residents' progress notes to identify problems. She did not know she was supposed to. During an interview conducted on 11/18/24, at 4:40 P.M., Licensed Practical Nurse (LPN) I said Resident #1 had behaviors. He/she frequently refused cares and cursed and yelled at staff. When the resident admitted to the facility, he/she was really nice. But for the last eight to twelve months, his/her behaviors had increased. He/she did not know the reason for the increase. When the resident exhibited behaviors, he/she just left him/her alone. He/she documented the behaviors in the nurses' notes. The facility used to have a facility dog who spent a lot of time with the resident. At the beginning of the year, former administration got rid of the dog. No one knew what happened to the dog. The LPN thought the resident's behaviors increased after they got rid of the dog. During an interview conducted on 11/19/24, at 12:45 P.M., LPN E said he/she did not know Resident #1 well, but he/she knew the resident often cursed and was not patient with staff regarding smoking times, but he/she did not usually keep bringing up the same issue over and over. On 11/16/24 and 11/17/24, Resident #1 had issues with Resident #2 and Resident #3. It started while waiting for smoke break and carried on to smoke break and two more times throughout the weekend. Resident #1 lashed out at Resident #2. Resident #3 came to Resident #2's defense. The nurse did not know what triggered Resident #1's anger. The nurse contacted the DON and physician when Resident #1 made a threatening statement. The nurse followed the physician and DON's instructions. On 11/17/24, the nurse contacted the physician again regarding the resident's continued behaviors. The physician ordered a new medication and asked the nurse why the resident acted that way. The nurse said the resident hated the facility and wanted to leave. The nurse told the resident to talk with the SSD which caused the resident to curse. The nurse spoke to the resident multiple times about his/her behaviors, and at times he/she was angry and other times he/she appeared calm. During an interview conducted on 11/20/24, at 10:40 A.M., LPN K said the following: -Sometimes the resident yelled but he/she thought the resident's response or yelling was related to how staff talked to the resident and their tone. -The resident had not been mean to the LPN. The resident did not really bother the day shift staff. Staff who worked the evening and night shift had told him/her in shift report, that the resident acted hateful towards them. He/she had not witnessed the resident yelling, and thought it usually occurred while he/she was in his/her room. -The LPN thought the resident may be situationally depressed. At that time, the facility did not have any psychologists who visited the facility, but he/she thought someone was working on getting those services to the facility. -The resident once told the LPN that he/she was leaving; he/she appeared angry. The LPN said okay, and that he/she would care for him/her until he/she left. The LPN did not argue with the resident and kept his/her tone soft. After that, the resident never said he/she wanted to go somewhere else. The LPN thought the resident spoke to social services about transferring to another facility, but it was not recent. He/she could not remember the exact timeframe. The LPN did not think the resident really wanted to leave. The resident only said it when he/she was upset. An observation and interview on 11/20/24, at 10:45 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room. -The resident said he/she lived at the facility for a while and wanted to go somewhere else. He/she talked to someone about transferring but could not remember who, and thought it was recent. It seemed that conversation happened more and more often. -The resident said the day shift staff were good. But the evening shift staff took a long time to answer his/her call light which caused him/her to yell out to get their attention. Then, when the staff finally come down the hall to his/her room, they were angry which caused him/her to be angry. -The resident resided at the end of the hall. The resident said he/she did not think staff liked walking all the way to the end of the hall to assist him/her. By the time they walked to his/her room, they were mad. He/she knew the staff were mad by their tone, it was not really what they said but how they said it. -The resident said smoking was very important to him/her. It was really the only activity he/she enjoyed since he/she was blind due to glaucoma. Day shift staff were mostly timely with taking the residents out for their scheduled smoke breaks, but the evening staff were often late which was frustrating. -The resident said he/she took an antidepressant for depression. He/she was depressed and he/she was not sure if the medication was even working. He/she talked to several people about his/her mood and emotional state. He/she did not think his/her mood/emotions were well managed, but he/she did not know what anyone could do about it. During an interview conducted on 11/20/24, at 12:36 P.M., the DON said the social services designee's duties included monitoring residents' behaviors, completing trauma screening, assisting with appointments, assisting with referrals to outside services such as mental health care, interviewing residents involved in abuse allegations, and assisting with facility to facility transfers. The DON considered yelling and cursing a behavior. Interventions for behavioral symptoms included redirection, offering activities, notifying the physician and obtaining orders if needed, and finding out the root cause of the behaviors. When staff notified her of the resident's behaviors over the weekend, she told the staff to send the resident to the emergency room . She thought that was what they did and did not expect to see him/her at the facility when he/she arrived on Tuesday (11/19/24). The DON did not know the resident well but did know that he/she became agitated when staff were late taking him/her out to smoke. During an interview conducted on 11/20/24, at 1:30 P.M., the SSD said she did not receive any training at the facility for her job as the SSD. She worked at another facility and tried to use that experience. The SSD had no one she could ask questions to or who could tell her what she should do in a situation.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when the facility failed to implement enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) and when staff failed to follow infection control practices, per standard of practice, when staff failed to wash or sanitize hands at appropriate times during wound care to two residents (Resident #1 and Resident #2) out of a sample of three residents. The facility census was 29. Review showed the facility did not provide a policy for Enhanced Barrier Precautions. Review of the Centers for Disease Control's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 07/12/22, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status or infection or colonization with an MDRO. -Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care. Review of a facility policy titled, Infection Control - Clean Dressing Change, undated, showed the following: -Facility to ensure clean dressing changes in accordance with state and federal regulations and national guidelines; -Staff should clean bedside table with a germicidal cloth and establish a clean field; -Supplies should be set up on a barrier; -Hand hygiene should be performed after supplies are set up, after removing used dressing, after wound is cleansed, and when wound care is complete. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (disease in which the immune system attacks the protective covering of the nerve cells), heart failure (chronic condition where the heart doesn't pump as well as it should), and type two diabetes mellitus (the body has trouble controlling blood sugar and using it for energy). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/17/24, showed the following: -Moderately impaired cognitive skills; -At risk for development of pressure ulcers; -Three Stage 2 (shallow open ulcer with red or pink wound bed) pressure ulcers; -Pressure reducing device for chair and bed; -Application of nonsurgical dressings other than to feet; -Applications of ointment/medications other than to feet. Review of the resident's care plan, revised 11/04/24, showed the resident had potential impairment to skin integrity related to fragile skin, multiple sclerosis, immobility, and incontinence. Review of resident's current Physician Order Sheet (POS) showed an order, dated 10/24/24, to cleanse the wound to the buttock crease with wound wash and pat dry. Pack wound with calcium alginate rope (dressing used for wounds with moderate to heavy drainage) and cover with hydro cellular foam dressing (highly absorptive foam dressing). Change as needed every time dressing is soiled. Observation and interview on 11/06/24, at 3:18 P.M., showed the following: -Licensed Practical Nurse (LPN) C obtained supplies from the treatment cart and entered the resident's room to visualize and measure resident's wound. There was no sign or indication of EBP or PPE outside of the resident's room. -LPN C washed hands upon entering room and applied gloves. LPN C did not don a gown. -Resident rested in bed on left side with no dressing noted to buttocks. LPN C proceeded to measure the resident's wounds on the gluteal fold, the right buttocks, and left buttocks with the same disposable measurement device. LPN C did not change gloves or sanitize between measurements of each wound possibly contaminating multiple wounds with infectious materials. -After measuring all wounds, LPN C removed gloves and threw gloves and measuring tape in trash. -LPN C reported resident's buttocks was excoriated (raw, irritated, or red skin) with two wounds on each buttock. -LPN C did not perform hand hygiene upon completion of task. Observation and interview on 11/07/24, at 9:48 A.M. showed the following: -The corporate nurse and LPN E entered resident's room, washed hands, and donned gloves. There was no sign or indication of EBP or PPE observed outside of resident's room. Neither staff donned a gown. -LPN E peeled off a dressing placed over the gluteal fold and measured the wound bed with a disposable measuring device, then replaced the dressing. -LPN E then proceeded to measure two wounds on the right buttocks and one wound on the left buttocks. LPN E did not change gloves, sanitize hands, or obtain a new measurement device which could possibly contaminate wounds with infectious material. -LPN E and the corporate nurse then removed gloves, disposed of trash, and washed hands prior to leaving room. 2. Review of Resident 2's face sheet showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia, depression, hypertension (high blood pressure) and type two diabetes mellitus (the body has trouble controlling blood sugar and using it for energy) with diabetic neuropathy (weakness, numbness, and pain from nerve damage). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired decisions; -At risk for development of pressure ulcers; -No unhealed pressure ulcers. Review of the resident's nurses' notes dated 11/04/24, at 8:50 A.M., showed a nurse documented two nurse aides came to the nurses' desk with the resident at approximately 8:20 A.M. and stated the resident spilt his/her coffee. This nurse went to the resident's room and carefully removed the resident's pants and noted an open area approximate 17 1/2 cm by 21 cm by 0.1 cm. The nurse applied a cool, moist towel and notified the physician's office of the incident. The physician ordered staff to apply Silvadene (topical antimicrobial drug used to prevent wound infections)1% cream daily and non-adherent telfa dressing and secure with gauze. Staff covered the resident's wound with non-adherent dressing and waited for the medication to be delivered. The wound nurse from the hospital came to the facility and assessed the resident's wound later in the afternoon and change the order to twice a day. Review of resident's current POS showed the following: -An order, dated 11/04/24, for staff to apply Silvadene 1 percent (%) topical cream to burn area twice a day and as needed until healed. Change dressing daily and as needed to keep area clean and dry, use Silvadene as ordered, cover with non-adherent telfa and secure with gauze wrap and tape, do not apply tape to bare skin, tape gauze to itself; -Wound consult with hospital wound nurse; -The hospital wound nurse wrote an order, dated 11/04/24, for staff to apply Silvadene 1% twice a day to burn area; -An order, dated 11/07/24, for wound care. Staff to apply maxorb alginate silver wound dressing, cover with 6 by 6 island dressing, cover with stocking, and change every two days and as needed. Review of the resident's care plan, revised 11/04/24, showed the following: -The resident was at risk for skin breakdown due to incontinent episodes and required assistance with bed mobility transfers and hygiene due to severely impaired cognition; -The resident had a burn to left thigh received on 11/04/24. Observation 11/06/24, at 2:49 P.M., showed the following: -LPN C obtained supplies from the treatment cart and entered the resident's room to provide wound care. There was no sign or indication of EBP or PPE observed outside of the resident's room. Nurse Assistant (NA) D was present to assist with positioning resident during wound care. -LPN C placed the wound care supplies including wound cleanser, bandage, medication, and gauze on resident's bedside table without a barrier possibly contaminating supplies or resident's bed with infectious organisms. Both staff washed hands prior to donning gloves. LPN C and NA D did not don gowns to provide wound care. -NA D assisted with positioning of resident during the procedure. LPN C removed a dressing from resident's left leg and did not change gloves or perform hand hygiene. LPN C cleansed the wound using wound cleanser and gauze and then measured the wound. -LPN C described the wound as 27 cm x 11 cm and reported the wound bed was red with some skin sloughing off. -LPN C did not sanitize hands and then gathered supplies from the bedside table and placed them on resident bed without a barrier. LPN C opened two nonadherent dressing packages and placed the Silvadene cream on top of each dressing. LPN C placed the dressings with medication on top of the wound and then removed gloves. The LPN did not perform hand hygiene. LPN C then wrapped the resident leg with gauze wrap and placed tape on the gauze to secure in place. -LPN C then gathered trash and threw the trash away. LPN C collected the remaining supplies and placed them in the treatment cart possibly contaminating the inside of the cart and other treatment supplies. -The LPN did not perform hand hygiene after wound care. 3. During an interview on 11/07/24, at 2:48 P.M., LPN E said the following: -He/she did not know what EBP were; -Nurses should wear gloves and a gown and possibly a mask when providing wound care; -The facility did not require staff to follow EBP; -Hand hygiene should be done before wound care, after removing dirty dressings, and when wound care is complete; -He/she usually sets wound care supplies on the bedside table and is unsure if he/she needs to do anything else. 4. During an interview on 11/07/24, at 3:30 P.M., LPN C said the following: -He/she did not know of the EBP procedures; -Staff should wear glasses, gown, mask, and gloves when providing care with splatters or airborne; -Staff should wear gloves and place wound care products on table or blanket for a clean barrier, change gloves and take off dirty gloves and wash hands when providing wound care. 5. During an interview on 11/07/24, at 2:33 P.M., Registered Nurse (RN) F said the following: -He/she did not know what EBP were; -Nurses should wear gloves for wound care, but if the wound has a lot of drainage a gown should be used as well; -All wound care supplies should be kept inside the package and the packaging should be used for a barrier when opened. 6. During an interview on 11/07/24, at 11:48 A.M., the Nurse Practitioner (NP) said the following: -He/she did not know what EBP were; -Nurses should sanitize and use gloves when providing wound care; -He/she would like nurses to provide a clean barrier for wound care supplies. 7. During an interview on 11/13/24, at 09:28 A.M., the Corporate Nurse said the following: -The facility did not implement EBP; -Staff should place a clean barrier, wash hands, and change gloves with wound care. Staff should wash hands when completing dirty to clean wound care and wash hands after wound treatment. MO00244324, MO00243801 34871

Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate weekly skin assessments, failed to complete weekly wound tracking, and failed to obtain treatment orders for all wounds for one resident (Resident #1) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three residents. The facility census was 29. Review of the facility policy titled, Treatment/Services to Prevent/Heal Pressure Ulcers, undated, showed the following: -The facility will ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing; -Pressure sores will be evaluated weekly and the nurse will document the size, location, odor (if any), drainage (if any), and current treatment order; -The nurse will notify physician anytime the pressure sore is showing signs of non-healing or infection and request treatment order changes. Review of the facility policy titled, Wound Management, undated, showed the following: -The admitting nurse will complete an initial wound exam for each wound identified; -The unit manager or supervisor will document wounds on appropriate tracking log; -Unit manager or supervisor will update the log and every Thursday turn the completed tracking logs to the Director of Nursing (DON), Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) Department, and Dietary Department. -Facility provides an outside wound care specialist who visits residents with wounds weekly; -Unit manager or designee will be responsible for completing the wound exam observation form. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (disease in which the immune system attacks the protective covering of the nerve cells), heart failure (chronic condition where the heart doesn't pump as well as it should), and type two diabetes mellitus (the body has trouble controlling blood sugar and using it for energy). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills; -At risk for development of pressure ulcers; -Three Stage 2 (shallow open ulcer with red or pink wound bed) pressure ulcers; -Pressure reducing device for chair and bed; -Application of non-surgical dressings other than to feet; -Applications of ointment/medications other than to feet. Review of the resident's care plan, revised 11/04/24, showed the following: -Resident had potential impairment to skin integrity related to fragile skin, multiple sclerosis, immobility, and incontinence; -Resident was dependent on staff for bed mobility, dressing, toileting, and showers. Review of the resident's nursing progress note, dated 09/17/24, showed an open area in crevice of his/her buttock measuring 1 centimeter (cm) by 0.4 cm by 0.2. Staff cleansed area with wound wash and covered with hydrocellular foam dressing. Review of the resident's nursing progress note, dated 10/15/24, showed Durable Power of Attorney (DPOA) concerned about open area to coccyx (small triangular bone at the base of the spinal column). Staff notified clinic of wound and asked to advise. Review of the resident's nursing progress notes, dated 10/15/24 to 10/24/24, showed staff did not document again regarding the wound or treatment until 10/24/24. Review of a nursing progress note, dated 10/24/24, showed a new treatment order for wound on buttock crevice. Wound measured 1.6 cm by 0.5 cm by 0.2 cm with a beefy red wound bed. Surrounding skin was fragile and no drainage. Wound is open to air. Review of resident's current Physician Order Sheet (POS) showed the following: -An order, dated 10/24/24, to cleanse the wound to the buttock crease with wound wash and pat dry. Pack wound with calcium alginate rope (dressing used for wounds with moderate to heavy drainage) and cover with hydro cellular foam dressing (highly absorptive foam dressing). Change as needed every time dressing is soiled. Review of resident's November Treatment Administration Record (TAR) showed the dressing to the buttocks documented as changed when soiled. Review of the resident's skin monitoring shower sheet, dated 10/30/24, showed a nurse assessment stating wound cleansed and dry dressing applied as ordered. The area on both buttocks were open, small area crevice wound open and packed. Review of a the resident's weekly skin assessment, dated 10/30/24, showed a nurse documented resident had an open area to buttocks on each side and crevice area with no odor or drainage. The areas were small on each buttock and treatment orders in place. Review of resident's POS showed no order for treatment of the areas on the resident's buttocks. Review of the resident's weekly skin assessment, dated 10/31/24, showed a nurse documented wound treatment in place and completed as ordered. Wound approximately 1 cm by 0.3 cm by 0.2 cm. (The nurse did not document regarding wounds to right and left buttock.) Review of the resident's weekly skin assessment, dated 11/07/24, showed a nurse documented wound treatment in place and completed as ordered. (Staff did not document an assessment of wound or indication of wounds to right and left buttock.) Review of the resident's skin monitoring shower sheet, dated 11/04/24, showed Certified Nurse Assistant (CNA) A documented an open break down area to buttocks with medicine and new patches applied with charge nurse. Review of the resident's nurse progress note, dated 11/06/24, showed treatment done to buttocks as ordered. Dressing applied to all three areas on buttocks. Red angry area with some clear drainage. Skin fragile with bumpy type blister. Review of resident's POS showed no order for treatment of the areas on the resident's buttocks. Observation and interview on 11/06/24, at 3:18 P.M., showed the following: -Licensed Practical Nurse (LPN) C obtained supplies from the treatment cart and entered the resident's room to visualize and measure resident's wound. -Resident rested in bed on left side with no dressing noted to buttocks. -LPN C measured the resident's wounds on the gluteal fold, the right buttocks, and left buttocks; -After measuring all wounds, LPN C removed gloves and threw gloves and measuring tape in trash; -LPN C reported resident's buttocks were excoriated (raw, irritated, or red skin) with two wounds on each buttock; -Right buttock wound measured 4 cm by 3 cm and had a red wound bed; -Left buttock wound measured 4 cm x 3 cm with a red wound bed. Observation and interview on 11/07/24, at 9:48 A.M. showed the following: -The corporate nurse and LPN E entered resident's room; -LPN E peeled off a dressing placed over the gluteal fold and measured the wound bed with a disposable measuring device, then replaced the dressing. -LPN E reported gluteal fold wound was approximately 1 cm by 0.3 cm by 0.2 cm and had a beefy red colored wound bed with white macerated (softened broken down skin related to prolonged exposure to moisture) surrounding skin. -LPN E then measured two wounds on the right buttocks and one wound on the left buttocks. -LPN E reported the buttocks had excoriation to both sides with scarring and dry peeling skin with reddened areas from previous wounds. -The wound on the left buttock measured 0.5 cm by 0.4 cm with a beefy red wound bed. -The wounds on the right buttock measured 1.5 cm by 0.6 cm and 1.4 cm x 0.5 cm, both with beefy red wound beds. -LPN E reported physician should be notified about additional open areas to obtain an order. During an interview on 11/07/24, at 9:48 A.M., the Corporate Nurse said the following: -The resident's wounds on right and left buttock appear to be stage two pressure ulcers; -He/she would expect the nurse to notify the physician and obtain orders; -The nurse should document description and measure wounds then notify physician and family. During an interview on 11/07/24, at 11:56 A.M., Nurse Aide (NA) B said the following: -CNA's inform the nurse, DON, or Administrator of any wounds; -Staff monitor for discoloration, redness, breakdown, and sore or raw spots on resident's skin; -The resident has two areas, dime size to his/her right buttock which opened a couple of weeks ago or longer; -The resident has one smaller than the ones on the right buttock, but open a little on the left buttock; -Nurses change the resident's bandage and apply ointment on it. The nurses place a bandage on each buttock which is about the size of a sticky note pad. During an interview on 11/07/24, at 10:30 A.M., Certified Nurse Aide (CNA) A said the following: -He/she informed the nurse of any skin concerns; -On approximately 10/30/24, the resident had three open areas on his/her buttocks; -The resident had open areas on his/her right buttock for about two months; -The resident's right buttock had two large open areas in the middle of a larger deteriorated area; -The resident's left buttock was red and started to deteriorate in the middle with more depth, bubbled up and open; -Some nurses place a large dressing over all the open areas on the resident's buttocks and some nurses place a bandage on each open area on the right and left buttock. During an interview on 11/07/24, at 10:57 A.M., LPN E said the following: -Wound assessments should include length and width of wound, description, and if there is any drainage; -Wound assessments should be in the progress notes or on the skin assessment sheet; -Charge nurses are responsible for documenting and monitoring of wounds; -Nurses should notify the clinic of any new wounds; -The resident had areas on buttocks that open and close with excoriation for a long time; -Any redness or open areas on skin should be included in the skin assessment; -He/she did not document the redness or open areas in the skin assessment done this morning; -He/she did not know why he/she did not document the maceration and open areas on the skin assessment this morning; -He/she probably did not document redness or open areas due to the problem has been going on so long with buttocks. During an interview on 11/07/24, at 3:30 P.M., LPN C said the resident had one area on either side of his/her buttocks. He/she put bandages on the crease and each buttock. The resident's buttocks had redness just recently. He/she initialed the bandage on each buttock. During an interview on 11/07/24, at 2:00 P.M., the Nurse Practitioner (NP) said the following: -The resident was observed to have redness to buttocks during sixty-day exam and he/she wrote an order for barrier cream; -He/she wrote a treatment order for the buttock crease wound when staff notified him/her; -He/she had not been notified of any skin concerns except for the buttock crease wound; -The resident had frail skin with some stage two pressure ulcers on buttocks; -LPN E notified him/her this morning to come reassess the wound; -The resident had three or four open areas with excoriation to buttocks; -Nurses should not do any treatment that is not ordered; -He/she does not want any bandages on right and left buttocks as it may peel skin off. During an interview on 11/13/24 at 09:28 A.M., the corporate nurse said the following: -Nurses should complete weekly skin assessments on residents; -Nurses should include a full wound description and measurements on the weekly skin assessments; -Staff should notify the physician of a new wound, document in the medical record, obtain a treatment order ,and notify the responsible party. MO00243801, MO00244324 34871

Based on record review and interview, the facility failed to ensure the home had registered nurse (RN) coverage including a RN assigned to serve as the Director of Nursing (DON) and able to complete needed DON duties on a full time basis when the facility's DON provided routine floor coverage prior to leaving employment at the facility. This resulted in leaving the facility being without a DON or RN. The facility census was 38. Review of the facility's policy titled, Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being; -The facility will have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care; -The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all resident in accordance with resident care plans; -Except when waived, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty; -The facility will have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment; -Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week; -Except when waived, the facility must designate a registered nurse to serve as the DON on a full time basis; -The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. 1. During an interview on 10/17/24, at 12:20 P.M., the Business Office Manager (BOM) said that the facility did not have a DON or RN, or interim DON, on staff. The facility had advertisements on the website Indeed for a DON, RN, and LPN positions. During an interview on 10/17/24, at 12:40 P.M., the Administrator said that the DON quit on 10/16/24 without notice. The DON walked in about mid-day and dropped off the keys and a note of resignation. Currently the facility only had one RN on staff that worked every other weekend only. Review of the facility's Daily Staffing Sheet showed the following: -On 10/01/24, staff listed the previous DON on the sheet and had no RN listed as working; -On 10/02/24, staff listed the previous DON on the sheet with no hours listed; -On 10/03/24, staff listed the previous DON as working from 9:00 A.M. to 2:00 P.M. and 3:00 P.M. to 6:00 P.M.; -On 10/04/24, staff listed the previous DON as working as charge nurse from 6:00 A.M. to 2:00 P.M.; -On 10/05/24, staff listed the previous DON as working as charge nurse from 10:00 P.M. to 6:00 A.M.; -On 10/06/24, staff listed the previous DON as working as charge nurse from 2:00 P.M. to 10:00 P.M.; -On 10/07/24, staff listed the previous DON as working as charge nurse from 10:00 P.M. to 6:00 A.M.; -On 10/08/24, staff listed the previous DON as working as charge nurse from 2:00 P.M. to 10:00 P.M.; -On 10/09/24, staff listed the previous DON as working as CNA from 1:00 A.M. to 6:00 A.M.; -On 10/10/24, staff listed the previous DON as working as CNA from 3:00 P.M. to 6:00 A.M.; -On 10/11/24, staff listed the previous DON as working as CNA from 5:00 P.M. to 2:00 A.M.; -On 10/12/24, staff listed the previous DON as working from 6:00 P.M. to 6:00 A.M.; -On 10/13/24, staff listed the previous DON as working as CNA from 6:00 P.M. to 6:00 A.M.; -On 10/14/24, staff listed the previous DON as working as CNA from 10:00 P.M. to 7:00 A.M.; -On 10/15/24, staff listed RN as quit then crossed out with error; -On 10/16/24, staff listed RN as quit; -On 10/17/24, staff listed no list an RN or DON. During an interview on 10/17/24, at 12:50 P.M., Certified Medication Tech (CMT) D said that he/she did not know who the DON was. He/she heard the DON quit. During an interview on 10/17/24, at 1:00 P.M., Licensed Practical Nurse (LPN) F said that there was no DON at this time. He/she thought the DON quit. During an interview on 10/17/24, at 1:15 P.M., Nurse Aide (NA) B said that there was no DON or RNs right now. He/she thought the only RN had been the DON. During an interview on 10/17/24, at 1:30 P.M., Certified Nurse Aide (CNA) E said he/she thought there was a new DON that was working night shift. He/she did not know the DON's name. During an interview on 10/17/24, at 1:40 P.M., Restorative Aide (RA) C said the DON was new and he/she had only seen the DON once or twice. During an interview on 10/17/24, at 2:15 P.M., LPN G said the DON quit a day or two ago. The only other RN worked every other weekend only. During an interview on 10/17/24, at 2:30 P.M., he Administrator said that the RN coverage plan included an advertisement on Indeed, called an RN that she knew, and called an applicant. There was the potential an RN would be on contract to only sign the MDS forms. MO00243576, MO00243630

Based on interview and record review, the facility failed to manage and account for all residents' personnel funds as required when staff failed to deposit residents' personal funds in excess of $50.00 into an interest bearing account and credit all interest earned back to residents for two residents (Resident #1 and #5) who received Medicaid services and when the facility failed to properly maintain an ongoing balance of and reasonable resident access to funds for seven residents (Resident #1, #5, #10, #21, #23, #28, and #100) personal funds. The facility census was 38. Review of the facility policy titled Resident Right - Protection/Management of Personal Funds, undated, showed the following: -It is the policy of the facility to protect and manage the personal funds of the resident in such a manner to acknowledge and respect resident rights; -If a resident chooses to deposit funds with the facility, upon written authorization of a resident, the facility will act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility; -The facility will deposit any residents' personal funds in excess of $100 in an interest bearing account that is separate from the facility's operating accounts, and that credits all interest earned on resident's funds to that account; -There will be a separate accounting for each resident's share; -The facility will maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund; -For residents whose care is funded by Medicaid: -The facility will deposit the resident's personal funds in excess of $50 in an interest bearing account that is separate from any of the facility's operating accounts and that credits all interest earned on resident funds to that account; -There will be a separate accounting for each resident's share. -The facility will maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. Review of the facility policy titled Resident Right - Accounting and Records of Personal Funds, undated, showed the following: -It is the policy of the facility to protect and manage the personal funds of the resident in such a manner to acknowledge and respect resident rights; -The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf; -The individual financial record will be available to the resident through quarterly statements and upon request. 1. During an interview on [DATE], at 12:20 P.M., the Business Office Manager (BOM) said the following: -He/she said that the facility kept around four residents' funds onsite. There was a separate checking account, but he/she did not know what money was in that account. The money for the residents was kept in a locked safe in the Administrator's office. -Each resident had a separate envelope with cash and a piece of paper where he/she documented when staff provided money to the resident. When a resident requested money the Administrator or BOM would check the amount available on the paper in the safe and then provide the resident with the money. -When a check arrived for the resident, he/she would take the money to the bank and deposit it into the account and then withdraw that amount and put it into the appropriate envelope in the safe. -The money was not kept in the interest bearing account. -Access to the safe was available to the Administrator and the BOM. No other staff had a key available. -He/She was aware resident funds over $50.00 should be kept in an interest bearing account. Observations and interview on [DATE], at 12:45 P.M., showed the following: -The Administrator opened a square fire safe that contained multiple hanging file folders. The file folders each had an envelope and hand written piece of paper with a resident's name and balance. The Administrator counted the money in each envelope. -Resident #1 had $73.00 in bills and $1.34 in change with receipts in the envelope. The paper balance showed $100.74 as of [DATE]. The receipts had not yet been subtracted. The resident was on Medicaid; -Resident #5 had $200.00 in bills with a paper that showed an available balance of $200.00. The resident was on Medicaid; -Resident #10 had a $5.00 bill with receipts and no paper with any balance available. The resident was on Medicaid; -Resident #21 had 78 cents in change, the paper showed a balance of 76 cents. The resident was on Medicaid; -Resident #23 had a wallet with $9.00 in bills, with no other documents. The resident expired on [DATE] and family was coming to pick up belongings. The resident was on Medicaid; -Resident #28 had $2.00 in bills and 24 cents in change, with no paper to show balance. The resident was on private pay and hospice; -Resident #100 had $20 bill with no paper to show balance. The resident was private pay. During an interview on [DATE], at 2:20 P.M., the Administrator said that she would expect the resident's money to be kept in an interest bearing account if that is what is required. MO00243630

