Every finding on record at Aspire Senior Living Pleasant Hill

Based on interview and record review, the facility failed to ensure a comprehensive investigation was completed that included details of the circumstances of the fall, failed to complete a fall risk analysis of what occurred to cause the fall, failed to update the care plan and add interventions implemented to prevent the fall from recurring, and failed to complete a post fall assessment and failed to access for injuries for one sampled resident (Resident #3) out of three sampled residents who fell on 6/4/26 sustaining significant pain and bruising to the left side of face, head and neck. The facility census was 56 residents.Review of the facility's Fall Prevention Program policy dated 10/1/25, showed:-Each resident would be assessed for fall risk and would receive care and service in accordance with their individualized level of risk to minimize the likelihood of falls. -A fall risk assessment would be completed every 90 days and as indicated when the resident had a change in condition. -Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive care plan, monitored for effectiveness, and the plan of care would be revised as needed. -When a resident was at a high risk for falls, the facility would provide interventions that addressed unique risk factors measured by the risk assessment tool. -When a resident experienced a fall, the facility would:--Assess the resident.--Complete a post fall assessment.--Complete an incident report.--Notify physicians and family.--Review the resident's care plan and update as indicated.--Document all assessments and actions.--Obtain witness statements in the case of injury. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Chronic Kidney Disease Stage 3 (the kidney's function has been cut by half, and most patients experience ancillary problems like high blood pressure or bone difficulties).-Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).-Osteoporosis (a disease that weakens your bones and makes them much more likely to fracture). -Major Depressive Disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities). Review of the resident's General Durable Power of Attorney (DPOA-a legal document that gives one person (such as a spouse, relative, friend, or lawyer) the authority to make medical, legal, or financial decisions for another) dated 6/23/23 showed the resident had a legal DPOA in place and active. Review of the resident's Care Plan revised 1/26/26 showed:-He/She was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits.-He/She had impaired cognitive function related to Dementia.-He/She had potential for pain related to Osteoporosis.-Interventions for pain control included:--Anticipating the resident's need for pain relief and respond immediately to anycomplaints of pain.--Monitoring and documenting for probable cause of each pain episode. --Removing and limiting the cause of the resident's pain. where possible.-He/She was high risk for falls related to confusion. -The resident would not sustain serious injury from a fall through the review date. -Interventions for high fall risk included:--Communication with the resident/family/caregivers regarding the resident's capabilities and needs.--Anticipating and meeting the residents' needs.--Reviewing information on past falls and attempting to determine the cause of falls.--Recording possible root causes of falls. --Altering and removing any potential causes of falls if possible. --Educating resident/family/caregivers/IDT as to causes of falls.-No updates or interventions were added to the care plan after the resident had a fall on 6/4/26. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/6/26, showed he/she had severe cognitive impairment. Review of the resident's Incident Note dated 6/4/26 at 10:35 A.M., showed:-The hospice (end of life care) aide arrived at the facility to assist the resident with his/her bath and noticed the resident complaining of pain all over. -The hospice aide observed the resident had bruising to left side of his/her head. -The resident was wincing, arched forward, and crying out in pain. -The hospice nurse and the resident's DPOA were contacted by the hospice aide.-The hospice nurse and resident family requested that the resident be sent out to the hospital for evaluation and treatment.-Emergency medical Services (EMS) was called at 10:55 A.M.-EMS arrived at the facility and transferred the resident to the hospital at 11:10 A.M. Review of the resident's electronic medical record (EMR) on 6/9/26 at 10:00 A.M., showed:-No incident report was documented on 6/4/26 after the resident allegedly fell during the night shift.-No post fall assessment was documented on 6/4/26.-No vital signs were documented on 6/4/26. -No nursing evaluation regarding sustained injuries. -No neurological assessments were documented on 6/4/26. -No risk analysis assessment was documented on 6/4/26. Review of the resident's Incident Note dated as a late entry on 6/9/26 at 11:00 A.M., showed the nurse received report from the previous shift nurse that the resident was observed on the floor in his/her bathroom. During an interview on 6/9/26 at 2:30 P.M., Registered Nurse (RN) A said:-He/She was the day shift nurse on duty when it was brought to his/her attention by the hospice aide that the resident had injuries from a fall the previous night. -He/She was told in the morning report on 6/4/26 by the night shift nurse that the resident had a non-injury fall during the previous night shift.-He/She was not told the time that the resident fell during the night shift.-He/She did not contact the resident's DPOA or hospice care team to notify them about the resident's fall. -He/She was not sure if the night nurse contacted the resident's DPOA or hospice care team after the resident fell. -There was no documentation in the resident's chart that the DPOA or hospice care team was notified when the resident fell. -The hospice aide was the one who notified the resident's DPOA and hospice nurse after he/she observed that resident's injuries around 10:00 A.M on 6/4/26.-The resident fell sometime during the night shift on 6/3/26.-He/She was not monitoring the resident's vital signs after the fall due to being told that it was a non-injury fall by the off going nurse.-He/She was not performing neurological assessments on the resident's after the fall due to being told that it was a non-injury fall from the off going nurse.-He/She did not assess the resident until hours after the fall when the hospice aide brought the injuries to his/her attention.-He/She was unsure of the previous night nurse assessed the resident after the fall.-There was no documentation in the resident's chart to support a post fall assessment that was completed from the previous night shift nurse.-He/She did not complete an incident report on the fall with details of the fall.-The previous nurse did not complete an incident report on the fall with details of the fall. -He/She did not update the resident's care plan with new interventions after the fall.-The night shift nurse did not update the resident's care plan with new interventions after the resident fell.-He/She was not sure if there were any witnesses to the fall.-The night shift nurse did not provide witness statements for the fall or share if there were any witnesses.-There was nothing documented in the resident's medical record from the nurse who was on duty when the fall occurred at all.-It would have been expected that the nurse that was on duty when the resident fell to follow the fall policy and document everything that was done pertaining to the fall. -There was no investigation completed into the resident's fall.-A fall investigation should have been started and completed by the night nurse that was on duty when the resident fell. During an interview on 6/9/26 at 3:00 P.M., the Hospice Certified Nurse Assistant (CNA) A said:-He/She was visiting residents in the facility on 6/4/26 between 08:00 A.M. and 10:00 A.M.-When he/she went into the resident's room to give the resident a shower, the resident was in bed.-He/She noticed that the resident was moaning, crying, and had very significant bruising on the left side of the head and face.-The resident was screaming out in pain and that was very unusual for the resident. -He/She called the resident's hospice nurse and called the resident's DPOA to notify them of his/her findings. -He/She notified the day charge nurse, RN A, that the resident had bruising and was screaming out in pain.-RN A informed him/her that it was reported to him/her that the resident had a non-injury fall during the previous night. -RN A did not appear to be aware that the resident had injuries and was in pain. -No interventions were done to decrease the resident's pain or get the resident evaluated until he/she found the resident hours after the fall, laying in bed crying and with injuries. During an interview on 6/9/26 at 3:30 P.M., the resident's DPOA said:-He/She was notified by the resident's hospice aide several hours after the resident fell.-He/She went to the facility to check on the resident after being notified by the hospice aide about the significant injuries. -The resident had significant injury and should have been sent to the hospital as soon as the fall occurred.-The resident was crying and screaming in pain when he/she arrived at the facility several hours after the fall occurred. -He/She would have requested earlier intervention and pain control for the resident if he/she was contacted at the time of the fall.-He/She was never told the full story of how the fall occurred.-The resident was not assessed after he/she fell.-He/She was told by the hospice care team that the fall was never investigated by the facility. -As soon as he/she saw the resident's horrible condition, he/she requested that the resident be sent to the hospital for evaluation and pain control.-The facility did not assess the resident properly after the resident fell.-The facility could not provide any evidence that vitals were assessed after the resident fell.-The facility could not provide any evidence that neurological assessments were completed on the resident after the resident fell.-The resident must have hit his/her head when falling as evidence by the significant bruising to his/her head, neck and face.-The facility knew that the resident was a fall risk.