Based on observation, interview, and record review, the facility failed to ensure residents were as free from accident hazards as possible when staff failed to follow physician orders to safely transfer one resident (Resident #7) using a Hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident). The facility had a census of 38. Review of the facility's policy, Hoyer Lift and Sit to Stand Lift Policy and Procedure, undated, showed the following: -Operating the Hoyer and Sit to Stand Lift is always and only a two-person operation. Do not operate lifts by self; -Any staff transferring a resident in a lift by themselves will be immediately terminated; -Always explain the steps to the resident; -Always double check sling attachment to Hoyer lift bar before lifting resident. Make sure colored loops match on both side and are completely on and secure to the hooks before transfer; -Lift a resident a few inches and double check all sling attachments again before continuing with transfer; -One aide operates the lift controls while the other aide guides resident during transfer. 1. Review of Resident #7's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included traumatic subdural hemorrhage (serious brain injury that occurs when blood pools between the dura mater (protective layer of tissue around the brain) and the brain's surface) with loss of consciousness (state in which a person is no longer aware of their surroundings or themselves), monoplegia (type of paralysis that affects a single limb, body part, or group of muscles) of upper limb affecting left nondominant side, irritability and anger, weakness, and abnormalities of gait and mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 07/03/24, showed the following: -Moderate cognitive impairment; -Resident was dependent on staff transfers and mobility; -Use of a wheelchair. Review of the resident's care plan, last reviewed 07/09/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit due to monoplegia of left side and weakness; -The resident was non-ambulatory; -The resident was totally dependent on staff for toilet use with Hoyer lift; -The resident was totally dependent on staff for transferring with Hoyer lift. Review of the Restorative/Nursing In-Service book, located in a 3-ring binder at the nurses' desk, showed the following: -An in-service, dated 09/10/24, noted the resident was now a mandatory Hoyer lift for all transfers per physical therapy and occupational therapy; -The resident required Hoyer lift with two staff. The resident required staff to assist with ADLs and resident's wheelchair to be propelled by staff; -The resident required maximal assistance for upper body dressing and was depending on staff for lower body dressing and to don/doff footwear. Review of the resident's medical record showed on 09/18/24, staff documented a care plan meeting conducted with the Director of Nursing (DON), therapy, restorative aide, social services, activity, dietary, and the resident's family. The resident was evaluated by therapy due to staff being unable to transfer the resident to and from bed, chair, toilet safely. After therapy evaluated the resident they recommended the resident be Hoyer lift transferred due to unsafe nature of two person transfer. Review of the resident's physician order sheet, current as of 10/17/24, showed an undated order for Hoyer lift to transfer. Observations on 10/17/24, at 12:05 P.M., showed the following: -The resident room door was closed. Upon entering the resident room, Nurse Aide (NA) A and the resident were in the bathroom with the door open. The resident was seated on the toilet and the NA was standing next to him/her. The NA then assisted the resident to a standing position, performed toileting hygiene care, and pulled up the resident's pants. The NA then pivoted the resident to sit in the wheelchair in the bathroom. -The NA pushed the wheelchair into the resident's room next to the recliner. The NA locked the wheelchair and assisted the resident to a standing position with his/her arms at the resident's waist and the resident's arms around the NA's neck. The NA did not use a gait belt. The NA pivoted the resident to his/her right and seated into the recliner. -The NA removed the wheelchair and ensured the resident was comfortable and put the feet of the recliner in the elevated position. The NA placed the call light in reach and left the resident's room. During an interview on 10/17/24, at 12:50 P.M., NA A said that he/she was able to look in the restorative book at the nursing station for how each resident was to be transferred. The NA said that the resident had orders for Hoyer transfer, but thought it was PRN (as needed) orders. There are a few staff that were able to transfer the resident without a Hoyer. He/she said there were days that the resident's legs were too tired. Staff should use a gait belt with pivot transfers, but he/she did not use one today. During an interview on 10/17/24, at 1:15 P.M., NA B said that if there was an order for a resident to be transferred by Hoyer lift the staff is required to follow the physician order. During an interview on 10/17/24, at 2:25 P.M., NA H said there is a book at the nursing station that has how to transfer the residents. The resident was now a Hoyer lift transfer. Staff should not transfer the resident without the Hoyer lift. Staff should follow physician orders. During an interview on 10/17/24, at 2:10 P.M., CNA E said the resident was a PRN Hoyer transfer per family request. It depended on the day and how the resident was feeling if he/she could transfer without the Hoyer lift. The aide said he/she had not transferred the resident without the Hoyer lift for a while. If there was a physician's order that should be followed. During an interview on 10/17/24, at 2:20 P.M., Restorative Aide (RA) C said therapy completed an evaluation on the resident and wrote that they recommended the resident be transferred by Hoyer lift. It did not specify when it should or should not be used. Staff should follow physician's orders if written to transfer with Hoyer lift. During an interview on 10/17/24, at 12:40 P.M., Certified Medication Tech (CMT) D said staff should follow physician orders. If a resident's order was to be transferred by Hoyer lift, that order should be followed and required two staff. During an interview on 10/17/24, at 1:05 P.M., Licensed Practical Nurse (LPN) F said if a resident had an order to be transferred by Hoyer lift then the staff have to follow that order. There is a book at the nursing desk for staff to easily tell how to transfer a resident. During an interview on 10/17/24, at 2:15 P.M., LPN G said that staff should follow physician orders for Hoyer transfers of resident. During an interview on 10/17/24, at 3:00 P.M., the Administrator said the resident was a two person transfer with Hoyer lift. The therapy department had screened the resident and deemed he/she required that. The staff should transfer by Hoyer lift if ordered, even if they felt comfortable not using the Hoyer, they should follow the physician's orders. He/she had helped staff transfer the resident by Hoyer and the resident did fine. MO00241910

Based on interview and record review, the facility failed to provide care per standards of practice for all residents when staff failed to administer medications as ordered, failed to monitor the resident as ordered, and failed to notify and follow-up with the physician as ordered and in a timely manner for one resident (Resident #23) with edema (fluid retention) resulting in increased edema, weight gain, and an inability of the resident to wear his/her shoes. The facility census was 38. Review showed the facility did not provide a policy related to monitoring of changes in condition. Review of the facility policy, Medication Administration Policy and Procedure, undated, showed the following: -Medications are administered to residents in a safe, efficient, timely manner in accordance with accepted standards of practice and resident's usual preferred routine; -Medications are administered in accordance with the written orders of the attending physician/nurse practitioner. 1. Review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included intracerebral hemorrhage (bleeding into the brain tissue), hemiplegia (paralysis) of left side, seizures, and muscle weakness. Review of the resident's care plan, revised on 06/13/24, showed staff to monitor for and document any edema and notify physician. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE], showed the following: -Severe cognitive impairment; -Resident not taking a diuretic (medication to reduce fluid buildup in the body). Review of resident's July 2024 Physician Order Sheet (POS) showed the following: -An order, dated 07/15/24, to check blood pressure daily for one week; -An order, dated 07/15/24, to decrease amlodipine (medication to reduce blood pressure) to 5 milligrams (mg) due to edema. Review of the resident's nurse practitioner progress note, dated 07/17/24, showed the resident had +2 pitting edema (swelling that occurs due to excessive fluid buildup and when pressure is applied an indentation, referred to as pitting, remains) to feet bilaterally. New orders to decrease amlodipine to 5 mg daily, monitor and log blood pressure daily, and present to the clinic. Staff to monitor lower extremity edema. Review of the resident's nursing progress note, dated 07/17/24, showed the nurse practitioner did rounds in facility. The resident had been having a lot of fluid on his/her body. Received new order to decrease the blood pressure medication due to it causing of edema and to check blood pressure daily for one week, then report. Review of resident's July 2024 Medication Administration Report (MAR) showed the following: -An order, dated 07/17/24, for amlodipine 5 mg once daily. Staff documented administering the medication as ordered. -An order, dated 07/17/24, for staff to take blood pressure daily for one week then report. Staff documented checking the resident's blood pressure on 07/18/24, 07/19/24, and 07/25/24. Review of resident's July 2024 weight showed a weight of 253.2 pounds. Review of the resident's July 2024 nursing progress notes showed staff made no further entries related to the resident's edema, monitoring of the resident's blood pressure, or notification to the clinic. Review of resident's August 2024 POS showed an order, dated 07/15/24, for amlodipine 5 mg once daily. Review of resident's August 2024 MAR showed the following: -An order, dated 02/09/22, for amlodipine 10 mg once daily. Staff documented administered daily as ordered except on 08/26/24 (twice the ordered amount). Review of resident's August 2024 weight showed a weight of 262.6 pounds (a gain of nine pounds). Review of the resident's physician progress note, dated 08/01/24, showed the resident had +2 pitting edema to feet bilaterally. Review of the resident's nursing progress note, dated 08/18/24, showed the resident was unable to wear shoes. Both lower extremities +4 edema, cool to touch, and unable to feel pedal pulses. Staff faxed information to clinic for further assessment or treatment. Review of the resident's nutrition evaluation, dated 08/23/24, showed the resident had +4 edema. Review of the resident's medical record, dated 08/18/24 to 08/28/24, showed staff did not document contact received from clinic or further monitoring edema. Review of the resident's nursing progress note, dated 08/29/24, showed the nurse practitioner in facility for rounds and resident had a new order for diuretic due to feet and ankles swelling so much. Review of resident's August 2024 POS showed an order, dated 08/29/24, for Lasix (mediation to reduce fluid buildup in the body) 20 mg once daily for a diagnosis of pedal edema. Review of the resident's nursing progress note, dated 08/30/24, showed the resident had order for a diuretic for edema to bilateral lower extremities. Review of resident's September 2024 POS showed the following: -An order, dated 07/15/24, for amlodipine 5 mg once daily; -An order, dated 08/29/24, for Lasix 20 mg once daily for a diagnosis of pedal (foot) edema. Review of resident's September 2024 MAR showed the following: -An order, dated 07/17/24, for amlodipine 5 mg once daily; -An order, dated 08/22/24, for Lasix 20 mg once daily; -Staff documented both as administered daily. Review of resident's September 2024 weight showed a weight of 267.4 pound (a gain of 5.2 pounds since last weight and a total weight gain of 14.2 pounds). During an interview on 09/06/24, at 10:10 A.M., Nurse Aide (NA) E said the resident's legs have increased swelling. He/she would report that to the nurse, but had not told the nurse yet. During an interview on 09/06/24, at 10:20 A.M., NA D said the resident's legs had been swollen for a couple of months. During an interview on 09/09/24, at 1:00 P.M., Licensed Practical Nurse (LPN) C said if a resident had increased edema, he/she would call the physician, review medications, evaluate feet, obtain a physician order, and monitor intake and output. He/she would expect a response to a fax regarding a resident by the end of the day or he/she would contact physician by telephone. During an interview on 09/09/24, at 1:00 P.M., the Assistant Director of Nursing (ADON) said edema should be included on the care plan. If a resident had +4 pitting edema, he/she would notify the physician, obtain vital signs, and complete an assessment. He/she would call the physician, but if a fax was sent, he/she would expect a response that day or would follow-up with a call. During an interview on 09/09/24, at 1:33 P.M., the Director of Nursing (DON) said the physician should be notified for increased edema. Staff should follow physician orders. MO00238710 41787 36974 50185

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 37. Review of the facility's policy Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being; -Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week; -The Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. 1. Review of the Monthly Work Schedule, dated July 2024, showed no RN scheduled on 07/07/24, 07/13/24, or 07/27/24. Review of the Monthly Work Schedule, dated August 2024, showed no RN scheduled on 08/04/24, 08/10/24, 08/11/24, 08/17/24, 08/24/24, and 08/25/24. Review of the Monthly Work Schedule, dated September 2024, showed no RN scheduled on 09/06/24 and 09/07/24. During an interview on 09/05/24, at 2:50 P.M., Licensed Practical Nurse (LPN) B said that he/she worked a as needed floor nurse and was IV (intravenous medications) certified. He/she did not know if there was an RN in the facility every day. During an interview on 09/05/24, at 3:00 P.M., Certified Medication Tech (CMT) F said there was always a nurse working, but unsure if there was always a RN available eight hours per day. During an interview on 09/06/24, at 1:30 P.M., the Administrator said that the previous DON did not clock in or out as he/she was salaried. Currently there were two RNs employed by the facility, one was employed to work every other weekend part-time basis. MO00240217

Based on observation, interview, and record review, the facility failed to ensure eight nurse aides (NA) (NA D, NA E, NA H, NA I, NA K, NA L, NA M, and NA N) of eight sampled NAs completed a certified nurse aide (CNA) training program within four months of employment at the facility as a nurse aide. The facility census was 38. Review of the facility policy, titled CNA Certification Policy, dated 8/22/22, showed the following: -This policy was made to ensure the residents' health and safety and to meet the residents' needs; -All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four months of employment; -Nursing assistants who have not successfully completed the nursing assistant training program prior to employment may begin duties as a nursing assistant and may provide direct resident care only if under the direct supervision of a licensed nurse prior to the completion of the seventy-five classroom hours of the training program; -Direct supervision means close contact, where the licensed nurse can respond quickly to the needs of the resident; -The nursing assistant shall not perform any care or services for which he/she has not been trained nor found proficient by a licensed nurse; -Prior to any direct resident contact, all staff will be enrolled in the nursing assistant training program's basic course completing at lease sixteen of the required seventy-five hours of instruction training in communication and interpersonal skills; infection control; safety/emergency procedure; promoting residents' independence; and respecting resident rights; -We will conduct an annual in-service/educational meeting for nursing personnel including training in restorative nursing; -A registered nurse of qualified therapist will teach; -The training will include: turning and position for bedridden resident, range of motion (ROM) exercises, ambulation assistance, transfer procedures, bowel and bladder retraining and self-care activities of daily living; -A registered nurse shall be responsible for the planning and then assuring the implementation of the in-service education program for nursing personnel. 1. Review of the facility provided list of NAs and hire dates showed NA N's date of hire was 04/18/19. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA N was certified as a CNA (five years and four months and 21 days from the date of hire). 2. Review of the facility provided list of NAs and hire dates showed NA H's date of hire was 05/02/19. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA H was certified as a CNA (five years and four months and 7 days from the date of hire). Observations on 09/04/24, at 3:30 P.M., showed NA H working, providing direct care to residents in the facility. 3. Review of the facility provided list of NAs and hire dates showed NA E's date of hire was 10/08/20. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA E was certified as a CNA (three years and eleven months and 1 day from the date of hire). Observations on 09/04/24, at 9:30 A.M., showed NA E working, providing direct care to residents in the facility. Observations on 09/06/24, at 9:30 A.M., showed NA E working, providing direct care to residents in the facility. During an interview on 09/06/24, at 10:20 A.M., NA E said he/she had been employed as a nurse aide for four years at the facility. In that time, he/she had been in the CNA class several times. There was never a date set up to complete the certification class due to various reasons from the facility staff. He/she said that he/she attended all of the classes. 4. Review of the facility provided list of NAs and hire dates showed NA K's date of hire was 12/04/20. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA K was certified as a CNA (three years and nine months and 5 days from the date of hire). 5. Review of the facility provided list of NAs and hire dates showed NA D's date of hire was 05/09/22. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA D was certified as a CNA (two years and four months from the date of hire). Observations on 09/04/24, at 9:30 A.M., showed NA D working, providing direct care to residents in the facility. Observations on 09/06/24, at 9:30 A.M., showed NA D working, providing direct care to residents in the facility. During an interview on 09/06/24, at 10:40 A.M., NA D said that he/she had been working at the facility as a nurse aide for three years. He/she said that the CNA classes had been restarted about four or five time for various reasons. The last instructor became ill before the he/she could be scheduled for certification testing. He/she said each time he/she had been almost to the point of testing and something occurred. He/she was ready to complete the course and receive the title of CNA. 6. Review of the facility provided list of NAs and hire dates showed NA L's date of hire was 07/28/22. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA L was certified as a CNA (two years and one month and 12 days from the date of hire). Observations on 09/04/24, at 3:30 P.M., showed NA L working, providing direct care to residents in the facility. 7. Review of the facility provided list of NAs and hire dates showed NA I's date of hire was 08/23/23. Review of the state agency CNA registry website, on 09/09/24, showed the NA I had an inactive CNA certificate as of 02/25/22 (one year and 20 days from the date of hire). 8. Review of the facility provided list of NAs and hire dates showed NA M's date of hire was 09/21/23. Review of the state agency CNA registry website, on 09/09/24, showed no documentation that NA M was certified as a CNA (eleven months and 17 days from the date of hire. 9. During an interview on 09/06/24, at 1:30 P.M., the Administrator said nurse aides should be certified in a timely manner once hired by the facility. The facility had hired an instructor that would begin classes sometime after 09/10/24.

Based on interview and record review, the facility failed to employ sufficiently qualified staff when the Director of Food and Nutrition Services (Dietary Manager) did not have required certification and/or experience. The facility census was 38. Review of the facility's policy titled, Dietary Services, undated, showed the following information: -The Director of Food Services (Dietary Manager) is designated by the facility administrator as responsible for the total dietetic service. The Dietary Manager receives frequently scheduled consultations from the qualified Dietitian; -Sufficient and competent dietary staff are employed to carry out the functions of the dietary services. Review showed the facility did not provide a policy regarding what the required qualifications were for a Dietary Manager. 1. Review of the facility's employee list showed the Dietary Manager was hired on 09/07/05. Review showed the facility did not provide documentation that the Dietary Manger met the minimum qualifications to serve in the Dietary Manger position. During an interview on 09/06/24, at 9:58 A.M., the Dietary Manager said the following: -She had been employed with the facility since 2005; -She was hired for the Dietary Manager position in May of 2024. Prior to that, she was the Activities Director and a nursing assistant; -She has not received any training or certification in food service management. During an interview on 09/09/24, at 2:20 P.M., the Administrator said the following: -She would expect the Dietary Manager to have some training; -She is aware that a lot of education is needed; -She is working on getting the Dietary Manager into some educational classes; -She has written down the dates and times of the classes offered and plans to get the Dietary Manager enrolled as soon as possible.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. The facility census was 38. 1. Review of the Food and Drug Administration (FDA) Food Code (2022 edition) showed nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's policy, titled Dietary Services, undated, showed effective procedures were established for cleaning of all equipment and work areas. Review of the facility's policy, titled Infection Control- Food Services, undated, showed the facility was to store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of food borne illnesses in accordance with State and Federal regulations. Observations on [DATE], starting at 11:23 A.M., showed the following: -The kitchen floor had debris present; -Stackable containers holding serving utensils showed a yellow greasy residue on the exterior, including handles; -A thick yellow greasy residue on the exterior of the stove and stove top; -Debris and soiled (previously used) cookware sat on top of the stove; -Steam table handles with yellow greasy residue; -Three compartment refrigerator handles were brownish tinged and slick textured to touch. During an interview on [DATE], at 9:58 A.M., the Dietary Manager (DM) said the following: -She has been doing the cleaning in the kitchen. All surfaces are wiped down and floors are mopped daily; -She does not have a cleaning list or assignment sheet. 2. Review of the FDA Food Code (2022 edition) showed the following: -Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. -Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. Review of the facility's policy, titled Dietary Services, undated, showed the following information: -Food is prepared, distributed, and served to residents under sanitary conditions. -Effective procedures are established for cleaning of all equipment and work areas. Review of the facility's policy, titled Infection Control- Food Services, undated, showed the following information: -The facility is to store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of food borne illnesses in accordance with State and Federal regulations. Observations on [DATE], starting at 11:23 A.M., showed the following: -Debris on the food preparation tables; -A box fan, turned on, and with brown, fuzzy debris blowing toward food preparation tables; -Dietary Aide (DA) P bagged trash and took it outside. He/she came in and rolled out trash bags on top of food prep area, put the bag in a trash can, and then washed his/her hands. The food prep area was not immediately cleaned or sanitized by staff after staff. Observation on [DATE], at 11:16 A.M., during lunch serve-out, showed the following: -Flies landing on kitchen serving items and the steam table; -Doors to the dining room, hallways, dishwashing room, and the outside were open; -Resident preference and diet cards were placed on top of the steam table, above the food. Some had debris on them. Staff touched the diet cards and then put plates (touching the food contact area) on trays before serving to residents; -Cook Q opened debris covered stackable containers with gloved hand and obtained serving utensils and began serving. During an interview on [DATE], at 9:58 A.M., the DM said the following: -She has been doing the cleaning in the kitchen. All surfaces are wiped down and floors are mopped daily. She does not have a cleaning list or assignment sheet; -She has had heard some concerns about flies in the dining room. Maintenance put up fly strips in kitchen, but none in dining. Kitchen staff will let maintenance know when the fly strip is full. She did not know of any other efforts in the facility to prevent flies. 3. Review of the facility's policy, titled Dietary Services, undated, showed the following information: -Food is prepared, distributed, and served to residents under sanitary conditions; -Hot food is served above 140 degrees Fahrenheit (F) and cold food is served below 45 degrees F; -Refrigerator temperature is maintained at 45 degrees F or below. Review of the facility's policy, titled Infection Control- Food Services, undated, showed the following information: -The facility is to store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of food borne illnesses in accordance with State and Federal regulations; -Temperatures of refrigerators and freezers will be monitored daily and documented. Refrigerator temperatures should be less than 40 degrees F and freezers should be at 0 degrees Fahrenheit, or below; -Food are to be held at appropriate temperatures while being served. Monitoring of food temperatures using a food thermometer should be performed regularly. Observations on [DATE], starting at 11:23 A.M., of the refrigeration and freezer units showed: -A thermometer on the exterior of the three-door refrigerator showed 50 degrees F. The interior thermometer showed 48 degrees F; -Temperature log papers hung on the side of the refrigerators showed staff had not made any temperature entries. Observation on [DATE], during lunch preparation, showed the following: -DA P obtained packaged ham and oven roasted turkey breast from the three-door refrigerator to make sandwiches. The exterior thermometer of the refrigerator read 48 degrees F. The interior thermometer read 51 degrees F. -The refrigerator also contained mayonnaise, uncooked bacon in a wrapper, applesauce, raw eggs, sour cream, cottage cheese, raw lettuce, peppers, and apples; -Temperature checks showed the refrigeration temperature to be 51 degrees F close to the door, 48.5 degrees F in the middle of the refrigerator, and 46.9 degrees F close to where staff stored the ham and oven roasted turkey breast. Observation and interview on [DATE], at 4:18 P.M., showed DA R obtained the temperature of the oven roasted turkey breast, ham (deli meat previously used to make sandwiches for residents), and mayonnaise from the three-door refrigerator. The ham was found to be at 41.7 degrees F, turkey at 45.8 degrees F, and mayonnaise at 43.1 degrees F. During an interview on [DATE], at 9:58 A.M., the DM said the following: -The three-compartment refrigerator was serviced yesterday, but it still did not maintain an appropriate temperature for cooling foods; -Staff should take the temperature of all food items before serving; -Staff should monitor and log refrigerator temperatures twice a day. Not all staff are recording and monitoring refrigerator temperatures as directed; -An appropriate range for cold storage should be below 40 degrees F, and above 32 degrees F. If any food is outside of those parameters, it should be discarded by kitchen staff; -Appropriate freezer temperature should be 32 degrees F and below. During an interview on [DATE], at 12:23 P.M., the Registered Dietician (RD) said the following: -She expected the temperature range for cold food storage to be between 32 degrees F and 40 degrees Ft; -If food items were not within the appropriate temperature range, she expected staff to discard those food items; -Staff should take temperatures of food prior to it being served. During an interview on [DATE], at 4:00 P.M., the Administrator said the following: -Foods in cold storage should have a temperature of 45 degrees F and lower; -If a food item is ever outside of the appropriate temperature range, the food should be discarded. 4. Review of the FDA Food Code (2022 edition) showed products which are damaged, spoiled, or otherwise unfit for use may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods. Review of the facility's policy, titled Dietary Services, undated, showed food in unlabeled or damaged containers is not accepted or retained. Review of the facility's policy, titled Infection Control- Food Services, undated, showed foods should be properly labeled and expired foods should be discarded. Observations on [DATE], starting at 11:23 A.M., of the refrigeration and freezer units showed: -The three-door refrigerator contained a package of ham dated [DATE]; a cling-wrapped item that contained an item black and blue with fuzz; two cling-wrapped undated packages of American cheese; cling wrapped undated sliced onion; pork inside a container thawing above a carton of eggs; open, undated containers of yogurt, cottage cheese, and mayonnaise; precooked hamburgers on top level of fridge above fresh vegetables; a jar of cherries dated [DATE], and a bag of undated red-tinged lettuce and celery; -The chest freezer contained an approximately five pound roll of ground beef with cling wrap on one end. The ground beef roll appears to have been thawed and refrozen and was about half the size of other ten pound rolls sealed in original packaging. Observations on [DATE], starting at 11:23 A.M., in the dry goods pantry showed the following: -Serving scoop inside of bulk flour in a two gallon bucket; -Open box of cream of wheat 28 ounce, dated ,d+[DATE], and unsealed; -Open box of cultured dry buttermilk with no date and unsealed. During an interview on [DATE], at 9:58 A.M., the DM said the following: -Once staff has opened a food item, staff should seal and label it with date and time; -Prepared foods should only be kept for seven days and then discarded; -Leftover food (cooked, prepared) items should only be kept for three days and then discarded; -She sometimes lets freezer items half-ways thaw, to where she can cut off the amount that is needed, and then she will place the half not needed, back in the freezer. During an interview on [DATE], at 12:23 P.M., the RD said the all food should be sealed and labeled with a date and time. 9. During an interview on [DATE], at 4:00 P.M., the Administrator said previously opened foods should be wrapped and sealed with an open date and time. 36974

Based on observation, interview, and record review, the facility staff failed to complete and document weekly skin assessments and monitoring for two residents (Resident #6 and #21), as directed by the residents' care plans, whom staff identified as at risk for pressure ulcer development, A sample of 12 residents were selected out of a census of 29. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, treatment of [REDACTED]. -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and [MEDICATION NAME] (healing by the growth of epithelium over a denuded surface); -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer; -Reassess pressure ulcers at least weekly; -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION] (swelling or puffiness from fluid), loss of granulation tissue, and a purulent (containing pus) discharge; -A clean pressure ulcer should show evidence of some healing within two to four weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's undated policy, titled Skin Care Protocol, showed the following information: -The physician will be notified within 24 hours of any open areas on skin; -Interventions for pressure ulcers will be added to the resident's care plan; -Wound measurements and assessments are to be completed and documented weekly; -All treatments will be re-evaluated in two to three weeks to determine if the treatment is appropriate: -The physician will document monthly on the wound status. 1. Record review of Resident #6's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission nursing assessment, dated 9/5/18, showed staff documented the resident's skin as intact. Record review of the resident's physician order [REDACTED]. -An order, dated 9/5/18, directed staff to assess the resident's skin weekly; -An order, dated 12/5/18, directed staff to apply zinc oxide (a topical skin medication used to treat diaper rash, severely chapped skin, or other minor skin irritations) to the open area on the resident's buttocks every shift and as needed (PRN) until healed. Record review of the resident's (MONTH) 2019 Medication Administration Record [REDACTED]. Record review of the resident's skin alteration record, dated 5/28/19, showed the following information: -Staff documented the resident had three open, stage II ulcers (partial-thickness loss of skin presenting as a shallow open ulcer) to the right buttock; -Staff did not document a complete assessment including measurements of the ulcers, or the appearance of the pressure ulcers. Record review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/16/19, showed the following information: -Cognitively intact; -Required extensive staff assistance of two for bed mobility, transfers, and toilet use; -Incontinent of both bladder and bowel; -At risk for developing pressure ulcers; -No current unhealed pressure ulcers. Record review of the resident's care plan, dated 6/19/19, showed the following information: -Potential for pressure ulcers related to immobility; -Monitor and document any changes in pressure ulcer to include, appearance, color, signs of infection, stage of wound, and measurement of ulcer, and healing status of the pressure ulcer; -Monitor for effectiveness of treatment; -Staff did not address skin breakdown on the care plan. Record review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. Record review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. Record review of the resident's medical record, dated 5/29/19 to 8/13/19, showed staff did not document an assessment of the pressure ulcers, to include any changes in the pressure ulcer, the appearance, color, signs of infection, measurements of the pressure ulcer, or the healing status of the pressure ulcer. Staff did not document any monitoring of the effectiveness of the treatment. Record review of the physician's progress note, dated 8/13/19, showed the physician documented the resident had an open area on his/her buttocks that had been present about a month. Record review of the resident's skin alteration record, dated 8/14/19, showed the following information: -Staff documented the resident had multiple open areas to the buttocks with excoriation and denuded skin; -Staff did not document any measurements or descriptions of the pressure ulcers. Record review of the resident's [DATE] MAR indicated [REDACTED]. Record review of the resident's skin alteration record, dated 9/10/19, showed the following information: -Staff documented multiple open areas to buttocks had serosanguineous (containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood) drainage. -Staff did not document measurements, staging, or a description of the pressure ulcers. Observations and interview on 9/10/19, at 2:35 P.M., showed the following: -The Director of Nursing (DON) rolled the resident onto his/her side to visualize the resident's buttocks; -A pressure ulcer, approximately 2.0 centimeter (cm) by 1.0 cm, to the upper gluteal cleft (crease of the resident's buttocks), the wound bed was pale with serosanguinous drainage. The surrounding tissue was deep purple in color; -A pressure ulcer, approximately 1.5 cm by 1.0 cm, to the middle region of the resident's gluteal cleft, the wound bed was pale with serosanguinous drainage. The surrounding tissue was deep purple; -Two pressure ulcers, both approximately 1.5 cm by 1.0 cm, to the resident's left lower buttocks. The wounds beds were bright red with serosanguinous drainage. The surrounding tissue was dark purple; -The bed pad under the resident showed red tinged stains in various locations. Serosanguinous liquid drained from the pressure ulcers; -The resident lay on a mattress without a pressure relieving device; -The DON said staff were applying the zinc oxide treatment. The treatment had not changed. -She said the resident did not have a pressure relief mattress. During an interview on 9/10/19, at 2:45 P.M., the resident said the open areas on his/her buttocks are painful and the areas hurt more when he/she is up in the chair. Record review of the resident's skin alteration record, dated 9/11/19, showed Licensed Practical Nurse (LPN) B documented the area to the resident's right and left buttocks to be healed. Observation on 9/11/19, at 4:20 P.M., showed the resident lay in bed on an air mattress. The DON and LPN B rolled the resident onto his/her side. The resident had a stage II pressure ulcer, approximately 2.0 cm by 1.0 cm to the upper gluteal cleft (crease of resident's buttocks) and a stage II pressure ulcer, approximately 1.5 cm by 1.0 cm to the middle of the gluteal cleft. Two stage II pressure ulcers to the left gluteal fold (lower buttocks at thigh area), each approximately 1.5 cm by 1.0 and four small denuded (loss of outer skin) areas to the middle of the left buttocks each approximately 0.5 cm by 0.5 cm. The entire buttocks area was covered in a white paste. 2. Record review of Resident #21's face sheet showed the following information: -admitted d 10/18/16; -[DIAGNOSES REDACTED]. Record review of the resident's POS showed the following information: -An order dated 11/5/18, directed staff to apply [MEDICATION NAME] ointment (a skin barrier cream that contains zinc) to buttocks every shift and PRN. Record review of the resident's care plan, dated 3/1/19, showed the following information: -Potential for pressure ulcers related to immobility; -Monitor and document any changes in pressure ulcer to include, appearance, color, signs of infection, stage of wound, and measurement of ulcer, and healing status of the pressure ulcer; -Monitor for effectiveness of treatment; -Staff did not address skin breakdown on the care plan. Record review of the resident's skin alteration record, dated 5/28/19, showed the following information: -Staff documented the resident had a Stage II pressure ulcer on the upper buttocks; -Staff did not document a complete assessment including measurements of the ulcers, the appearance of the pressure ulcer or whether there were signs of infection. Record review of the resident's medical record showed staff did not document contacting the physician regarding the Stage II pressure ulcer. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's medical record, from 5/29/19 to 8/13/19, showed staff did not document an assessment of the pressure ulcer, to include any changes in the pressure ulcer, the appearance, color, signs of infection, and measurements of the pressure ulcer, and the healing status of the pressure ulcer. Staff did not document monitoring regarding the healing status of the pressure ulcer. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Required total staff assistance of two for bed mobility, transfers, and toilet use; -Incontinent of both bladder and bowel; -At risk for developing pressure ulcers; -No unhealed pressure ulcers. Record review of the resident's skin alteration records showed the following information: -On 8/14/19, staff documented the resident had three open pressure ulcers to the right buttocks. The three areas measured 3.0 cm by 2.0 cm. Staff did not document the stage of the pressure ulcers, a depth measurement, the appearance of the pressure ulcers, or whether there were signs of infection; -On 8/27/19, staff documented the pressure ulcer opened into one pressure ulcer. Staff did not document the stage of the pressure ulcer, the measurements, the appearance or whether there were signs of infection. Record review of the resident's medical record showed staff did not document contacting the physician regarding the pressure ulcer or a treatment or a change in treatment for [REDACTED]. Record review of the resident's skin alteration records showed the following: -On 9/4/19, staff documented an open area measured 6.0 cm by 8.0 cm, with skin darkened in the surrounding area and no drainage. Staff did not document the stage of the pressure ulcer, the measurements, the appearance or whether there were signs of infection. Staff did not document notification of the physician. No treatment changes made. -On 9/10/19, the pressure ulcer to the buttocks measured 6.0 cm by 8.0 cm, with skin darkened in the surrounding area and showed serosanguinous drainage. Staff did not document the stage of the pressure ulcer, the depth measurement, the appearance or whether there were signs of infection. Observation and interview on 9/10/19, at 2:20 P.M., showed the DON assisted the resident onto his/her left side. The resident had an open area approximately 6.0 cm x 8.0 cm to the his/her upper right buttock. The wound showed a shallow crater with a pale wound bed, with serosanguinous drainage and well defined edges The buttock area was deep purple in color. The DON said the resident had three open wounds that opened into one large wound. She said the resident is incontinent of bowel and bladder and does not like to get out of chair. Record review of the nurse's progress note dated 9/10/19, at 2:30 P.M., showed the resident's physician on site and notified of the resident's pressure ulcer to the buttocks. The physician wrote an order directing staff to apply duoderm (a wound dressing to aid in healing) to the pressure ulcer. During an interview on 9/11/19, at 8:30 [NAME]M., the resident said staff had been putting cream on his/her bottom for a long time. He/she said on 9/10/19, staff put a dressing on his pressure ulcer. He/she said the cream didn't help as it wiped right off when the staff dressed him/her. The resident said the ulcer on his/her buttocks hurts a lot. 3. During an interview on 9/12/19, at 8:40 [NAME]M., LPN C said staff should notify the nurse if a pressure ulcer is identified. The nurse should assess the ulcer and contact the physician for a treatment order. All residents with identified wounds will be added to the wound round list so the ulcer can be assessed and measured weekly. Skin barrier is not an appropriate treatment for [REDACTED]. Resident #6 and #21 have had pressure ulcers for an extended time. They both stay up in their chairs too long. 4. During an interview on 9/12/19, at 9:53 [NAME]M., Certified Nurse Assistant (CNA) D said the following: -The nurses tell staff if the residents are at risk for pressure ulcers; -Staff will try to reposition those residents frequently using pillows; -Resident #6 and #21 have open wounds that have been there for a long time; -Staff are instructed to put barrier cream on the residents' bottoms with each incontinent care; -Staff apply zinc oxide to Resident #6 and [MEDICATION NAME] ointment to Resident #21. 5. During an interview on 9/12/19, at 10:00 [NAME]M., the DON said the nurses should assess all new pressure ulcers and obtain a treatment order immediately. She expects staff to notify the DON so the resident can be added to the weekly wound list. If the wound is not improving in two weeks, the physician should be notified. The physician should be notified if a decline in status is seen. Zinc oxide and [MEDICATION NAME] ointment should not be used for open pressure ulcers and can cause harm. Resident #6 and #21 did not have new treatment orders. Staff continued to to use the zinc based barrier cream for treatment to their open pressure ulcers. There is no tracking records for pressure ulcers for Resident #6 and #21 after 5/28/19. Tracking was started again on 8/14/19. The care plan should reflect if the resident has a current pressure ulcer and interventions to heal and prevent. The facility had a recent in-service on residents' at risk for pressure ulcers and the appropriate action for staff to take to include interventions, treatments, and documentation. The facility did not have a policy specific to pressure ulcers.