-The resident was unable to speak for himself/herself or communicate needs due to the resident's dementia. During an interview on 6/9/26 at 4:23 P.M., the Interim Director of Nursing (DON) said:-He/She was the interim DON for the facility and acting in place of the Administrator who was currently on vacation. -It was the expectation that the nurse who was on duty when the resident fell was the nurse who contacted the resident's DPOA, the Administrator, the DON, the physician, and in this case, the hospice care team, after the resident fell.-The notifications should have occurred before the night shift was over and before the nurse left his/her shift.-The facility did not complete a fall investigation on the fall.-The nurse did not document a neurological assessment on the resident after the fall.-The nurse did not complete a risk analysis after the resident fell.-The nurse did not document vital signs or post fall assessment after the resident fell. -The nurse did not update the residents care plan with new interventions after the reident fell.-It was the expectation that the nurse followed the fall policy after the resident fell.-After the resident fell, the nurse should have assessed the resident, obtained vitals, started a neurological assessment, completed an incident report, completed a risk analysis, contacted the DPOA, DON, administrator and physician.-The nurse should have started and completed a fall investigation after the resident fell.-The nurse should have updated the resident's care plan after the resident fell.-The nurse did not follow the facility policy in handling the resident's fall. -The night nurse who was working the night that the resident fell was placed on administrative leave for not following the facility policy and will be educated on the policies and procedures. During an interview on 610/26 at 11:00 A.M., the Hospice Case Manager RN said:-He/She was not notified of the resident falling until contacted by the hospice aide the morning after the resident fell.-When he/she was notified of the resident's injuries by the aide, he/she called the resident's DPOA and went to the facility to assess the resident.-The resident had significant injuries and upon assessment, he/she decided that the resident needed to be sent to the emergency room for evaluation and treatment.-When he/she arrived at the facility the resident was screaming in pain and had bruising on the entire side of the left face, head, and neck. -The resident could at baseline move around and help with care but was unable to help at all or move when he/she arrived at the facility. -The facility did not perform neurological assessments on the resident after the fall.-It was apparent and obvious that the resident hit his/her head when falling.-This situation could have potentially been life threatening with major injuries and proper nursing assessments were not conducted by the facility to ensure that resident's safety after the resident fell. Complaint number: 3037533

Based on interview and record review, the facility failed to notify the responsible party for one sampled resident (Resident #3) when on 6/4/26 the resident had a fall with significant bruising and pain that resulted in being transported to the hospital for evaluation out of 3 sampled residents. The facility census was 80 residents.Review of the facility's Notification of Changes Policy dated 10/1/25 showed:-The purpose of the policy was to ensure the facility promptly informed the resident, consulted the residence physician, and notified, consistent with his or her authority, the resident's representative when there was a change requiring notification.-The facility must inform the resident, consult with the resident's physician and or notify the residents family member or legal representative when there was a change requiring such notification.-Circumstances requiring notification included accidents that resulted in injury and had potential to require physician intervention. Review of the facility's Fall Prevention Program Policy dated 10/1/25 showed when a resident experienced a fall the facility would notify the physician and the family. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).-Osteoporosis (a disease that weakens your bones and makes them much more likely to fracture). Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 4/6/26, showed he/she had severe cognitive impairment. Review of the resident's Care Plan revised 1/26/26 showed:-He/She was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits.-He/She had impaired cognitive function related to Dementia.-Interventions included communication with the resident/family/caregivers regarding the resident's capabilities and needs. Review of the resident's General Durable Power of Attorney (DPOA-a legal document that gives one person (such as a spouse, relative, friend, or lawyer) the authority to make medical, legal, or financial decisions for another) dated 6/23/23 showed the resident had a legal DPOA in place and active. Review of the resident's Incident Note dated 6/4/26 at 10:35 A.M., showed:-The hospice (end of life care) aide arrived at the facility to assist the resident with his/her bath and noticed the resident complaining of pain all over. -The hospice aide observed the resident had bruising to left side of his/her head. -The resident was wincing, arched forward, and crying out in pain. -The hospice nurse and the resident's DPOA were contacted by the hospice aide.-The hospice nurse and daughter requested that the resident be sent out to the hospital for evaluation and treatment.-Emergency medical Services (EMS) was called at 10:55 A.M.-EMS arrived at the facility and transferred the resident to the hospital at 11:10 A.M. During an interview on 6/9/26 at 2:30 P.M., Registered Nurse (RN) A said:-He/She was the nurse on duty when it was brought to his/her attention by the hospice aide that the resident had injuries from a fall the previous night. -He/She was told in the morning report on 6/4/26 by the night shift nurse that the resident had a non-injury fall during the previous night shift.-He/She was not told the time that the resident fell during the night shift.-He/She did not contact the resident's DPOA or hospice care team to notify them about the resident's fall. -He/She was not sure if the night nurse contacted the resident's DPOA or hospice care team after the resident fell. -There was no documentation in the resident's chart that the DPOA or hospice care team was notified when the resident fell. -The hospice aide was the one who notified the resident's DPOA and hospice nurse after he/she observed that resident's injuries around 10:00 A.M on 6/4/26.-The resident fell sometime during the night shift on 6/3/26.-The facility policy stated that the nurse on duty when a resident fell was to contact the resident's DPOA and hospice care team to notify them of a resident's fall. -The expectation was that the night nurse should have called the resident's DPOA and hospice care team when the resident fell during the night shift the previous night. During an interview on 6/9/26 at 3:00 P.M., the Hospice Certified Nurse Assistant (CNA) A said:-He/She was visiting residents in the facility on 6/4/26 between 08:00 A.M. and 10:00 A.M.-When he/she went into the resident's room to give the resident a shower, the resident was in bed.-He/She noticed that the resident was moaning, crying, and had very significant bruising on the left side of the head and face.-The resident was screaming out in pain and that was very unusual for the resident. -He/She called the resident's hospice nurse and called the resident's DPOA to notify them of his/her findings. -The resident's DPOA was not aware of the fall when he/she notified them.-The hospice nurse was not aware of the fall when he/she notified them.-The facility did not contact the resident's DPOA or the hospice care team about the resident's fall. -He/She notified the day charge nurse, RN A, that the resident had bruising and was screaming out in pain.-RN A informed him/her that it was reported to him/her that the resident had a non-injury fall during the previous night. -RN A did not appear to be aware that the resident had injuries and was in pain. -Note: Left a voicemail on 6/9/26 at 3:30 P.M., and again on 6/10/26 at 10:00 A.M., for the night nurse who was on duty when the resident fell. As of 6/10/26 at 1:00 P.M., the nurse has not returned the call. During an interview on 6/9/26 at 3:30 P.M. the resident's DPOA said:-He/She was never notified by the facility about the resident's fall.-He/She was notified by the resident's hospice aide several hours after the resident fell.-He/She went to the facility to check on the resident after being notified by the hospice aide about the significant injuries. -The resident had significant injury and should have been sent to the hospital as soon as the fall occurred.-The resident was crying and screaming in pain when he/she arrived at the facility several hours after the fall occurred. -He/She would have requested earlier intervention and pain control for the resident if he/she was contacted at the time of the fall.-He/She was never told the full story of how the fall occurred.-He/She was never told what time the fall occurred during the night shift. -He/She had never spoken to the nurse who was on duty when the resident fell. -His/Her first contact with the facility staff about the resident's fall was when she arrived at the facility after the hospice aide contacted her. -As soon as he/she saw the resident's horrible condition, he/she requested that the resident be sent to the hospital for evaluation and pain control.-It was the policy of the facility to contact him/her when the resident had a fall as he/she has an active DPOA on file for the resident and makes all of the resident's medical decisions.-The resident was unable to speak for himself/herself or communicate needs due to the resident's dementia. During an interview on 6/9/26 at 4:23 P.M., the Interim Director of Nursing (DON) said:-He/She was the interim DON for the facility and acting in place of the Administrator who was currently on vacation. -The DPOA should be notified as soon as possible after a resident has fallen.-It was the expectation that the nurse who was on duty when the resident fell was the nurse who contacted the resident's DPOA, the Administrator, the DON, the physician, and in this case, the hospice care team, after the resident fell.-The notifications should have occurred before the night shift was over and before the nurse left his/her shift.-The night nurse who was working the night that the resident fell was placed on administrative leave for not following the facility policy and will be educated on notification of DPOA policy. During an interview on 610/26 at 11:00 A.M., the Hospice Case Manager RN said :-He/She was not notified of the resident falling until contacted by the hospice aide the morning after the resident fell.-When he/she was notified of the resident's injuries by the aide, he/she called the resident's DPOA and went to the facility to assess the resident.-The facility did not contact the residents' DPOA and notify the DPOA of the resident falling.-The resident had significant injuries and upon assessment, he/she decided that the resident needed to be sent to the emergency room for evaluation and treatment.-When he/she arrived at the facility the resident was screaming in pain and had bruising on the entire side of the left face, head, and neck. -The resident could at baseline move around and help with care but was unable to help at all or move when he/she arrived at the facility. Complaint number: 3037533