Based on observation, interview, and record review, the facility failed to complete an investigation to determine the cause of leg blisters and burns (damage the outer layer and the layer underneath) on one resident (Resident #11), with moderate cognitive impairment, failed to assess and document injuries resulting from hot coffee for one resident (Resident #9) with moderate cognitive impairment, failed to obtain a treatment order for one resident (Resident #9) and failed to immediately develop and implement interventions to protect residents from any further burns in a selected sample of nine residents. The facility census was 33. According to the National Institute of Health, U.S. National Library Department of Health and Human Services, updated 11/30/15: -A burn is damage to body tissues caused by heat, chemicals, electricity, sunlight or radiation. -Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns. -There are three types of burns: First-degree burns (damage only the outer layer of skin), second-degree burns, and third-degree burns (damage or destroy the deepest layer of skin and tissues underneath). -Burns can cause swelling, blistering, scarring and, in serious cases, shock and even death. They also can lead to infections because they damage your skin's protective barrier. -treatment for [REDACTED]. Record review of information from the Consumer Product Safety Commission (cpsc.gov) showed most adults would suffer third degree burns if exposed to 150-degree hot water for two seconds. 1. Record review of Resident #11's face sheet (admission information) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/17, showed: -Moderate cognitive impairment; -Extensive assistance of two staff for transfers, dressing, toileting and bathing; -Limited assistance of one staff for eating; -Impairment on one side of upper and lower extremity, limiting the residents range of motion; -Used a wheelchair for mobility. Record review of the resident's care plan, updated on 11/23/16 and reviewed on 5/24/17, showed: -The resident needed two staff to assist him/her with transfers, bed mobility, toileting, dressing, and hygiene; -The resident had contractures to his/her right hand; -The resident had a splint to the right hand when up and off for showers and bed; The resident has impaired visual function. Record review of the resident's nurses' notes showed the following: -On 4/11/17, at 3:00 P.M., a nurse documented the resident had fluid filled blisters on his/her left thigh. The nurse documented, on a daily skilled nurse's note, the blister was about two inches wide by six inches long. The resident said he/she did not know how the blisters got there and it did not hurt. The nurse applied a dressing and explained to the resident sometimes the fluid will go back into the body and not open the blister and the resident said he/she would not touch the blister. The nurse did not document notifying the resident's physician or family; -On 4/11/17, at 11:30 P.M., a nurse documented the resident had fluid filled blisters on his/her left thigh. The LPN did not document measurement or description of the blisters; -On 4/12/17, at 8:00 A.M., a nurse documented the resident had fluid filled blisters on his/her left thigh. The nurse did not document measurement or description of the blisters. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's nurses' notes on 04/14/17 showed the following: -The evening shift nurse documented he/she completed the treatment to the resident's left thigh; the large blister on the resident's thigh was draining red fluid; -The resident complained of pain during the treatment and denied pain after the treatment was completed. Record review of the resident's care plan, showed the following updates: -On 4/14/17 an order to cleanse left upper thigh with NS, TAO cover with non-adhesive dressing and change daily; -On 4/19/17 staff documented the resident has a tendency to spill liquids, staff should provide the resident with a handled cup and lid for all hot liquids. Record review of the social services notes, dated 4/19/17, showed the MDS coordinator/social service designee (SSD) documented due to the recent spilling of hot liquid, the resident's care plan has been updated to show all hot liquids need to be served in a handled cup with lid. Record review of the treatment administration record (TAR) showed the following: -On 4/14/17 an order for [REDACTED]. -Staff documented completing the treatments daily from 4/14/17 through 6/14/17. -On 06/14/17 staff documented the area was healed. An observation and interview on 7/20/17, at 7:45 A.M., showed the resident lay in bed while the Certified Nurse Aides (CNA) assisted him/her up of bed and into his/her wheelchair. The resident's left upper thigh had a pink colored scar measuring approximately 1 1/2 to 2 inches wide and 5 to 6 inches long. The CNA asked the resident what happened to his/her leg, and the resident said he/she spilled hot coffee on his/her leg and it hurt. He/she was burned by the hot coffee quite a while ago. During an observation and interview on 7/19/17 at 11:30 A.M. and 7/20/17, at 7:05 A.M., the Dietary Manager (DM) said there were concerns about the coffee machine being too hot. She was aware of residents getting burned by coffee spills. She thought the coffee machine should be moved back to the kitchen area so residents did not have such easy access. The coffee machine should be locked when there are no staff present in the dining room. She typically arrived at the facility at 4:30 A.M., and the coffee machine should be locked. There were usually four to five residents in the dining room with no staff present. Today when she arrived, the coffee machine was unlocked and there were residents unsupervised in the dining room. The dietary supervisor was very concerned for the residents. When the dietary supervisor took the temperature of the coffee, brewed in the commercial/restaurant style coffee server, it measured 180 degrees Fahrenheit (F). The DM did not document the temperature. During observation on 7/20/17 at 8:00 A.M., CNA G and Nurse Assistant (NA) H assisted Resident #11 with toileting. Observation of the resident's skin during transfer showed a pinkish-red scar to the resident's left lateral thigh, approximately 6 inches long by 1.5 inches wide and a second circular pinkish-red scar to the upper left lateral hip, approximately 1 inch in size. During an interview on 7/19/17, at 5:55 P.M., CNA K said she was working the day Resident #11 spilled the hot coffee on his/her left leg. The burn left a scar on the residents leg. During an interview 7/20/17 at 8:05 A.M., NA H said staff told him/her Resident #11's left hip/thigh scars were caused from a hot coffee burn; he/she did not work on the day the injury occurred. The first time he/she saw the resident's injury; it appeared as a large fluid filled blister. The resident complained of pain to the left thigh. The NA reported the resident's pain to the resident's nurse. During an interview on 7/20/17 at 8:10 A.M., CNA G said she did not work with Resident #11 until approximately one week after he/she sustained the burn. At that time, the resident had a dressing on his/her left hip/thigh. The resident complained of pain to his/her left thigh. saying the burn hurt her. After the resident was burned, staff started giving the resident his/her coffee in a cup with a lid. During an interview on 7/20/17 at 9:50 A.M., the restorative supervisor (RS) said Resident #11 received a burn to his/her left thigh approximately two months ago. After a few residents were burned by the coffee, they checked the coffee temperature and his thermometer showed a temperature of 160 degrees F, but his thermometer did not read above 160 degrees F. The RS thought someone else checked the temperature and got a reading of 180 degrees F. He spoke to the dietary manager (DM) about getting the coffee temperature lowered. The DM contacted the coffee machine company, but they could not adjust the temperature. After the resident's burn, staff began giving the resident coffee in an insulated coffee cup with a lid. He said staff were supposed to put ice in the coffee as well, but he was unsure if this was being done all the time. Approximately two weeks ago, the dietary staff began locking the coffee machine located in the dining room between meals, so residents could not access without staff assistance. During an interview on 7/20/17 at 10:05 A.M., Licensed Practical Nurse (LPN) I said approximately two months ago, Resident #11 sustained an injury to his/her left thigh resulting in a large fluid filled blister. The nurse said he/she was not on duty at the time of the injury and she believed the injury was not witnessed by staff. Staff suspected the resident's blister was caused from a hot coffee spill. The nurse said the resident had multiple blisters to his/her left thigh and the nurses kept the areas covered with a non-adherent dressing. The nurse said the resident's blisters eventually popped and then the nurses applied antibiotic ointment and a non-adherent dressing. The resident's open blisters eventually scabbed over. The nurse did not report the blisters to the physician or notify the family. Staff now give the resident his/her coffee in a metal mug with a lid. He/she asked the restorative supervisor to check the coffee machine temperature in the dining room. The nurse said the coffee was way too hot and the restorative supervisor asked the dietary manager multiple times to turn the coffee machine temperature down. The nurse did not ask any one else. The coffee temperature were between 160 to 180 degrees F. The nurse thought the DM called the coffee machine company, and they said if they turned the machine down it would not make coffee. During an interview on 7/20/17 at 11:30 A.M., the physician said he takes care of 25 residents and sees them at least one time a month and as needed. Staff should notify him by fax for incidents that do not involve injury. Staff should notify him by telephone if there was an accident with injury. Resident #11 was alert and oriented with some confusion and had a stroke that affected both sides of his/her body. The resident had braces on his/her right hand, wrist and leg. Staff notified the physician regarding Resident #11 spilling coffee on his/her leg and he ordered a treatment for [REDACTED]. Resident #11 had decreased sensation due to his/her stroke. The physician did not believe the resident was safe drinking hot coffee on his/her own, (without staff supervision) the elderly in general are compromised. Blisters indicate a second degree burn. During an interview on 7/20/17, at 12:05 P.M., the Assistant Director of Nursing (ADON) said nurses were responsible for completing an incident report for any resident accident or injury. The ADON said she reviewed all completed resident incident reports and logged the information into a book. After reviewing the log, the ADON said staff did not complete an incident report on Resident #11's burn and she was unaware the resident had sustained a burn. If a resident sustained [REDACTED]. During an interview on 7/21/17, at 9:40 A.M., LPN E said a few months ago a CNA reported when laying Resident #11 down around 10:00 P.M., staff noticed the residents clothing was wet and when they took off the residents pants they noticed blisters to the residents left leg. The LPN assessed the resident and the blisters were approximately 6 inches in length and 2 inches wide. The blister was long and yellow in color. The LPN did not recall any redness. There was another blister above this area broken off approximately one inch long and one inch wide. LPN was not sure if the resident expressed any pain at this time. The previous nurse did not report any concerns with the resident or that the resident had blisters to his/her left leg. The resident did not recall what caused the blisters. The CNAs speculated the resident had spilled coffee and burned his/her leg. Staff should complete an incident report for any injury and contact the physician and family. The LPN said he/she didn't think he/she filled out an incident report. He/she did not contact the physician or family on 4/11/17 related to the note where the CNAs found the blisters. The LPN thought the previous shift must have contacted the physician and family. The physician should have been notified when he/she found the injury related to the blisters. During an interview on 7/21/17 at 11:35 A.M., LPN J said in April of 2017, while the CNAs were doing their rounds, they found blisters on the resident's left leg. The CNAs said nobody knew about the blisters. The LPN assessed the area and said the blisters were two to three inches long and about one inch wide. He/she applied a dressing to the blistered area. One of the nurses pulled the dressing off which in turn pulled the residents skin off, popping the blisters. The LPN did not notify the physician or family during the night unless it was an emergency. The staff coming on shift, after the LPN, said they already knew about the resident's blisters so he/she did not complete an incident report. The LPN was told it was a coffee burn and as far as he/she knew there was no treatment ordered and the staff were watching for the blister to break open. 2. Record review of the Resident #9's face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of resident's care plan, initiated 11/11/16, showed the following information: -The resident will have no complications related to diabetes. Avoid exposure to extreme heat or cold; -The resident was able to feed himself/herself after meal set-up. The resident required cueing and close observation; -The resident required skin inspections daily with cares. Observe for redness, open areas, scratches, cuts and bruises, and report changes to the nurse. -Weekly skin assessments on night shift -The resident has potential impairment to skin integrity. The resident will maintain or develop clean and intact skin. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Dependent on staff for bed mobility, transfers, dressing, toileting and bathing; -Required staff supervision for eating; -No skin issues ulcers. Review of the resident's nurse's note, dated 4/18/17, at 2:00 P.M., showed a nurse documented the resident had a tendency to spill liquids. All hot liquids served to resident in handled cup with lid to help prevent injury from spills of hot liquids. Review of the resident's care plan, updated 4/19/17, showed the following: -The resident has tendency to spill liquids when drinking; -Serve all hot liquid in handled cup with lid. Review of the resident's April 2017 POS showed the following information: -An undated order for all hot liquids to be in handled cup with lid; -No order for wound treatment to the resident's abdomen. Review of resident's April 2017 TAR showed the following information: -Clean the abrasion (cut or scrape) on the resident's left lower abdomen with normal saline (a sterile mixture of salt and water), apply Bactatracin (bacitracin-an anti-bacterial ointment), cover with a non-adherent dressing and secure with tape until healed. -Staff documented completing the treatment seven out of nine opportunities. -Weekly Skin Summary (located on the back of the TAR) showed on 4/19/17 a nurse documented the resident had a quarter sized scab to his/her left lower abdomen and three small scabs on his/her left chest. Review of the resident's May 2017 POS showed no order for wound treatment to the resident's abdomen. Review of resident's May 2017 TAR showed the following information: -Clean the abrasion on the resident's left lower abdomen with normal saline, apply Bactatracin (bacitracin), cover with a non-adherent dressing and secure with tape until healed. -Staff documented completing the treatment 10 out of eleven opportunities. On 05/12/17 staff documented OTA (open to air) indicating they no longer covered the area with a dressing. -Weekly Skin Summary (located on the back of the TAR) showed on 5/3/17 and 5/10/17 showed a nurse documented the resident had a scab to his/her left lower abdomen. -On 5/22/17 staff documented the abrasion was healed. Review of the resident's annual MDS, dated [DATE] showed the following information: -[DIAGNOSES REDACTED]. -Moderate Cognitive Impairment; -Total dependence for bed mobility, transfers, dressing, toileting and bathing; -Oversight and encouragement needed for eating and hygiene; -Used a wheelchair for mobility; -Limited assistance for locomotion; -No skin issues ulcers. During an interview conducted on 07/19/17, at 5:20 P.M., LPN M said the following: -He/she knew the coffee was hot but did not know the temperatures because dietary took care of that. -He/she knew of at least one resident who had been burned from the coffee within the last few months; the LPN did not know the exact date other than it occurred on a weekend. He/she thought the resident was Resident #9. The incident occurred during breakfast. -Dietary removed the hard plastic coffee cups near the coffee dispenser and replaced them with Styrofoam cups. Staff served the resident coffee in a Styrofoam cup. The cup full of hot coffee slipped out of the resident's hand spilling on his/her hand. The LPN knew the hot coffee caused the resident's hand to become red (1st degree burn) but thought it also may have caused his/her hand to blister (2nd degree burn). -After the coffee burned the resident, dietary removed the Styrofoam cups and placed the hard plastic coffee cups by the coffee dispenser. During an interview conducted on 07/20/17, at 8:40 A.M., the resident's family said the following: -One day, about three months ago, the resident said he/she did not like a particular staff member. The family member asked why he/she did not like that staff member and the resident said because he/she caused him/her (the resident) to burn himself/herself with coffee. The family member did not know anything about the burn. The resident showed the family member a scabbed area, about an inch long, on his/her chest. The area looked like a healing burn. -The family member found the MDS coordinator and asked her what happened. The MDS coordinator did not know and asked staff. Staff told her, a staff member gave the resident a full cup of coffee in a Styrofoam cup which slipped out of the resident's hand. The resident told the family member the burn was horrible and really hurt. The MDS coordinator told staff she did not see anything about the incident documented and got on them about that. -When the resident showed the family member the burn on his/her chest, he/she did not know the resident also sustained a burn on his/her abdomen. By the time the family saw the burn on the resident's abdomen, it was pretty much healed and presented only as a quarter-sized pink area. -After the family member talked to the MDS coordinator, Resident #9 got a new handled cup with a lid to help prevent spills. -The family member was really concerned when he/she saw the burns, they were pretty bad, and he/she did not know why the staff did not tell him/her about the incident. The family member did not know if facility staff notified the physician of the incident but staff told him/her they were treating the burn. An observation and interview on 07/20/17, at 10:05 A.M., showed the following: -NA H and CNA G entered the resident's room to perform cares. The CNAs transferred the resident to his/her bed, pulled up his/her shirt which showed a quarter-sized area of pink skin on the resident's left lower abdomen. The resident's upper chest was reddened with a small pencil eraser-sized area of dark pink skin. -CNA sierra said he/she was not working when the resident sustained [REDACTED]. The resident had two fluid filled blister, one on his/her chest and one on his/her lower abdomen. During an interview conducted on 07/20/17, at 2:45 P.M., the DON said she remembered a family member voiced concerns, during a recent care plan meeting, regarding the resident getting burned from hot coffee. The DON was not aware of the incident until the family member brought it up in the care plan meeting. During an interview conducted on 07/20/17, at 3:30 P.M., the medical director said he was Resident #9's primary physician. He assessed the resident the day of or the day after she sustained coffee burns. He/she had some superficial burns (first-degree) and a couple of small blisters (second-degree). The physician did not remember if he ordered a treatment to the burns, the area mostly presented as a bad sunburn. During an interview conducted on 07/20/17, at 4:00 P.M., the MDS coordinator said on 04/19/17 the resident's family member came to me concerned about an accident with hot coffee. The MDS coordinator did not know anything about the resident sustaining burns from hot coffee and asked staff. The staff told the MDS coordinator they were treating the burns, they just did not document. After the MDS coordinator found out what happened, she bought handled cups with lids to prevent spills. She also added the intervention to the resident's care plan at the DON's direction. The MDS coordinator talked to the nurses about documenting incidents. Any time she finds something, like a treatment without an order, she notifies the ADON. The MDS coordinator did not know the coffee was 180 degrees F. 3. During an interview conducted on 07/19/17, at 5:38 P.M., CNA N said he/she knew of two residents, Resident #9 and Resident #11, who sustained burns from hot coffee. Resident #9 sustained burns all over his/her chest and on his/her left lower abdomen. Resident #11 sustained a large burn on his/her leg. Both incidents occurred not too long ago, around the same time. After the residents got burned, dietary started locking the coffee dispenser so none of the residents would have unsupervised access. If a resident asks, staff will add ice to the resident's coffee, but if the resident does not ask, staff tell the residents to let the coffee cool before drinking it. No one told the CNA of either residents' burns. She found both residents' burns, which presented as blisters, while performing cares on the residents. 4. During an interview on 7/19/17, at 5:55 P.M., CNA K said there had been residents burned by the hot coffee. The coffee is really hot and now, the staff are supposed to fill the coffee cups half way and put ice into the cup before serving the hot coffee to residents. When Resident #11 burned him/herself a new policy was put into place for Resident #8, #9 and #11 have special coffee cups with lids. 5. During an interview conducted on 07/20/17, at 2:45 P.M., the DON said the following: -When a resident sustains an injury, the nurse should assess the injury, document the assessment in the nurses' notes, complete an incident report, and contact the physician and resident's family. -The ADON reviews and investigates all incident reports and updates the care plans to reflect any new interventions related to the incident. The ADON usually tells the DON of the incidents during the quality assurance (QA) meeting, but they are talking all of the time; -The facility did not have an assessment specifically for hot liquids; -On 06/28/17, the Dietary Manage (DM) came to a QA meeting concerned about the potential for injury related to the temperatures of the coffee and wanted to discuss interventions they could put into place to decrease the potential for injury. Interventions included locking the coffee dispenser between meals and from 8:00 P.M. to 6:00 A.M. They were also going to in-service staff, add the protocol to the policy and add coffee temperatures to their quarterly QA meetings. They have not conducted in-services yet. -The nurses complete a weekly skin assessment and the DON reviews their documentation. During an interview conducted on 07/20/17, at 3:30 P.M., the medical director said the following: -He has been the facility's medical director for over [AGE] years. He does not routinely go to QA meetings; but staff keep him informed of any problems. 6. During an interview conducted on 07/20/17, at 3:30 P.M., the medical director said the following: -He has been the facility's medical director for over [AGE] years. He does not routinely go to QA meetings; but staff keep him informed of any problems. -Coffee served to residents should not be 180 degrees F. That is too hot and is dangerous. The physician recommends coffee be 160-165 degrees, he would even like to see it be 150 degrees F. -Because the coffee is so hot, they may need to place the coffee dispenser in the kitchen so the coffee cools down before reaching the residents. 7. An observation on 07/19/17, at 5:20 P.M., showed the following temperatures of the liquids from the coffee dispenser: -Coffee 279.0 degrees F; -How water 176.4 degrees F; -Hot chocolate 151.1 degrees F. 8. Observations and interviews of the dining room on 07/20/17 showed the following information: -At 7:00 A.M., the coffee dispenser was unlocked. Several resident were in the dining room awaiting the morning meal. No staff were present in the dining room and the kitchen doors were closed. Three residents sat in the dining room drinking coffee from hard plastic coffee cups. Resident #9 drank liquid from a handled cup with a lid. -At 7:07 A.M., dietary staff entered the dining room from the kitchen and a Certified Medication Technician (CMT) entered the dining room from the hall. -At 7:07 A.M., Dietary Aide (DA) L served a cup of coffee, without adding water or ice, to Resident #12. The resident said the coffee was hot and he/she had to wait for it to cool down; -At 7:17 A.M., staff served Resident #13 a cup of coffee from the coffee dispenser. The resident took a sip of the coffee, flinched and sat the coffee down on the table. The resident said coffee directly from the dispenser was hot enough to burn your mouth, that is why he/she waited a little while before taking a big drink. -At 7:20 A.M., DA L served Resident #14 a cup of coffee; the DA did not add water or ice to the cup before serving it to the resident. The Resident said the coffee was usually hot and he/she had to let it cool down before drinking it. He/she tested the temperature by sipping it carefully before drinking a lot. -At 7:45 A.M., A resident asked CNA O for a cup of coffee. The CNA gave the resident the coffee and told him/her to be careful, the coffee was hot. 9. During an interview conducted on 07/21/17, at 11:30 A.M., the DM said they did not monitor the coffee dispenser's hot water/coffee temperatures prior to the residents sustaining burns from hot coffee. During a QA meeting on 06/28/17, we discussed coffee temperatures and interventions to decrease the potential for injury. Starting today, the coffee dispenser will be locked at all times and staff will serve coffee out of a thermos. The coffee poured directly out of the dispenser was 180 degrees F.

Based on observation, interview and record review, the facility failed to utilize appropriate assistive devices and follow the facility's policy when transferring one resident (Resident #6) resulting in a fall that fractured the resident's leg. Staff involved did not report the fall to the charge nurse until the next day causing a delay in assessment and treatment of [REDACTED]. Record review of the facility's (undated) gait belt policy, provided by facility staff, on 07/31/15, showed each aide should use a gait belt when transferring and ambulating residents. Record review of instructions provided by the facility for the transfer pivot disc (a pivoting floor disc used by staff to assist a resident to turn during transfers) showed the following information: -The resident stands on the disc and staff rotate the disc in the direction of the turn. Then, the resident steps off the disc and transfers. -Staff should place the disc on the floor with the resident's feet positioned completely on the disc to facilitate a smoother transfer. -For maximum support and safety, it is recommended that staff use a sling or belt in conjunction with the disc. 1. Record review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 07/18/15, showed the following information: -Cognitively intact; -Required extensive assistance of two or more staff with transfers and toileting; -Left sided [DIAGNOSES REDACTED] (paralysis/inability to move muscles on one side of the body) from a stroke; -Transfer balance, not steady. Record review of the resident's care plan, dated 03/05/15, showed the resident as at risk for falls due to left sided paralysis from a stroke. Staff listed the following interventions: -Notify the physician and family if an incident occurs; -Assist of two staff and Hoyer lift (mechanical lift) for transfers. Record review of the nurses' notes, dated 07/23/15 at 1:38 P.M., showed staff documented the resident's left foot slipped off a transfer disc during a transfer. The resident complained of pain in the left knee and above the left knee. Nursing notified the resident's physician. Record review of the x-ray report, dated 07/23/15, showed the resident had a suspected large hemarthrosis (blood in the joint) and a possible acute fracture of the left lateral tibial plateau (upper shin bone). Record review of the resident's nurses' notes, dated 07/23/15 at 10:25 P.M., showed staff documented the physician called to follow up on the resident's incident. Staff applied ice to the resident's knee for pain and swelling. The physician gave an order to repeat the x-ray in one week and protect the resident's knee, as he/she may have a possible fracture. Record review of the incident investigation, initiated on 07/24/15 by the Assistant Director of Nursing (ADON), showed three staff assisted the resident, including certified nurse assistant (CNA) O, CNA H, and nurse aide (NA) I. Staff attempted to transfer the resident in his/her bathroom from a wheelchair to the toilet using a transfer disc and no gait belt. In the midst of transferring the resident, staff placed a gait belt on the resident. The resident's left foot slipped off the transfer disc and moved sideways by the wall. NA I noted the resident's foot was not on the disc after CNA O placed the gait belt around the resident. NA I said to CNA O his/her foot!, but CNA O continued to swing the resident around to the toilet with the resident's foot sideways, causing the resident's knee to twist. The restorative aide said, later in the day, during another transfer to the toilet, the resident complained his/her left knee hurt. Staff called the physician and received an order for [REDACTED]. During an interview on 07/30/15 at 2:30 P.M., CNA H said he/she assisted with the transfer of Resident #6, along with two other staff members. CNA H said he/she assisted with propelling the resident in his/her wheelchair into the bathroom. Two additional staff, CNA O and NA I stood on either side of the resident and assisted the resident to stand by holding onto the resident's arms. After assisting the resident to stand on the transfer disc, staff realized the resident did not have on a gait belt. The two staff attempted to place a gait belt around the resident in the bathroom while the resident stood. The resident's foot slid off the transfer disc during this time. One of the staff attempted to stop the transfer, but the other staff continued to attempt to pivot the resident. The inside of the resident's left foot was against the bathroom wall with the resident's toes pointed outward (externally rotated). The staff member continued to pivot the resident to the right, resulting in a twisting of the left leg away from the direction the resident's toes pointed. During an interview on 07/28/15 at 2:30 P.M., Resident #6 said staff assisted him/her in the bathroom. The resident's foot slipped in urine on the floor and he/she hit his/her knee. The resident said staff took him/her next door to the hospital. Later in the week, the physician told the resident he/she had a fracture. During an interview on 07/31/15 at 2:10 P.M., the resident's family member said the resident contacted him/her on 07/22/15 by phone and said staff dropped him/her in the bathroom, injuring his/her left leg. The fall happened on 07/22/15 at approximately 3:00 P.M. During an interview on 07/30/15 at 12:10 P.M., Licensed Practical Nurse (LPN) P said staff attempted to transfer Resident #6 off the toilet and the resident's foot slipped off the disc during the transfer. The LPN said staff did not notify him/her of the incident until the following day after it occurred. During an interview on 07/31/15 at 2:00 P.M., the Physical Therapist (PT) said the resident received physical therapy and was discharged three to four weeks ago. The PT said he worked with the resident on transfers, but did not recommend a transfer disc for Resident #6. The PT said he did not know staff currently used a transfer disc with the resident. The PT said he did not use transfer discs because they increased a resident's fall risk. Record review of Resident #6's physical therapy discharge summary, dated 07/07/15, showed the resident received PT service from 03/26/15 to 07/07/15 and would be appropriate to be discharged from PT with restorative therapy. During an interview on 07/30/15, at 3:00 P.M., the restorative aide said he/she had not started restorative therapy on the resident since the resident's discharge from physical therapy. The restorative aide said a former physical therapy company (a company used by the facility prior to the current company) had recommended the transfer disc for use on Resident #6. Record review of the resident's left knee x-ray report, dated 07/31/15, showed highly suspicious for occult fracture (hidden broken bone). Radiologist recommended further diagnostic tests. During an interview on 07/31/15 at 3:10 P.M., the Director of Nursing said she expected staff to use a gait belt at all times when physically assisting a resident with transfers or ambulation. The DON said staff should have placed a gait belt on Resident #6 prior to attempting to transfer him/her. The DON said staff should report a resident injury immediately to the charge nurse. The charge nurse should report to the physician and family. The DON did not know the resident did not have recommendations from PT for a transfer disk.