Based on observation, interview and record review, the facility failed to provide written notification of room changes for two sampled residents (Residents #4 and #7) out of three residents sampled for room change notification. The facility census was 70 residents.Review of the facility's policy titled, Change of room or roommate showed:-Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible.-The notice of a change in room or roommate will be provided in writing and will include the reason(s) why the move or change is required.-The Social Services (SS) staff can assist the resident to adjust to the new room or roommate by informing the resident and family as soon as possible of the room or roommate change. 1. Review of Resident #4's admission record dated 11/11/25 showed the resident admitted to the facility on [DATE]. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/22/25 showed the following staff assessment of the resident:-Was residing in a room on the back hall of the facility.-Was cognitively intact.-Had adequate vision and hearing.-Understood others and was understood by others.-Had clear speech. Review of the resident's medical record showed no room change notice. Observation on 2/13/26 at 9:04 A.M. showed the resident resided in a room in the front of the building. During an interview on 2/13/26 at 9:04 A.M., the resident said:-His/Her roommate in the front of the building went to the rehabilitation unit in the back and wanted him/her to be his/her roommate back there, so the facility let him/her move back there with his/her roommate. -His/Her roommate went to the hospital and didn't return to the facility, so facility staff didn't let him/her stay in that room.-He/She was not given a written notice of the room change.-He/She talked with SS about his/her room change.-He/She was not sure how long ago he/she was moved up front. During an interview on 2/13/26 at 9:45 A.M., SS said:-The resident was up front before, and his/her roommate moved to the back unit and that resident requested that the resident move to the back with him/her.-The resident's roommate went to the hospital and didn't come back so they moved the resident back up front.-The resident has been back up front about six weeks. During an interview on 2/13/26 at 3:10 P.M., SS said:-He/She did not give the resident a written room change notice.-The previous company did not do written notices for room transfers (the new company took over 10/1/25).-The new company does have a room change form.-He/She didn't want the resident to move from the front to the back with his/her roommate in the first place because he/she knew his/her roommate was looking to live somewhere else.-He/She explained to the resident before moving from the front to the back that he/she would have to move back up to the front if his/her roommate moved out of the facility.-He/She gave the resident at least a one-day notice of the room change from the back to the front unit. During an interview on 2/17/26 at 11:13 A.M., the Director of Nursing (DON) and Administrator said they would have expected the resident/family/next of kin to be notified in writing. 2. Review of Resident #7's admission record dated 11/8/25 showed the resident moved to the facility on 9/10/25. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-Was residing in a room on the back hall of the facility.-Was cognitively intact.-Had adequate vision and hearing.-Understood others and was understood by others.-Had clear speech. Review of the resident's medical record showed no room change notice.Observation on 2/17/26 at 10:10 A.M. showed the resident resided in a room in the front of the building. During an interview on 2/17/26 at 10:10 A.M., the resident said:-He/She was moved from the back unit to the front unit a couple of weeks ago.-They said they were renovating and that he/she would be moved back but that did not happen.-The facility did not give him/her written notice of the room change. During an interview on 2/17/26 at 11:13 A.M., the DON and Administrator said:-They would have expected the resident to be notified in writing.-They thought the notifications might be in a pile that medical records needed to be scanned into the electronic health records.-They would provide the notice if it was found and as of 2/19/26, no notices have been provided. 2730199

Based on interview and record review, the facility failed to maintain dignity for one sampled resident (Resident #1) out of six sampled residents, when on 12/5/25, Activity Director (AD) A, became confrontational with the resident, used foul language and was disrespectful. The facility census was 75 residents.The Administrator was notified on 12/11/25 at 4:20 P.M. of the Past Non-Compliance. The facility immediately provided education for all employees on Abuse and Neglect and Customer Service. The deficiency was corrected on 12/6/25. Review of the facility policy on Professionalism-Customer Service dated 10/1/25 showed:-A customer was anyone within the facility including the resident.-Professionalism was a way of conducting oneself that included courtesy and respect for others.-The facility was the residents' home and was to have been regarded as such meaning that each resident was to have been always treated with compassion and respect.-When interacting with residents, the staff was to have considered what they would have wanted if in that position.-Staff was to never argue or bicker with residents and if staff felt themselves becoming angry or confrontational, the staff was to have stepped away from the situation and ask a co-worker or supervisor for assistance. Review of Resident #1's facility Face Sheet showed the resident was admitted on [DATE] with a diagnosis of Paraplegia (a condition when a person had no ability to deliberately control or move the muscles below the waist, usually because of damage to the nervous system). Review of the resident's quarterly Minimum Data Set- (MDS- a federally mandated assessment tool completed by staff and used for care planning) dated 11/7/25 showed he/she:-Was cognitively intact.-Had no issues with mood.-Had issues with behaviors such as verbal outbursts, yelling, screaming and refusing some cares. Review of the resident's Nursing Care Plan dated 12/1/25 showed:-The resident had a history of issues with his/her psycho-social well-being exhibited by verbal outbursts and refusing some medications when angry.-The staff was to allow the resident an opportunity to make choices and participate in care.-The staff was to discuss with the resident appropriate ways to channel his/her anger.-The staff was to never argue with the resident. Review of the facility Abuse Investigation dated 12/5/25 showed:-The incident occurred out in front of the facility by the entrance on 12/5/25 at approximately 1:00 P.M.-The incident was verbal in nature and no injuries occurred.-The incident took place between Resident #1 and AD A witnessed and first reported by Admissions and Marketing Director (AMD) A.-AD A approached Resident #1 to discuss the resident's concern over AD A having been late in delivering the resident's mail.-AD A yelled at the resident stating he/she was evil.-Upon entering the facility, AD A flung open the facility door which hit the resident's wheelchair wheel.-The summary of the investigation after having done staff and resident interviews showed the resident was sitting outside when AD A confronted him/her, yelling and calling him/her evil.-There was no injury as the door only hit the wheel of the resident's wheelchair and in interviewing the resident, he/she felt AD A spoke to him/her and acted inappropriately. -AD A was suspended pending the investigation and was terminated on 12/9/25. Review of AMD A's written statement dated 12/5/25 showed:-At approximately 1:10 P.M., on 12/5/25 he/she was fixing the arch decorations outside at the front of the facility.-Resident #1 was outside smoking in the designated smoking area when AD A came outside saying, Look, I am going to come straight up to you and say this.I did not withhold your mail on purpose. I am sorry I don't know all my job duties.-The resident then told AD A that if he/she didn't know his/her job, maybe he/she should ask for help.-AD A responded back to the resident that he/she had asked and got no help.-AD A then stated, I am sorry. I am trying to do my fucking job to get paid to support my kids. I have been a parent for 29 fucking years!-The resident did not respond and began heading inside when AD A following the resident, AD A said to the resident, You are fucking evil!-AD A then swung open the door accidentally hitting the resident's wheel of his/her wheelchair.-AD A then turned to the resident stating, I bet you are going to say I did that on purpose, too!, referring to hitting the wheelchair wheel with the door.-Resident #1 then stated he/she should call 911.-AMD A then intervened telling AD A to go inside and suggested that Resident #1 go speak with the Social Worker with whom he/she had a good relationship.-AMD A then escorted the resident to the Social Work office. During an interview on 12/10/25 at 2:15 P.M., AMD A said:-He/she was outside the front entrance putting up holiday decorations.-Resident #1 was outside smoking in the area.-AD A, who had only been in the position a month or so, came out to the area and immediately confronted Resident #1.-AD A said to Resident #1, I am going to come right out and say to you, I didn't withhold your mail on purpose.-Resident #1 remained very calm saying to AD A that he/she didn't say AD A held his/her mail back on purpose.