Based on observation, interview, and record review, the facility failed to ensure staff appropriately assessed, monitored, documented and placed interventions to ensure two residents (Residents #3 and #4) maintained adequate body weight out of nine sampled residents. Staff did not implement weight loss interventions in a timely manner to address Resident #3's weight loss and did not maintain an accurate care plan to address the resident's risk for weight loss and impaired nutritional status. Resident #3 had a loss of 27.6 pounds or 16.4% (severe weight loss) in five months. Staff did not provide adequate assistance and cueing for Resident #4 with meals and did not maintain an accurate care plan to address the resident's risk for weight loss and impaired nutritional status. Resident #4 had a 14.6 pounds or 12.3% severe loss in less than 30 days. In addition, staff failed to assess, monitor, or document when one resident (Resident #6) had a hospitalization and returned with a loss of 14.2 pounds or 10% (severe weight loss) in 60 days. Staff did not implement weight loss interventions in a timely manner to address Resident #6's weight loss. Staff did not provide adequate assistance and cueing for Resident #6 with meals and did not maintain an accurate care plan to address the resident's risk for weight loss and impaired nutritional status. The facility census was 36. Federal Guidelines define suggested parameters for evaluating significance of unplanned & undesired weight loss as: -1 month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; -3 months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; -6 months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. Record review of "The Diet Manual", a comprehensive resource and guide for facilities (available on the Department's website), Becky Dorner and Associates, Inc, Akron, Ohio, 2006 showed the following information: -The goal of medical nutrition therapy is to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem; -Significant weight loss (which also included a 1-2% weight loss in one week in addition to the federal guidelines); -Review the food intake records; -Assess the risk of malnutrition, identify potential causes, and document findings in the medical record; -Review the plan of care; -Interview the individual to identify possible causes and to determine appropriate interventions; -Request/implement nutrition interventions; -For residents that have 1% to 2% weight loss in a week, staff should provide individualized aggressive calorie augmentation. This may include, but is not limited to: high calorie/high protein supplement, whole milk or cream, extra mayonnaise or gravy on foods, pudding/ice cream/milk shakes/sherbet; enhanced foods (high calorie/protein), and cater to individual preferences as much as possible; -Confer with appropriate family, staff and physicians regarding intervention to be taken. Record review of the facility policy for weight loss, updated on 8/27/13, showed, in part, the following information: -It is the policy of this facility that all residents will be continuously well nourished while following the diet prescribed by their attending physician and as recommended by the consulting registered dietitian;-The following steps are to be followed to ensure this is done:-If it is noted a resident is not consuming all foods and fluids, they will be offered substitutes;-If a resident is noted to have weight loss, staff will attempt to determine the cause for the loss, i.e., medications, underlying disease process, change in mood, placement during dining. Once a cause is identified it will be treated as indicated, with input from the attending physician, Director of Nursing (DON) and registered dietitian (RD);-The individually based processes will be documented in the resident's chart and on their individualized care plan;-If a resident is on the weight loss program, they will be observed during the eating process to see if assistance from staff is needed;-This process will be continued until the resident stabilizes in weight;-The resident's care plan will be updated as indicated with addition or deletion of any and all interventions;-Many of our resident's can't afford to reach the guideline of 5% or more in a 30 day period or 10% in 180 day period, therefore the DON has chosen to follow a four pound loss or gain as the marker for placing a resident on the facility weight loss program. This is in addition to the Minimum data set guidelines;-If a resident is assessed and found to require a nutritional supplement, the facility will start with the Carnation Instant Breakfast (CIB) milkshake (high calorie supplement) to be given after meals in an attempt to entice the resident to eat nutritional food;-In addition to the CIB, it may be determined a resident requires the facility-approved condensed nutritional supplement as well;-Any resident who has the potential for and/or actual weight loss will be reviewed every week. 1. Record review of Resident #3's weight flow sheet showed the following information:-On 3/28/14: 167.4 pounds;-On 4/4/14: 161 pounds (a 6.4 pound loss);-On 5/5/14: 153.8 pounds (a 13.6 pound loss or 8.1% severe loss). Record review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/14/14, showed the following information:-Severe cognitive impairment;-Extensive staff assistance for transfers and mobility;-Supervision and set-up assistance for eating;-Weight 154 pounds:-Loss of 5% or more in last month: Yes, not on physician-prescribed weight loss program;-[DIAGNOSES REDACTED]. Record review of the care plan, dated 5/21/14, showed the following information:-Resident had a stroke and has trouble chewing and swallowing;-Diet as ordered;-Remind resident to take his/her time eating;-Staff did not develop problems, goals, or interventions to address the resident's weight loss. Record review of the weight flow sheet showed the following information:-On 6/11/14: 146.0 pounds;-On 7/9/14: 141.6 pounds (a 90 day loss of 25.8 pounds or 15.4% severe loss). Record review of the July 2014 physician order sheet (POS) showed the following information:-Mechanical soft diet with nectar thickened liquids. -Staff did not document any further dietary orders and/or dietary interventions. Record review of the nutrition assessment and dietary progress notes showed staff and/or the RD had not documented on the resident since 2/12/14. Staff did not document any assessment, monitoring, or interventions put into place to address the resident's weight loss. During the initial tour of the facility on 7/28/14, at 2:30 P.M., licensed practical nurse (LPN) C said the resident was alert and oriented. The resident required extensive staff assistance; he/she had a stroke. LPN C said the resident did not have any concerns with weight loss. The resident fed him/herself at meals. Observation on 7/29/14, showed the following information:-At 11:10 A.M., the resident sat in the dining room at the assist table;-At 11:31 A.M., the staff served the resident mechanical soft chicken/rice, broccoli and a cookie. Staff did not offer the resident any choices for lunch;-From 11:32 A.M. to 11:57 A.M., the resident ate independently. The resident ate approximately 50% of the chicken dish and broccoli, and the entire cookie. Staff did not offer other foods to resident;-At 11:58 A.M., the resident propelled his/her wheelchair up the hall corridor;-At 12:15 P.M., the resident sat in the wheelchair in his/her room. The resident said the lunch was "alright". He/she liked the cookie. Observation on 7/30/14, showed the following information:-At 11:17 A.M., the resident sat in the dining room at the assist table. The staff served the resident a grounded meat, Brussels sprouts, potatoes and cake. Staff did not offer the resident any choices for lunch. The resident ate independently;-At 11:34 A.M., the resident had eaten 50% of the meat and Brussels sprouts, no potatoes and 75% of the cake; -At 12:22 P.M., the resident had eaten 75% of the meal. The resident said he/she liked the cake. Record review on 7/30/14, of the resident's care card (a computer generated form placed in the resident's closet and used by staff for directing care) dated 3/23/13, showed the following information:-Diet: pureed/nectar thick liquids;-Supplements needed: None;-Resident is NPO (nothing by mouth due to difficulty with swallowing;-Fluids per tube feeding (tube surgically inserted into the stomach to administer nutrition and hydration);-Food intake: tube feeding only;-Staff had not updated the care card to reflect the resident's current level of care and weight loss. Record review of the quarterly MDS, dated [DATE], showed the staff did not use the resident's tube feeding for nutrition/hydration. Interview and record review on 8/1/14, at 10:30 A.M., showed the restorative nursing assistant (RNA) said the resident weighed 139.8 pounds (a 27.6 pound loss or 16.4% loss since 3/28/14). During an interview on 8/4/14, at 1:06 P.M., the DON, administrator, and dietary manager (DM) said Resident #3 had several hospitalization s. They had not documented on the resident or made any follow-up assessments regarding his/her weight loss. During an interview on 8/5/14, at 1:06 P.M., the DON said the staff reviewed Resident #3's weight loss history over the last few months. The RNA said he/she felt the resident was accepting the nectar thickened liquids and eating better. Staff will be offering Resident #3 snacks from the snack cart, the special cake and fluffy foods during activities. Record review of a fax received on 8/11/14, showed the following information:-The RD completed a nutrition assessment on 8/6/14;-The RD recommended 2 Plus (high calorie supplement) 60 cc twice a day plus 300 calorie dessert twice a day and weekly weights. 2. Record review of Resident #4's nutrition assessment and dietary progress notes showed the following information:-On 7/24/13, staff last documented on the resident. The resident's weight was stable at 125.4 pounds;-Staff did not document any further information. Record review of the weight flow sheet and weekly weights showed on 4/3/14, the resident weighed 120.2 pounds. Record review of the care plan, dated 4/16/14, showed the following information:-Regular no added salt diet related to [MEDICAL CONDITION];-Monitor meal intake;-Monitor weight monthly;-Notify physician with weight gain or loss;-Offer a substitute if resident does not want or like what is served. Record review of the annual MDS assessment, dated 4/22/14, showed the following information:-Severe cognitive impairment;-Independent with transfers and mobility;-Supervision and set-up for eating;-Weight 119 pounds. Record review of the weight flow sheet and weekly weights showed the following information:-On 5/5/14: 118.4 pounds;-On 6/11/14: 118.8 pounds. Record review of the June 2014 POS showed the following information:-Diet orders for regular no added salt diet.-Carnation instant breakfast (CIB) milkshake (high calorie supplement) 240 cubic centimeters (cc) twice a day (no start date);-On 6/25/14, staff marked across the CIB as discontinued;-Staff did no document any further dietary orders and/or dietary interventions. Record review of the July 2014 POS showed the following information:-Diet orders for regular no added salt diet.-Staff did not document any further dietary orders and/or dietary interventions. Record review of the weekly weights showed on 7/18/14 the resident weighed 104.8 pounds. Record review of the quarterly MDS assessment, dated 7/18/14, showed the following information:-Weight 119 pounds (staff documented the resident weighed 104.8 pounds on 7/18/14 which indicated a loss of 13.6 pounds in 30 days or 11.4% severe loss);-Staff did not check the resident had a loss of 5% or more in the last month. Record review of the weekly weights showed the following information:-On 7/25/14: 103.8 pounds (a loss of 14.6 pounds or 12.3% severe loss in less than three months). Observation on 7/29/14, showed the following information:-At 11:29 A.M., the resident sat at the dining room table. Staff served the resident chicken/rice, broccoli and a cookie. Staff did not offer the resident any choices for lunch; -Between 11:30 A.M., and 12:25 P.M., the resident ate independently. The resident had eaten less than 20% of the meal. He/she pushed the food on the plate. The resident sat with his/her eyes closed and head down several times throughout the meal. Staff did not offer any cues or prompts. Staff did not offer other food items to the resident. Observation on 7/30/14, showed the following information:-At 11:14 A.M., the resident sat at the dining room table. Staff served the resident a meat, Brussels sprouts, potatoes, and cake. Staff did not offer the resident any choices for lunch. The resident had only eaten a few bites of the meat;-At 11:21 A.M., the resident had eaten 25% of the meat, 1-2 bites of the Brussels sprouts, no potatoes, and no cake. The resident did not take any further bites and folded up the clothing protector onto his/her lap. Staff did not offer any cues or prompts. Staff did not offer other food items to the resident;-At 11:34 A.M., the resident had his/her head down and eyes closed. The resident did not take any further bites. Staff did not offer any cues or prompts. Staff did not offer other food items to the resident;-At 11:41 A.M., the resident had his/her head down and eyes closed. The resident did not take any further bites. Staff did not offer any cues or prompts. Staff did not offer other food items to the resident;-At 11:46 A.M., the resident did not take any further bites;-At 11:50 A.M., the resident had stacked his/her dishes up in front of him/her;-At 12:02 P.M., the RNA asked the resident if he/she wanted something else. This was the first prompt and cue from staff since 11:14 A.M. The RNA asked the resident if he/she wanted some ice cream, the resident said, "Yes."-At 12:15 P.M., the resident had eaten 100% of the ice cream. Record review of the resident's care plan, printed on 7/30/14, and the DON's handwritten notes added on 7/30/14, showed the following information:-On 5/16/14, staff discontinued weekly weights, weight stable;-On 7/1/14, weekly weights, check for fluid retention, monitor intake at meals, CIB milkshake twice a day, RNA to consider different seating in dining room. (Record review showed staff discontinued the CIB on 6/25/14, POS and treatment administration record (TAR) show staff did not restart the CIB in July 2014);-Staff did not develop any additional problems, goals, or interventions to address the resident's weight loss. Record review on 7/30/14, of the resident's care card (a computer generated form placed in the resident's closet and used by staff for directing care), dated 9/24/12, showed the following information:-Diet: regular no added salt;-Appetite: Good;-Food intake: 50-75%;-Supplements needed: None;-Staff had not updated the care card to reflect the resident's current level of care and weight loss. Interview and record review on 8/1/14, at 10:30 A.M., the RNA said the resident weighed 100.6 pounds (a loss of 19.6 pounds or 16.3% loss since 4/3/14). During an interview on 8/4/14, at 1:06 P.M., with the DON, administrator, and DM, the DM said the resident comes out to the dining room early and does not always eat lunch. The resident comes back to the dining room around 2:00 P.M. to 3:00 P.M. and wants a sandwich. Staff should be offering the resident "fluffy foods" (foods served at activities like cake and cookies), milkshakes and ice cream. They had not documented on the resident or made any follow-up assessments regarding his/her weight loss. The staff had discussed moving the resident to an assist table, but the resident sat with his/her family (who is a resident) and did not feel it would be a positive move. During an interview on 8/5/14, at 1:06 P.M., the DON said the staff reviewed Resident #4's weight loss. The resident had a decreased appetite and decreased intake. When asked, the resident said he/she was, "just not hungry". The DON requested labs to be drawn and notified the physician to assess the resident for a possible hospice consult. 3. Record view of Resident #6's weight flow sheet showed the following information: -January 2014: 142.0 pounds; -February 2014: no weight- resident hospitalized [DATE] to 2/26/14; -March 2014: 127.8 pounds (loss of 14.2 pounds or 10%) -April 2014: No weight noted; -May 2014: 128.0 pounds; -June 2014: 123.8 pounds. Record review of the quarterly MDS, dated [DATE], showed the following information: -Brief Interview for Mental Status (BIMS) score of 4 (represents severe cognitive impairment); -Weight: 124 pounds; -Weight loss of 5% or more in the last month or 10% or more in the last 6 months: Yes, no weight loss regimen; -Nutritional approach: Mechanically altered diet. Record review on 7/30/14, of the Dietary Consult and nutritional progress notes showed the following: -On 7/10/13, the RD completed an initial assessment; -The resident's weight was 129 pounds but the resident's family reported the resident has lost weight (unknown amount); -Resident feeds self with a good appetite; -The staff made no further documentation. Observations of the resident in the facility dining room on 7/29/14 showed the following: - At 11:17 A.M., the resident had a cup of hot chocolate, water and a clothing protector on the table; -At 11:35 A.M., the resident sat in wheelchair with a food plate on the table. The staff did not provide any assistance to the resident; -At 11:45 A.M., the resident did not eat off of the food plate. The staff did not offer any assistance with the meal; -At 12:00 P.M., the resident did not eat off of the food plate. The certified medical assistant (CMT) provided the resident's ordered medications. The staff did not offer any assistance with the meal; -At 12:03 P.M., the resident picked up the cookie off his/her plate and took a bite and placed the cookie back on the plate; -At 12:20 P.M., staff approached the resident and asked if he/she was hungry. The resident said, "I'm tired ", the staff walked away without offering any assistance with the meal; -At 12:24 P.M., staff asked the resident if he/she had finished eating and the resident said, "just about". The staff offered more coffee and the resident accepted it, but did not drink the coffee; -At 12:30 P.M., staff asked the resident what was wrong and the resident said, "Don't feel good". Staff offered to take the resident to his/her room and the resident agreed. The resident took a second bite of his/her cookie and laid it on the plate. Staff took the resident to the nurses' station and administered pain medication to the resident. Observations of the resident in the facility dining room on 7/30/14 showed the following: -At 11:10 A.M., the resident sat in the wheelchair with a meal plate on the table. Staff did not offer any assistance with the meal. The resident raised his/her head up occasionally and made several facial grimaces; -From 11:30 A.M. to 11:45 A. M., the resident took two bites of potatoes and one bite of meat. The resident sat with his/her head down with a hand resting on the side of his/her head. The resident continued to make facial grimaces; -From 11:45 A.M. to 12:00 P.M., the resident did not eat any of the meal. Record review of the care plan, printed on 7/30/14, showed the following information: -The resident sometimes does not finish eating meals due to confusion; -Needs verbal encouragement to finish meal; -Needs to have utensil placed in hand and cueing; -Feed as necessary; -Open container: arrange tray to make it easy for resident to reach. Offer one dish at a time to reduce confusion/distraction; -Place small amount of food on utensil PRN; -The DON handwritten notes added to the 7/30/14 printed care plan showed the following:-On 2/26/14: readmitted from hospital, weight is 127.8 pounds, weight before hospital stay 142 pounds. Has 14.2 pound weight loss. Staff did not document any problems, goals or interventions started for the resident's post-hospitalization weight concerns; -On 4/28/14 (two months later): start Carnation instant Breakfast (CIB) with ice cream at 10:00 A.M. and 2:00 P.M.; -On 5/16/14: Leave resident on the weekly weights; -Noted dentures not fitting well, speak with family about the problem (felt to contribute to not eating well), get approval to have dentist assess denture fit; -On 6/23/14: Out to dentist to have dentures assessed for fit and/or relined; -On 7/01/14: Had dentures assessed/fixed, CIB milkshake at 10:00 A.M. and 2:00 P.M. continue weekly weight; -On 7/15/14: Weight has stabilized, continue with current interventions. Record review on 7/30/14, showed staff had not placed a care card in the resident's closet. During an interview on 8/4/14, at 1:06 P.M., the DON, administrator, and DM said Resident #6 was in the hospital for two months. The resident lost the weight while in the hospital. The DON said when he/she came back from the hospital, the staff should have acknowledged and documented regarding the resident's weight loss and determined what interventions needed to be in place to prevent further weight loss. During an interview on 8/5/14, at 1:06 P.M., the DON said the following information:-Staff reviewed Resident #6's weight loss. The resident had been in the hospital for two months. When the resident readmitted , he/she had lost weight. The resident had stabilized over the last few months. However, the DON said the staff was going to continue to monitor the resident to ensure he/she had no further loss. Staff should have assessed the resident upon readmission, and had interventions and documentation in place at that time to address the resident's weight loss. 4. During an interview on 7/30/14, at 11:01 A.M., the DON said:-Staff discuss residents with weight concerns weekly. During meetings, the changes are noted and reviewed at the next meeting;-The new dietary manager started January 2014;-The DON said she knew there were problems with dietary and the weight management program. 5. During an interview on 8/4/14, at 1:06 P.M., the DON, administrator, and DM said the following information:-The RNA weighs the residents weekly and monthly as ordered;-The DON inputs the weights into the computer. She monitors for weight loss and uses a variance of four pounds instead of the 5% loss when putting interventions in place because some residents could not handle a 5% weight loss;-The RD comes to the facility monthly. The RD sees new admissions, residents with MDS assessments due and residents with weight loss;-The RD makes recommendations. She gives the recommendations to the DON and DM;-Nursing and dietary are both responsible for implementation of any new orders and interventions;-The previous DM was not actively involved in the weight management program. For this reason, the DON took over all aspects of the diets and weight loss;-The DON said she was not sure how much training the RD had provided the DM;-The DM said when she took over at the end of January 2014, the residents' food histories with likes and dislikes had not been kept up-to-date. There were so many issues in the kitchen when she took over, that had been her real focus. -The RD did identify areas of concern each month and was working on having the DM get more involved in the weight loss process;-The administrator said he thought the RD was seeing the residents with weight loss, but, "guessed she wasn't". 6. During an interview on 8/5/14, at 1:06 P.M., the DON said the following information:-Staff had their weekly weight meeting this morning (8/5/14). Since the interview with the surveyors on 8/4/14, nursing and dietary were now more on-track with each other and it was a very productive meeting. They discussed Resident #3, #4, and #6;-The DM was going to make a special high calorie cake to give the residents with weight concerns at 10:00 A.M., and 2:00 P.M.;-They were going to have a staff person in the dining room at meals, just to monitor residents and give cues and prompts;-The DM was going to try ordering extra calorie ice cream for residents.