-AD A then stated something like, I don't fucking know all the jobs in this position yet!-Resident #1 then said to AD A, Then ask someone for help.-AD A responded back to the resident that he/she had asked and got no help.-AD A was yelling at the resident when he/she spoke to him/her.-After that response, AMD A told AD A that he/she should go back inside.-When AD A went to go inside, Resident #1 was also going inside and when AD A flung open the door, the door hit the wheel of the resident's wheelchair.-The resident stated he/she was going to call 911, but AMD A suggested going to see the Social Worker instead and assisted the resident to the Social Work office.-He/she then went and reported the incident to Administration. During an interview on 12/10/25 at 2:4 P.M, the Social Worker said:-Resident #1 came to see him/her, escorted by AMD A, after the incident had occurred.-The resident was calm and did not appear to be afraid or severely upset.-He/she explained what happened saying he/she felt he/she needed to come talk. -They spoke about the incident calmly and then he/she went and got the resident's mail/check for him/her as it had recently arrived.-When the resident left, he/she was calm and said he/she was okay with how things were handled, however, felt that AD A needed to do his/her job. During an interview on 12/10/25 at 3:00 P.M., Resident #1 said:-AD A had worked in the business office before he/she took the AD position.-It seemed like AD A didn't know what he/she was supposed to do in the new position.-He/she was waiting on a check that usually came on the fourth of every month, but he/she hadn't gotten it yet.-He/she found out later that it hadn't come until the fifth, and he/she ended up getting the check from the Social Worker on the fifth, however, AD A came and confronted him/her after he/she had filed a grievance over not having gotten his/her mail/check.-He/she didn't feel like he/she needed to go into the whole incident, but AD A was mad, and he/she felt that was why AD A confronted him/her outside.-He/she kept calm the whole time and didn't really care that he/she had been a parent for 29 years.-He/she stayed calm the whole time and he/she was aware that he/she could get mouthy at times, but this time, he/she was not the one being loud and inappropriate.-He/she was aware that he/she could drop a few F-bombs, but this time he/she wasn't the one dropping the F-bombs, it was AD A.-The resident felt as though the interaction was inappropriate and disrespectful and he/she should have never been treated that way as AD A's job was to take care of him/her, not be disrespectful to him/her.-Being talked to the way AD A talked to him/her made him/her feel upset and disrespected.-He/she understood that hitting his/her wheelchair with the door was an accident and he/she overreacted at the time and felt better after he/she spoke with the Social Worker.-Prior to this incident, he/she got along with AD A. -He/she just wants the staff to do their jobs. Review of AD A's written statement taken on 12/5/25 by the facility Administrator showed:-AD A stated he/she had heard from multiple people that Resident #1 was gunning for AD A.-He/she said he/she went outside to talk with Resident#1 to apologize to the resident for not getting his/her mail to him/her in a timely manner.-He/she said Resident #1 began cussing and being loud and rude to him/her.-AD A said he/she got upset with the resident and told the resident that the resident was evil.-When he/she flung the door open, the door hit the foot peddle of the resident's wheelchair.-He/she said he/she never meant to hit the wheelchair that it was just an accident.-AD A said he/she never got in the resident's face or used the F word. During an interview on 12/10/25 at 3:20 P.M., AD A said:-He/she was new in the position but had worked at the facility for a few months.-He/she got no training in his/her job and didn't know what he/she was supposed to do.-He/she always went over and above in his/her job, even staying late to help residents and coming in on the weekends on his/her own time, so he/she had no idea why he/she got fired.-He/she stayed over and came in on weekends without pay because his/her supervisor had been riding his/her ass over having too much overtime.-He/she did come to confront the resident because the resident had filed a grievance on him/her over not getting a check in the mail that hadn't even come in yet.-He/she had never worked in healthcare but had worked in human resources and customer service and had been a parent for 29 years so felt he/she knew how to treat the residents.-He/she did tell the resident that the resident was evil, but he/she never used the F word. -He/she never raised his/her voice and would never raise his/her voice at a resident.-He/she knew he/she should have never told the resident he/she was evil, but he/she felt it was just a fight or flight response.-He/she feels that his/her livelihood should not have been taken away because of Resident #1. During an interview on 12/11/25 at 4:00 P.M., the Administrator and Director of Nursing (DON) said:-They would have never expected AD A to have confronted the resident in the first place.-All staff were educated in orientation and frequently thereafter, that the resident is always right, and they were to never be confrontational with any resident for any reason.-They would have never expected AD A to use foul language or raise his/her voice to the resident or any resident.-They felt it best to terminate the employee over the incident as they felt it was completely unacceptable behavior from any staff member. 2685913

Based on interview and record review, the facility failed to re-admit one resident (Resident #6) out of nine sampled residents, back to the facility after an inpatient psychiatric hospital stay and the resident was assessed and documented by the psychiatric hospital as being stable enough to return to the facility. The facility census was 80 residents. Review of the facility policy for Transfers, Discharges and Therapeutic Leaves, dated 6/26/19 showed:-Emergency Discharges were to have been completed only for medical reasons, or for the immediate safety and welfare of the resident/guest, or other residents/guests.-A physician's order for emergency discharges was to have been obtained, stating the reason the discharge was necessary on an emergency basis. 1. Review of Resident #6's facility Resident Face Sheet showed he/she was admitted to the facility with the following diagnoses:-High Blood Pressure.-Colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon).-Vascular Dementia (a type of cognitive decline caused by damage to the blood vessels in the brain).-Bi-polar Disorder (a mental health condition characterized by extreme mood swings between periods of mania (high energy, euphoria, and impulsivity) and depression (low mood, fatigue, and hopelessness).-Schizophrenia (a chronic mental illness characterized by a combination of symptoms that disrupt a person's thoughts, feelings, and behaviors).-Mood Disorder (a mental health condition characterized by a persistent and significant disturbance in mood). Review of the resident's Notice of Discharge for Emergency Situation-Safety of Individuals Endangered dated 8/19/25 showed:-The letter was directed to the resident, the resident's Guardian/Public Administrator, and the Ombudsman.-The letter was listed as a notice of discharge from the facility.-The letter was as a result of careful evaluation and in consultation with the resident's attending physician.-The facility concluded the safety of individuals in the facility were endangered by the resident's continued residence and therefore the resident was being discharged from the facility for the safety of all residents residing in the facility.-The safety of the other facility residents was of concern due to the resident's behaviors including his/her refusal to take any medications, resulting in aggressive behaviors toward staff, continued noncompliance with taking medications while at the hospital, the need for intramuscular (IM-a medical procedure where a medication or vaccine is injected directly into a muscle. medications for his/her severe anxiety and agitation, physical attacks on hospital staff and continued paranoid behaviors.-It was the responsibility of the facility to provide a safe environment for all residents in which to live.-The effective date of the discharge was 8/19/25.-The resident had the right to appeal with discharge within 30 days of the date of the notice. -Filing an appeal would allow him/her to remain in the facility until a hearing was held unless a hearing officer found otherwise.-However, the resident's discharge had already been effectuated, and it would have been unsafe to the facility to readmit the resident during the pendency of any appeal filed. Review of the Facility Attending Physician's letter written on behalf of the facility's decision to refuse the resident's readmission to the facility dated 8/21/25 showed:-The resident's recent history both prior to and since admission to the facility showed the resident's continued agitation, and bizarre behaviors.-While hospitalized , the resident was treated for a urinary tract infection with intravenous (IV-the administration of substances like fluids, medications, or nutrients directly into a vein through a needle or tube) antibiotics.-Following stabilization of his/her medical conditions, he/she was admitted to the facility where he/she continued with medication noncompliance, physical and verbal aggression towards facility staff and increased agitation.-There were concerns at the facility regarding other residents' safety due to the resident's behaviors.-Due to the resident's continued non-compliance and behaviors, he/she was sent to an inpatient behavioral facility.-The physician concluded that with the resident's psychiatric history coupled by his/her noncompliance with care, he/she was not a good candidate to return to the facility. During an interview on 9/11/25 at 11:30 A.M., the Ombudsman said:-He/She did get the notice of the resident's Emergency Discharge from the facility on 8/19/25.-He/She had been involved with the resident for quite some time now as the facilities had reached out for assistance with the resident's behaviors.-He/She had spoken to the resident on multiple occasions and had been involved in attempting to resolve the resident's past issues.-He/She was shocked with the current facility accepted the resident to their facility in the first place as they did not usually take residents with mental illness, and certainly not residents with the types of behaviors the resident had.-He/She did not believe the facility had accurate information on the resident from the hospital or they would not have accepted him/her.-He/She was aware the facility never obtained the resident's most recent PASRR (Preadmission Screening and Resident Review is a federal program that ensures individuals with mental illness, intellectual disabilities, or developmental disabilities are placed in the most appropriate, integrated setting and receive any needed specialized services) prior to the initial admission.-He/She felt that without recent and accurate information, the facility should have denied the resident's admission to the facility back in July when they first accepted him/her as a resident.-He/She was not surprised the facility refused to re-admit the resident after the inpatient psychiatric hospitalization. During an interview on 9/12/25 at 11:19 A.M., the Admissions/Marketing Coordinator (A/MC) and Director of Nursing (DON) said:-The facility should have never agreed to accept the resident in the first place back when the resident was sent by his/her previous facility to the hospital. -When the A/MC got the initial referral on the resident in mid-July, he/she flagged the referral as a yellow.-The facility had three levels of referrals, green which meant the resident was appropriate, yellow which meant the referral required an on-site visit for acceptance into the facility and a red meant the resident was likely not appropriate for admission.-The reason the resident flagged as a yellow was the history of behaviors such as throwing feces onto staff.-They did not get a lot of information on the resident prior to the resident's initial facility admission.-They requested the resident's PASRR but were never able to receive it from the hospital.-The DON who was new to the facility and still on his/her orientation, and A/MC went to visit the resident in the hospital and when they arrived, the staff were attempting to rouse the resident by doing a sternal rub (a medical procedure used to assess a patient's level of consciousness and response to pain, involving firmly rubbing the knuckles of a closed fist over the middle of the patient's sternum (breastbone), as the resident was not able to be awakened to interview and evaluate.-The DON attempted to get a copy of what medications the hospital had given the resident that would have make him/her so groggy, but the hospital staff refused to provide the DON with the medication record.-The hospital staff told the DON they were not able to release any documentation to the facility staff.-The A/MC reached out to the hospital Social Worker stating the onsite evaluation was unsuccessful and they would not be able to accept the resident into the facility. -The A/MC reached out to the Regional Admissions staff regarding his/her and the DON's concerns over accepting the resident.-A short time later, the A/MC had discharge orders for the resident's facility admission as the Regional Admissions staff had accepted the resident for admission to the facility. During an interview on 9/12/25 at 12:30 P.M., the facility Administrator said:-He/She acknowledged the facility should have never accepted the resident for the initial admission as they could not provide the resident the appropriate care.-The resident's behaviors concerned the facility staff as they were afraid the resident would lash out at another resident potentially causing injury.-He/She acknowledged the facility should have done more work on the front end of the resident's initial facility admission and they would not have had the issues they had.-He/She had to keep the other residents safe and allowing the resident to return to the facility would have placed those other residents, as well as the staff in potential danger.Complaint # 2574065

Based on interview and record review, the facility failed to ensure staff performed urinary catheter placement according to acceptable standards of practice for one sampled resident (Resident #1) out of 16 sampled residents resulting in pain and the presence of blood on the resident's bed after Licensed Practical Nurse (LPN) A attempted to insert the urinary catheter. The facility census was 83 residents. Review of the Facility's Nursing Procedures Manual for Urinary Catheterization revised 3/30/17 showed: -Catheters were to have been inserted by licensed nurses under the orders of the attending physician. -The standard of practice did not support routine changing of urinary catheters at any fixed interval. -The standard for urinary catheters was to change them as needed only. -The procedure for placing urinary catheters showed that after sterilizing the resident's perineal area (surface area between the thighs extending from the pubic bone to the tail bone), the tip of the urinary catheter tubing was to have been well lubricated up the tube approximately two to two and one-half inches. -The urinary catheter was to have then been gently inserted into the meatus (external opening of the urinary tract) approximately two to three inches or until urine flowed from the bladder. -If resistance was continually met, the nurse was not to have forced entry and report the issue to the nursing supervisor. 1. Review of Resident #1's Facility Face Sheet showed the resident was admitted on [DATE] with the following diagnoses: -Neurocognitive disorder with Lewy Bodies (a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Vancomycin-Resistant Enterococci (VRE-antibiotic resistant bowel infection) of the urine. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 3/12/25 showed he/she was moderately cognitively intact. Review of the resident's Physician's Order Sheet (POS) dated 5/13/25 showed the resident's Urinary Analysis (UA) came back positive for VRE, therefore the resident required a urinary catheter be placed to contain the urine for isolation purposes to prevent transmission. Review of the resident's Nurse's Notes dated 5/13/25 at 10:33 P.M., showed: -The resident told LPN C that LPN A was unable to place the urinary catheter and the resident was still in a lot of pain from it. -LPN C noted blood in the resident's brief but no visible external injuries. -An ambulance was called to have the resident taken to the hospital for evaluation and treatment. -LPN C spoke to the hospital emergency room (ER) nurse who stated they would do a urine test as well as a Computed Tomography (CT- scan, is a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) of the resident's abdomen and pelvis to check for any internal injuries. Review of LPN C's written statement dated 5/13/25 showed: -Around 5:30 P.M., LPN C noticed the resident had straight urinary catheter materials in his/her room but no catheter bag so he/she asked the resident if anyone had inserted his/her catheter. -The resident said no, the nurse had tried but couldn't get it in. -The resident said the nurse got a little urine in the tube and then left. -LPN C notified the former DON and Administrator A. During an interview on 6/3/25 at 3:30 P.M., LPN C said: -At around 5:30 P.M., he/she noted LPN A coming out of the resident's room. -He/She knew the resident was to have had a urinary catheter placed so he/she asked the resident if that had been done or not. -The resident then told him/her that LPN A tried to get the urinary catheter placed but was unsuccessful and left without placing the catheter. -He/she noted the resident's bed had blood on it near where the catheter would have been placed. -When he/she asked the resident if LPN A hurt him/her while attempting to place the urinary catheter, the resident said it did hurt. -If he/she had any issues with inserting a urinary catheter, he/she would have asked for assistance and not force the catheter tubing into the resident. -If there were continued issues with inserting the urinary catheter, he/she would have notified his/her DON. Review of the City Police Report for LPN A dated 5/13/25 at 8:11 P.M., showed: -The resident was located in an ambulance in the facility parking lot awaiting transport to the hospital for further evaluation and treatment. -The resident said that he/she had received a catheter placement procedure from a nurse. -The resident stated during the place of the catheter, he/she was subjected to an unusual amount of pain, stating the nurse placed the device then removed it, leaving the room. -When the resident told the nurse he/she was in pain, the nurse said nothing, turned, leaving the room without replacing the catheter. - The resident reported the incident to another nurse saying that nurse the nurse hurt me and I am bleeding. -The resident stated that he/she had catheters placed in the past, including one just placed within the past week, and none had been painful like the last on and none had ever caused him/her to bleed. -The resident was then transported by ambulance to the hospital for evaluation and treatment. Review of the resident's Verification of Investigation dated 5/13/25 showed: -The resident made a statement, He/She hurt me and made me bleed. He/She took my pee and left, after having LPN A insert the resident's urinary catheter. -The resident was assessed as having been alert and oriented with occasional confusion. -He/She was frequently incontinent of urine and often refused to allow the staff to assist him/her. -Upon investigation, it was determined the nurse, LPN A appeared to have been under the influence. -At that time, LPN A went to the resident's room to perform a urinary catheterization. -When the resident complained of pain and bleeding from the urinary catheterization by LPN A administration removed the nurse who inserted the urinary catheter from all resident care. -The resident was sent to the hospital for evaluation of any potential trauma. -The resident returned from the hospital with no evidence of trauma. During an interview on 5/27/25 at 1:15 P.M., the resident said: -He/She did not recall anything about his/her urinary catheter placement. -He/She did not remember anything about the nurse or the events of 5/13/25. -He/She stated, My memory isn't so good anymore. During an interview on 5/27/25 at 4:15 P.M., the DON and Administrator B said: -They would have expected that given LPN A appeared to be impaired, or at the least, struggling with his/her shift, that he/she would not have attempted to place a urinary catheter in the resident. -They never wanted any harm to come to a resident at the hand of a staff member. -They would have expected the employee to have submitted a urine drug screen on site and that as soon as there was sufficient indications from other employees that LPN A was behaving in a manner which could have been reasonable suspicion of working under the influence, LPN A would have been removed from resident care and tested. -They would have expected if there were issues in inserting the urinary catheter the nurse would have asked for assistance and/or notified the DON. MO00254215