Based on record review and staff interviews the facility failed to provide all staff with updated information related to bathing safety for one resident (Resident #1). Nursing staff failed to review the resident's care card and updated care plan to assure safe bathing process was used. Resident #1 sustained a serious injury while receiving a whirlpool bath instead of a shower. The resident slid from the whirlpool chair and became trapped by the strap holding the resident in the whirlpool chair causing four rib fractures that punctured the resident's right lung. The resident subsequently died at the hospital as a result of the punctured lung. A sample of four residents was selected for review (including Resident #1) based on receiving whirlpool baths from a facility census of 34. 1. Record review of Resident #1's medical record showed the following: -The facility admitted the resident on [DATE]; -Vital sign and weight flow sheet showed on [DATE], the resident weighed 227.2 pounds. -The resident's [DIAGNOSES REDACTED]. Record review of Resident #1's 14-day MDS (a federally mandated comprehensive assessment tool completed by the facility staff), dated [DATE], showed the following: -BIMS score of 15 (which indicated no cognitive impairment); -Activities of daily living showed the resident required limited assistance of two or more staff with bed mobility, transfers and toilet use, extensive assistance of one person for walking in room and corridor, dressing and personal hygiene, limited assistance of one staff on the unit and off the unit; -The resident required physical help in part of the bathing activity and was not steady during transitions and moving from a seated to a standing position. Mobility devices used by the resident included a walker and a wheelchair. Record review of the resident's care plan dated [DATE], showed the following: -The facility admitted the resident for further skilled nursing and therapy related to a recent stroke. The resident required assistance to stand, transfer, and walk due to weakness in all extremities and required assistance with most all movements; -On [DATE], staff documented on the care plan the resident was to receive showers only due to sliding in the whirlpool chair. Record review of the resident's care card (accessible to all staff in the resident's room on inside of closet door) showed staff documented on [DATE], the resident was to have showers only due to sliding. Record review of nurses' notes dated [DATE], showed staff documented at 11:04 A.M. the resident was in the whirlpool chair (WP) getting a bath. After completion of the bath, certified nurse aide (CNA) A lifted the resident up out of the WP tub in the WP chair and moved the chair over the side of the bath when the resident slid down in the WP chair. The belt on the WP chair caught the resident under the breasts. The resident's toes touched the floor. Staff documented additional staff came into the shower room, lowered the WP chair, and then transferred the resident to a wheelchair. The resident complained of pain in both hips and under the breasts. The resident's skin was intact. A family member of the resident came to the facility and staff informed the family of the incident. Staff left a message with an employee of the resident's physician's office. The resident rated the pain as 8 out of 10 and vital signs were 98% oxygen, blood pressure (BP) ,[DATE] and the resident's pulse at 70. Record review of the facility's investigation documentation, started on [DATE], showed the following: -On [DATE], CNA A was assigned to give resident baths because CNA B scheduled two days off. CNA B told CNA A there was a list in the bath house (shower/bath room) of the residents and who received bed baths, whirlpools or showers. CNA A told the Assistant Director of Nursing (ADON) on [DATE], that CNA B did leave a list in the bath house; -On [DATE], the ADON said CNA A said he/she reviewed the list on [DATE], but did not get the list out when giving showers and whirlpools on [DATE]. CNA A said he/she should have reviewed the list again on [DATE]. -On [DATE], CNA A told the ADON when he/she was in Resident #1's room the resident said, "I'd like to have a whirlpool instead of a shower". CNA A asked CNA D to assist with getting the resident into the WP chair. CNA D told CNA A the resident was not to have a whirlpool bath because something had happened with the WP chair and the resident. The resident received showers only. CNA A told the resident that he/she would check with another staff member. Resident #1 said he/she did not want to get anyone in trouble because normally he/she received a shower but a WP would be nice. CNA A checked with restorative nurse aide (RNA) E who replied, "I'm sure it is okay". CNA A proceeded to give the resident a WP bath with help from CNA F who assisted CNA A with transferring the resident from the wheelchair to the whirlpool chair with the assistance of a Sabina lift. -The ADON documented CNA A did not check the list on [DATE], for what type of bath to provide to the resident and did not check with a charge nurse or the Director of Nursing (DON) for clarification. Record review of the bath list left by CNA B for CNA A on [DATE], showed Resident #1 was to receive a shower. Record review of the resident's bath record dated [DATE], showed the following: -[DATE] and [DATE], the resident received a whirlpool bath. Out to the side of the [DATE] entry, staff wrote that the resident slid. -[DATE] through [DATE], the resident received showers. -On [DATE], the resident received a whirlpool. During an interview on [DATE], at 11:45 A.M., CNA B said during the first part of [DATE], he/she had the resident in the whirlpool and the resident slid down in the WP chair with the belt around the resident. The belt slid up to the upper part of the abdomen. CNA B said with four additional staff they were able to hold the resident up enough to release the belt and transfer the resident to a wheelchair. CNA B said from then on the resident received only a shower due to sliding in the WP chair. CNA B said the DON and all other staff were told, uncertain by whom. CNA B said on [DATE] and [DATE], the ADON scheduled CNA A to give baths, showers and whirlpools because CNA B went on vacation. CNA B left a list in the bath house for CNA A with the names of residents and who were to receive showers, baths, or whirlpools on [DATE] and [DATE]. The list showed Resident #1 was to receive a shower. CNA B was not aware of CNA A giving baths prior [DATE] and [DATE]. CNA B said CNA D knew the resident did not get a whirlpool bath because CNA B told CNA D on [DATE], when the first incident occurred. CNA B told CNA A of informing CNA D of this. During an interview on [DATE], at 12:15 P.M., occupational therapist (OTR) G said on [DATE], he/she heard muffled cries for help from staff. OTR G went to the bath house, as did RNA E, and found the resident had slid down in the whirlpool chair. CNA A was in front of the resident with her arms around the resident attempting to prevent him/her from sliding any further. Additional staff came to the bath house. Staff members positioned themselves on each side of the resident in an attempt to keep him/her from sliding any further. RNA E attempted to release the belt from around the resident and found it was too tight to release. The staff could not lift the resident high enough to release the belt. RNA E left the room and returned with a pair of scissors. RNA E then cut the belt to release the resident. OTR G said she overheard CNA A say, "I talked the resident into it, the resident was scared, and I told the resident it would be okay". During an interview on [DATE], at 12:45 P.M., CNA/certified medication technician (CMT) F said [DATE] was his/her first day back. CNA/CMT F said he/she was not aware the resident was a shower only and was not aware of the incident that occurred on [DATE]. CNA/CMT F said he/she assisted CNA A to transfer the resident from the wheelchair to the whirlpool chair and then he/she left the room. CNA/CMT F asked CNA A if they were doing what they were supposed to in reference to the type of lift to transfer the resident (Sabina lift vs. gait belt or Hoyer lift), and the type of bath to give (whirlpool vs. shower). CNA/CMT F said CNA A said, "Yes". CNA/CMT F said he/she did not work with the resident any further that day but was aware of the resident dying shortly after getting to the hospital that same day. CNA/CMT F said CNA A continued to work that day giving showers and baths. During an interview on [DATE], at 1:10 P.M., the ADON said, since the incident on [DATE], the facility had not provided in-servicing. She reported CNA A had worked the floor since [DATE]. The ADON said the incident occurred on [DATE] (Friday). CNA A was scheduled off the weekend ([DATE] and [DATE]), returned to work on [DATE] and worked through [DATE]. CNA A worked the floor during this time but did not give baths. She said CNA A did not normally do baths but that CNA B went over everything with CNA A before he/she left on vacation. The ADON reported she was gone on [DATE] and through the weekend. When she returned to work on [DATE], she started an investigation. At 4:10 P.M., the ADON said the DON told her she remembered CNA B telling CNA A about the resident sliding in the whirlpool chair on [DATE]. The ADON said the DON put notes in the resident's care plan and on the care card kept in the resident's room and the nursing station. The ADON said CNA A had given baths before. She said CNA A had a list with resident names and whether they were a shower or bath. CNA A told the ADON he/she looked at the list on Thursday but not on Friday. The ADON said CNA A asked RNA/CNA E about the resident. The ADON said she would expect CNA A to ask the charge nurse not the RNA/CNA. The ADON said the DON would do in-servicing sometime during the week of [DATE], on communication, who to go to with questions about resident care, and where to look for the information. During an interview on [DATE], at 1:30 P.M., licensed practical nurse (LPN) I said he/she was not aware the resident was not to have a whirlpool shower. LPN I said he/she was not aware of the incident on [DATE], until the resident was back in his/her room and the DON reported it to him/her. LPN I said he/she went to the resident's room and took vital signs. The resident's blood pressure was up and his/her oxygen level 98% with a nasal cannula in his/her nose and mouth. LPN I said the resident kept saying, "I need more air". LPN I said he/she told the resident his/her oxygen level was 98 % and normal and he/he had two sources of oxygen on at that time. LPN I reported the resident's vital signs to the DON and asked to remove one of the oxygen sources, the DON said yes. When LPN I went back to the resident's room the resident reported he/she had pain in the right upper abdomen area and hips. LPN said he/she thought the pain in the resident's upper abdomen was a result of the belt being caught in that area during the incident. LPN I said a resident family member came to the facility at that time to visit and LPN I updated the family member on the incident. LPN I then called the resident's physician, both cell and home numbers, and found the physician was out of town. LPN I then called the physician's office and left a message with the staff at the office. LPN I said he/she went back to the resident's room and took vital signs again and found no blood pressure in either arm, oxygen at 98 % and respirations normal. The DON told LPN I to talk with family and the family said they wanted the resident sent to the ER. The resident told LPN I he/she thought his/her ribs were broken. The resident kept indicating he/she needed more air and kept pushing on his/her chest. LPN I reported seeing some visual signs of shortness of breath. EMT's were called to transport the resident to the hospital next door. After two attempts to transfer the resident by the two EMT's, staff attempted to do a four person transfer which was unsuccessful. Staff then used a Hoyer lift to transfer the resident to his/her wheelchair. LPN I said no one asked for a statement until [DATE], and there had been no in-services since the incident. During an interview on [DATE], at 2:00 P.M., CNA A said he/she did not normally give baths but on [DATE] and [DATE], he/she was scheduled to be the bath aide while CNA B was on vacation. CNA A said this was the first time he/she had done baths or showers ever, she had assisted staff to place residents in whirlpool chairs, but never given the whirlpool bath to a resident. CNA A said there were no in-services or training on giving showers or whirlpools. CNA A said he/she did meet with CNA B before CNA B left on vacation and went over the paperwork to complete when giving baths and showers. CNA A said CNA B gave him/her a list for those two days with resident names and whether they received a shower or whirlpool and Resident #1 was shown as a shower on [DATE]. Resident # 1 said he/she was afraid of taking a whirlpool because he/she would get in trouble since he/she had been getting showers. CNA A said CNA D told him/her Resident #1 was not to have a whirlpool because of something about the whirlpool chair, but CNA D did not elaborate on the details. CNA A said it was not until after the incident occurred that CNA D told CNA A of the details why the resident received showers. On [DATE], CNA B told CNA A why the resident received showers not a whirlpool. CNA A said after the incident on [DATE], he/she returned to giving baths and showers on the hall and no one asked for a statement at that time. CNA A said when he/she came to the facility [DATE], to talk to the surveyor the ADON told him/her he/she was on administrative leave until the investigation was completed. During an interview on [DATE], at 2:35 P.M., CNA/CMT J, said when EMTs arrived he/she took them to the resident's room. The resident complained of pain under the right breast area and said he/she was having a hard time breathing. When staff transferred the resident to the wheelchair, the resident moaned and appeared short of breath. CNA/CMT J said he/she worked two days a week and was not aware the resident received only showers not whirlpools baths. During an interview on [DATE], at 3:30 P.M., RNA/CNA E said he/she was not aware of the incident on [DATE], when the resident slid in the whirlpool chair and did not know the resident was a shower only. He/she said when CNA A asked him/her to talk to the resident and tell him/her it was okay to take a whirlpool bath he/she just thought that resident had the right to take a whirlpool if he/she wanted. RNA/CNA E said when the EMT's arrived and staff transferred the resident to the wheelchair the resident said his/her ribs hurt and the resident was holding his/her right side rib area, grimacing and struggling to talk. At that time the EMTs took the resident to the hospital. During a telephone interview on [DATE], at 12:15 P.M., the physician who evaluated the resident in radiology, as he/she was in the dying process said it was unusual to break ribs and puncture lungs during a fall or incident. The physician said it was not uncommon for elderly residents to break ribs, but not to the extent that had happened to Resident #1. During a telephone interview with the resident's physician on [DATE], at 4:45 P.M., the physician said he was not aware of the incident that occurred on [DATE] and had no comment about whether the staff knew the resident was a shower only due to the incident on [DATE]. During a telephone interview on [DATE], at 2:20 P.M., CNA D said CNA A asked him/her to assist with getting the resident into the whirlpool. CNA D said he/she told CNA A the resident was not to have a whirlpool since the incident on [DATE] when the resident slipped down in the whirlpool chair and became caught in the seat by the belt. CNA D said he/she made it very clear for CNA A not to give the resident a whirlpool bath. CNA D said after the [DATE] incident he/she did not remember telling anyone but the DON about the resident sliding down in the WP chair. On [DATE], after CNA A asked for his/her help and he/she refused he/she did not tell anyone about his/her conversation with CNA A nor of CNA A wanting to give the resident a whirlpool not a shower. During a telephone interview on [DATE], at 10:10 A.M., the DON said on [DATE], at approximately 10:15 or 10:30 A.M., she was asked to come to the bath house and found the resident had slid down in the whirlpool chair. The resident was slumped down with his/her buttocks resting on CNA A's legs and other staff were holding the resident up. A staff member left the room to retrieve scissors to cut the belt that was under the resident's breast. The DON said the resident was distraught and slightly bluish. Staff placed a nasal cannula in the resident's mouth and another cannula in the resident's nose. The DON said no other assessment was completed at that time. Staff then wheeled the resident to his/her room and LPN I came in to do an assessment. The DON said she did not remember anything unusual except that the resident's oxygen was at 98 percent. The DON told LPN I to call the family and the physician. The DON said at that time a family member came to her office and asked that she come to the resident's room. Upon entering the resident's room the resident said he/she was nauseated. The resident was cold and clammy and due to the resident's history of heart issues the DON thought the resident needed to go to the hospital. The DON said on [DATE], when CNA B told her of the incident with the whirlpool she told CAN B to tell the charge nurse and she updated the care plan and care card. The resident was changed to a shower only. The DON said she was not in the daily report meeting and was uncertain if the information was passed from shift to shift. The DON said she knew CNA B left a list for CNA A and it showed the resident as a shower. She said after the incident CNA A returned to the floor and continued to give showers and baths. The DON said she started the investigation and getting statements from staff. The DON said her expectation of staff when they are uncertain what to do would be to go to their charge nurse, the ADON, DON or administrator. The DON said she thought the staff probably just thought CNA A wouldn't give the resident a bath. The DON said two family members contacted her and asked why the resident received a whirlpool because he/she was to have showers since the incident on [DATE]. The DON told family she would be doing an investigation. MO 629