Based on interview and record review, the facility failed to keep two residents (Resident #4 and #16), safe from posssible narcotic misappropriation when three milliliters (mls) was missing from Resident #4 and four mls from Resident #16's personal supply out of 16 sampled residents. The facility census was 83 residents. Review of the facility policy for Inventory Control of Controlled Substances revised 1/1/2013 showed: -The purpose of the policy was to set forth the procedures for inventory control of controlled substances. -The facility was to have maintained separate individual controlled substance records on all controlled substances with a potential for abuse or diversion in the form of declining inventory using the Controlled Substances Declining Inventory Record. -The Inventory Record was to show the resident's name, prescription number, medication name, strength, dosage form, dosage, total quantity received by the facility, the date and time of administration and the signature of the person administering the medication. -The facility staff was not to enter more than one prescription for a controlled substance medication on each page of a declining inventory record. -The facility staff was to ensure that the incoming and outgoing nurses count all controlled substances and other medication with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet. -The facility nurses were to reconcile the total number of controlled medications on hand, add newly received medications to the inventory and remove medications that were not completed or discontinued from the inventory. -The staff nurses were to reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet. -The facility nurses should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet, to the medication administration record. -The facility was to ensure that staff immediately reported suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up. -Upon receipt of such a report, the facility was to have ensured that the appropriate facility personnel confirm the discrepancy and follow facility policy and applicable law regarding documentation of the incident. -The facility should have also investigated to determine whether a dose was in fact administered and, if so, the reason the administration was not charged we well as whether a dose was refused by a resident. -A facility representative should have regularly checked the inventory records to reconcile inventory. -They should have reconciled current and discontinued inventory of controlled substances to the log used in facility's controlled medication inventory system; current inventor to the controlled medication declining inventory record and to the resident's Medication Administration Record (MAR); and, unused controlled substances held in storage awaiting destruction to the declining inventory record. 1. Review of Resident #4's admission Record showed he/she was admitted with the following diagnoses: -Congestive Heart Failure (CHF- a disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -Dilated Cardiomyopathy (a condition where the heart muscle weakens and the heart's chambers, especially the ventricles, enlarge causing symptoms including shortness of breath). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's May 2025 Physician Order Sheet (POS) showed a physican order for Morphine Sulfate 100/milligrams (mgs) (20 mgs/ml) oral concentrate, 0.25 mls (5 mgs) by mouth or under the tongue every three hours as needed for pain or shortness of air. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) date 5/6/25 showed he/she: -Was cognitively intact. -Had no stated pain during the look-back period. -Had shortness of air with exertion. During an interview on 5/23/25 at 3:05 P.M., Resident #4 said: -He/She was doing okay. -He/She was not aware any Morphine was taken from him/her. -He/She never missed a dose when asked for Morphine. -He/She mainly took the Morphine for shortness of breath. 2. Review of Resident #16's Facility Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Pneumonia (inflammation of one or both lungs with consolidation). -Chronic respiratory failure with hypoxia (a long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, resulting in persistent low blood oxygen levels). Review of the resident's significant change MDS dated [DATE] showed he/she was severely impaired. Review of the resident's POS dated 5/20/25 showed he/she no longer had a current order for Morphine. 3. Review of the Facility Verification of Investigation dated 5/13/25 showed: -LPN A was reported to the former Director of Nursing (DON) as suspected to have been working impaired during his/her shift on 5/13/25. -Licensed Practical Nurse (LPN) A was informed he/she needed to count the narcotics he/she was responsible for with another nurse. -Once he/she was told to count the narcotics, he/she handed his/her keys to another nurse and walked away leaving the facility to smoke a cigarette with the Administrator's knowledge. -The narcotics were immediately recounted by the former DON and two additional nurses and there was a noted discrepancy with the liquid Morphine for two residents, Resident #4 and Resident #16. -The unaccounted for Morphine was a combined total of 7 mls. -Resident #16 no longer had an active order for Morphine, and a new prescription was requested from the physician for Resident #4 to allow the facility to replace the resident's Morphine at the facility's cost. Review of LPN B's written statement dated 5/13/25 showed: on 5/13/25 at around 5:00 P.M., a full narcotics count was completed which showed two resident's Morphine liquid medication counts off. Review of LPN C's written statement dated 5/13/25 showed: -He/She and LPN B counted the narcotics and noted that two separate Morphine count numbers were off. -LPN C notified the former DON, Administrator A and the regional nurse. Review of the City Police Report for LPN A dated 5/13/25 at 8:11 P.M., showed: -The offense was listed as Abuse of healthcare recipient-physical, sexual, or emotional harm or injury. -The Incident Code was listed as stealing. -Administrator A was then advised there were two liquid Morphine counts off during shift narcotic count. -Administrator A also told city police that the Morphine bottles that had been tampered with were secured in an office where LPN A could not access them. -He/she also advised city police there was a total of 6.75 mls missing from the narcotics drawer in the medication cart from the start of the shift to the change of shift. -There were 3.75 mls missing from one Morphine bottle and 3.0 mls missing from a bottle that had been ordered for Resident #16 and had never been used. -The seal on the new bottle had been clearly tampered with. MO00254220

Based on interview and record review, the facility failed to ensure Unlicensed Registered Nurse (RN) A had a valid registered nurse (RN) license in order to provide nursing care to residents such as assessments, wound care, medication administration and all nursing cares allowed by law. This had the potential to affect all residents. The facility census was 78 residents. On 3/14/25, the Administrator was notified of the past noncompliance which took place over a period of time to include 5/3/24 through 1/30/25. Nurse licensing and state issued identification discrepancies were discovered during audits by the facility Wound Nurse. Education to address the problem was provided to facility staff, including the Director of Nursing (DON), Administrator, Financial Services, and Financial Services Assistant on 2/4/25. The deficiency was corrected on 2/4/25. Review of Facility assessment dated [DATE] showed: -Staff competencies for resident population included: --Abuse training. --Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) training. --Behavior management. -- Post-Traumatic Stress Disorder ((PTSD) is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it)/Trauma informed care (is an approach to healthcare, social services, and other systems that recognizes the prevalence and impact of trauma and seeks to minimize its harmful effects). --Wandering and elopement. --Wander alert system. --Secure unit. --Gradual dose reductions. --Psychoactive (affecting the mind) medications. -- Abnormal Involuntary Movement Scale ((AIMS) is a standardized tool used to assess and monitor involuntary movements) testing. -Skills needed for resident population included: -Medication Administration. --Oral medication. -- Intramuscular (IM) the injection of a substance directly into a muscle)/ subcutaneous ((SQ) beneath the skin) /intradermal injection ((ID) injection administered into the dermis, the layer of skin between the epidermis and hypodermis) injections. --Ophthalmic (eye) medications. --Inhalers/MDI ' s (meter dose inhalers). --Topical. --Otic (ear) medications. --Intravenous (IV) medications. --Enteral medications. --Insulin administration. ---Sliding scale. --Blood glucose monitoring. --Anticoagulant (commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) monitoring. --- Coumadin (a medication used to thin the blood for the prevention of blood clots and stroke). --- Prothrombin time ((PT) test measures how many seconds it takes for a clot to form in a blood sample) /International normalized ratio ((INR) s the specific blood test used to measure the time it takes for blood to form a blood clot). ---Bleeding precautions. --Wound Care ---Wound Vac (Negative-pressure wound therapy, also known as a vacuum assisted closure, is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess wound exudate and to promote healing in acute or chronic wounds)/Negative Pressure Wound Therapy (NPWT). ---Dressing changes. ---Wound classification and staging. ---Surgical incision care. ---Suture/staple removal. ---Cast/splint care. ---Adaptive equipment. --Immunizations. ---Influenza. ---Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms in most people. ---COVID (a disease caused by the SARS-CoV-2 virus). ---Pneumonia. ---Tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening. --Psychotropic Medication monitoring. ---Gradual dose reduction. ---AIMS testing. ---Behavior management. --Nutrition Administration/Monitoring ---Weight scales (Patient uses scales standing/lift) ---Dysphagia (inability or difficulty swallowing) symptoms. ---Percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) tubes ---Gastrostomy tube ((G-tube) is a thin, flexible tube inserted through the abdominal wall directly into the stomach. Its purpose is to provide an alternative route for delivering nutrition, fluids, and medications to patients who cannot eat or drink normally) tube replacement ---Enteral (A form of nutrition that is delivered into the digestive system as a liquid) feeding administration (continuous/bolus) ---Special diets. ---Thickened liquids. ---Adaptive feeding equipment. ---Intravenous (IV) fluids. --Respiratory (Lung) treatments/monitoring. ---Oxygen administration. ---Oxygen storage. ---Pulse oximetry (measures the amount of oxygen in the blood and the pulse) monitoring. ---Nebulizer (a device for producing a fine spray of liquid) treatments. ---Tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions) care. --- Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle). ---Bilevel positive airway pressure (BiPAP) it is a type of ventilator-a device that helps with breathing ---Aspiration (breathing in fluid or foreign material, especially stomach contents or food) precautions. ---Incentive spirometer (a medical device used to encourage deep breathing and improve lung function). --Investigations and accidents (I&A) prevention/assessment. ---I&A policy. ---I&A completion and documentation ---Care plan interventions. ---Root cause analysis. -- Dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). monitoring. ---Hemodialysis (process of filtering the blood of a person whose kidneys are not working normally). --- Peritoneal dialysis (a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood. --Gastrointestinal/Urinary. ---Indwelling catheter. (a thin, flexible tube inserted into the urinary bladder through the urethra to collect and drain urine. It remains in place for an extended period, typically days or weeks, to continuously drain urine). ---Suprapubic catheter ((SPC) a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen, used to drain urine when a person cannot urinate on their own or when a urethral catheter is not feasible) ---I&O catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder and then removed, used for intermittent bladder emptying, often for individuals with urinary retention or difficulty emptying their bladder) ---Incontinent care/peri care. ---Ostomies ((artificial or surgical opening) (Colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), Jejunostomy (a surgical procedure that creates an opening (stoma) in the jejunum, which is the middle portion of the small intestine)). ---Urostomy. --Infection Control/Contagious disease management. ---Transmission-based precautions ((TBP) are additional infection control measures implemented in healthcare settings to prevent the spread of infectious diseases that are transmitted through specific routes, such as contact, droplets, or airborne particles) (contact, droplet, airborn) ---Enhanced Barrier Precautions ((EBP) are an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in skilled nursing facilities (SNFs) by expanding the use of gowns and gloves during high-contact resident care activities). ---Personal protective equipment (PPE) don/doff (gown, gloves, mask) ---N95 mask application. ---Equipment cleaning and disinfection. --Activities of daily living ---Transfers. ---Baths/showers. ---Feeding assistance (calculated fluid intake and percentage of meals consumed). ---Side rails. ---Lifts (total, standing lift). ---Oral hygiene. ---Vital signs measurements (blood pressure, temperature, pulse, and respirations). ---Ambulation. ---Restorative nursing program. --End of life care. ---Hospice (special kind of care that focuses on a person's quality of life and dignity as they near the end of their life). ---Post-mortem (after death) care. ---Palliative care (specialized form of medical care that focuses on providing relief from pain and other symptoms of serious illnesses). ---Advanced directives (are legal documents that express a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness, injury, or incapacity). ---Pain management. --Emergency Care. ---Heimlich maneuver (known as abdominal thrusts, is a first-aid procedure used to dislodge a foreign object from a person's airway). ---Cardiopulmonary resuscitation (an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped). ---Crash carts. ---Ambu bag (also known as a bag-valve mask (BVM), is a handheld, self-inflating device used to provide positive pressure ventilation to patients who are not breathing or breathing inadequately, often in emergency situations). ---Significant change in status. --Intravenous/central lines. ---Midline catheters (type of peripheral intravenous (IV) catheter, longer than a short peripheral IV, typically inserted into a vein in the upper arm, with the tip positioned below the shoulder, but not reaching the central circulation) ---Peripherally inserted central catheter ((PICC) is a long, thin, flexible tube inserted into a vein in the arm and threaded to a large vein near the heart, used for long-term intravenous access and medication administration) lines. ---Peripheral I.V.'s (a small, short, flexible tube inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products, and is used for short-term treatments). ---Central lines (known as a central venous catheter (CVC), is a long, thin, flexible tube inserted into a large vein near the heart, used for administering medications, fluids, blood products, and drawing blood, often for long-term or complex treatments). ---Total Parenteral Nutrition ((TPN) (a medical treatment where all necessary nutrients are provided directly into the bloodstream through a catheter. It is used when a patient is unable to receive nutrition through their mouth or digestive tract). --Orthopedic (bones)/Musculoskeletal (muscles). ---Adaptive equipment (walkers, wheelchairs, canes/crutches) ---Recliners/adaptive seating. ---Positioning devices. ---Physical restraints. ---Splints/braces/immobilizers. -For any new admission of continuing care for residents with a new diagnosis or profile that required a different type or level of care from that listed above, the condition was reviewed to determine whether it might pose a challenge to the facility in meeting the needs of the resident. The Director of Nursing, or designee, reviewed the medical information for approval of the of the admission or recommendation for continued care. -The facility had the necessary care and services, equipment, and staff competencies that addressed the current and future needs of the facility. -Those items included care planning by nursing. -The facility offered seven days per week wound care by qualified professionals. -Medication administration all routes. -Risk assessments (falls, nutrition, elopement, pressure ulcer, etc.). -Respiratory treatments. -Weekly skin assessments by qualified nurses. -Weekday staffing was three Registered Nurses (RN). -Weekend staffing was two RN's. 1. Review of facility investigation dated 3/11/25 showed: -Unlicensed RN A was employed at the facility, as a RN, on the following dates 6/6/23-6/16/23; as a Staffing Coordinator (no resident care), and on 5/3/24-1/30/25 as a RN Charge Nurse. -During a routine audit of employee files, it was discovered that Unlicensed RN A had a different name than that of his/her state issued identification. -Unlicensed RN A worked in the capacity of a RN and provided skilled nursing care to residents until termination on 1/30/25. -Residents still in the facility were assessed for any negative outcomes and none were identified. -Interviewed residents did not voice any concerns with the care provided by the unlicensed staff. -Unlicensed RN A was suspended on 1/30/25 pending the results of the investigation. -Unlicensed RN A claimed to not know his/her RN license number. -Unlicensed RN A did not know when his/her license was renewed because his/her mother did that and paid for his/her license yearly, and that the facility would need to contact his/her mother to find out when the license was renewed. -Unlicensed RN A then said that his/her mother had forgotten to renew his/her license. -Unlicensed RN A was tearful and did not realize he/she did not have a current RN license. -Unlicensed RN A said it was a discrepancy with his/her name and the state licensing board. -The facility requested him/her to contact the state licensing board and get the matter straightened out and provide them with the necessary documentation. -Unlicensed RN A claimed to have called the state licensing board and was waiting on a call back. -The facility requested transcripts from the nursing program and Unlicensed RN A agreed to get them but never produced the transcripts. -The facility called a neighboring state licensing board and were able to verify that the license number Unlicensed RN A provided to the facility did not match the social security number or date of birth of Unlicensed RN A. -A search of the state licensing board showed no license for Unlicensed RN A. -When the facility informed the Unlicensed RN A of this information he/she admitted that they had taken the National Council Licensure Examination (NCLEX) exam for his/her nursing license and provided screen shot of the registration for the exam and when asked the results he/she reported that it was a failing score. -Unlicensed RN A stated they never retook the test. -When investigation was completed both state licensing boards were notified. -A police report was made. -Root Cause analysis was completed with the findings: --Upon employment Unlicensed RN A presented themselves as another person with a valid nursing license from a neighboring state. --The name on the government issued documents did not match the name on the nursing license. --Facility staff involved in the onboarding process for new employees were re-educated on the verification process when a name on government issued documents does not matched the name on the professional license. -Reviewed the one-on-one reeducation given to the staff responsible for new hire documentation dated 2/4/25. Review of police report dated 3/11/25 at 11:32 P.M. showed: -Police Officer responded for a citizen contact via phone call. -The citizen identified themselves as the Regional Administrator for the facility -Regional Administrator stated the following: --While a routine employee file audit was conducted: ---It was discovered that the name on a RN license did not match the name of other documents used to verify the identity of the employee. ---The employee was suspended, and an internal investigation was started. ---The conclusion of the investigation was that the employee did not have an RN license in any state. ---The license provided belonged to another RN. ---The social security number and date of birth for the RN license did not match the number or date of birth on the government documents. ---When the Regional Administrator confronted the employee about this the employee admitted to finding the license in a similar name to the employee's and used it to obtain employment as a RN. ---Unlicensed RN A had attended a nursing program and registered to the take the NCLEX-RN exam, but was unable provide proof of passing the examination. -Unlicensed RN A was employed as RN at the facility. -During the time of employment, Unlicensed RN A was responsible for directly carrying out Physician's orders for a multitude of residents. -Unlicensed RN A was responsible for completing skilled nursing assessments and oversaw the care provided by other staff. Review of supplemental police report dated 3/16/25 at 10:21 P.M. showed: -Police officers arrived at the station and conducted a follow-up interview with unlicensed RN A. -Unlicensed RN A said that from 6/6/23 to 6/16/23 he/she was not employed as a licensed nurse but as a Staffing Coordinator. -When asked Unlicensed RN A said he/she had attended two nursing programs. -Unlicensed RN A was unsure what state had issued his/her nursing license because they had attended school in a neighboring state and lived in another state. -Unlicensed RN A had taken the NCLEX exam but was unable to recall the location or dates of testing. -Unlicensed RN A had thought they had passed the NCLEX examination. -Unlicensed RN A had a Certified Nursing Aide (CNA) license but let it lapse. -When asked where unlicensed RN A got the other RN license, he/she said that a Staffing Coordinator helped him/her look it up online. -Unlicensed RN A said he/she never had a physical copy of his/her state nursing license. -Unlicensed RN A stated he/she knew it was wrong to practice nursing care without a valid license. During an interview on 3/14/25 at 12:21 P.M. Financial Services said: -He/She did not hire the nurses. -He/She was not at the facility when Unlicensed RN A was hired as a RN. -He/She does not process new hire paperwork. -If the Human Resources Specialist was out of the office, he/she was educated on the two-step process to verify a license. -He/she would verify the name on the state issued identification and the nursing license to ensure the names matched. -Once the facility verified the information it was sent to cooperate office Human Resources for a double check. During an interview on 3/14/25 at 12:27 P.M. Financial Services Assistant (FSA) said: -He/She was not at the facility when Unlicensed RN A was hired as a RN. -The former Staff Development Coordinator was responsible for hiring the unlicensed staff as a RN. -The former Staff Development Coordinator handled all the new hire paperwork. -There was no auditing process for new hire paperwork before. -There was no new hire checklist before. -The process now for new hire nurses was: --A new checklist was developed for new hire employees. --He/She reviews the government paperwork and the nursing license to ensure that the names match. -The government paperwork and nursing license are kept in a binder together. -There is a three-folder system now. -Once he/she has checked and verified the information is correct it is sent to corporate for a double check. During an interview on 3/14/25 at 12:40 P.M. DON said: -He/she was not at the facility when Unlicensed RN A was hired as a RN. -The former Staff Development Coordinator hired Unlicensed RN A as a RN. -He/She believed Unlicensed RN A was hired because he/she had worked at the facility sometime before. -The FSA now does the new hire paperwork and verifies nursing license matches government paperwork required for new hire. -The Administrator and Corporate Human Resources both have verified the information before a job interview was scheduled. During an interview on 3/14/25 at 12:50 P.M. Administrator said: -At the time Unlicensed RN A was hired it was the Staff Development Coordinator's responsibility to complete and verify all the new hire paperwork. -The Staff Development Coordinator quit in September and since that time the FSA has been doing the new hire paperwork. -Now most of the applications for new nurses come from computer websites. -He/she then would request the required paperwork and review the paperwork. -If he/she saw no red flags would schedule and interview and then double check the paperwork to ensure all was correct. -Once license was verified a job offer would be made after the Corporate double checked all the supplied information. Review of undated Unlicensed RN A employee file showed: -A state identification card/non drivers licence in the name of Unlicensed RN A with a same state address on it. -Social Security card in the name of the Unlicensed RN A . -A neighboring nursing license with a name that did not match that of Unlicensed RN A's legal documents. NOTE: Certified letters were mailed on 3/28/25 to Unlicensed RN A and the former Staff Development Coordinator. An EDL was not referred due to this was forwarded to CMS for potential fraud. MO00250897

Based on observation, interview and record review, the facility failed to protect one sampled resident (Resident #69) when on 12/27/24 Resident #387 grabbed Resident #69 in the hallway resulting in him/her twisting and causing bruising to the resident's left forearm out of 17 sampled residents. The facility census was 76 residents. On 1/2/25 the Administrator was notified of Past Non-Compliance which occurred on 12/27/24. Facility training for abuse, neglect, dignity and customer services was completed for all staff 12/28/24 prior to the start of their shift. The deficiency was corrected 12/28/24. Review of the facility Resident Rights Policy dated 5/1/23 showed: -Purpose: --This policy is concerned with all incidents and accidents involving residents. --All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. --Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 1. Review of Resident #387's Face Sheet showed the resident was admitted on [DATE], with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone or posture), seizures, intellectual disabilities, and brain disorder. Review of Resident #387's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/25/24, showed the resident: -Had memory problems with severe cognitive incapacity. -Did not have any behavioral symptoms, mood, depression or anxiety. -Needed moderate to maximum assistance with bathing, dressing, toileting, mobility and used a wheelchair for ambulation. Review of Resident #387's Care Plan dated 11/21/24, showed the resident had an intellectual disability, memory and recall problems and difficulty making himself/herself understood. There was no documentation showing the resident had any aggressive behaviors. Interventions showed staff would: -Maintain a structured environment and provide instruction at the resident's level of understanding. -Provide personal space. -Provide a daily tasks activity schedule. -Develop personal supports, family is very supportive. -Redirect the resident when entering unsafe areas. -Follow up with facility representatives to ensure recommendations are fully implemented. Review of Resident #69's Face Sheet showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, depression, anxiety, pain and respiratory disease. Review of Resident #69's quarterly MDS dated [DATE], showed: -He/she had significant cognitive impairment. -He/she had no behavioral issues during the look back period but showed signs/symptoms of depression. -He/she needed partial to moderate assistance with bathing, dressing, toileting, mobility and used a wheelchair for ambulation. Review of Resident #387's Nursing Notes dated 12/27/24 at 3:10 P.M. showed he/she had an altercation which was witnessed by staff involving this resident reaching out and grabbing another resident's arm causing bruising to occur. Review of Resident #69's Nursing Notes dated 12/27/24 showed: -He/she had a resident to resident incident where he/she was not the aggressor. A skin assessment was completed on the resident and the resident sustained two dark purple bruises to his/her left forearm that measured 6 centimeters (cm) length by 6.5 cm width, and 1.5 cm length by 2 cm width. The resident denied any complaint of pain or discomfort. Review of the facility investigation report dated 12/27/24 showed: -Staff reported Resident #387 was seen holding Resident #69's arm. Staff immediately separated the residents and the resident was placed on one to one monitoring. -Resident interview summary showed the facility staff was unable to successfully interview the residents to find out what occurred due to both of the resident's dementia and ability to recall the incident. -Resident #69 said they were friends and it was all in good fun. Observation and interview on 12/31/24 at 9:35 A.M., showed Resident #69's was laying in his/her bed awake and wearing oxygen. On the resident's left forearm were two fading purplish bruises. The resident said: -He/She felt safe in the facility and was not afraid of any residents. -He/She was not in any pain or discomfort. During an interview on 12/31/24 at 11:44 A.M. Certified Medication Technician (CMT) A said: -He/She was working and observed the resident incident on 12/27/24 that was after breakfast when residents were exiting the dining area. -Resident #387 was sitting in his/her wheelchair in the hallway and was tapping residents on the arm or shoulder as they went by. -Resident #387 was swinging his/her arms so he/she told the resident he/she was going to move him/her over since he/she was blocking the entryway to the dining area, and moved the resident over out of the middle of the entryway. -The resident continued to swing his/her arms and hit a resident. The resident became agitated, so he/she moved Resident #387 down the hallway toward his/her room, but the resident did not want to go into his/her room and stayed outside of his/her room. -A few minutes later he/she saw the resident by the nursing station where Resident #69 was sitting and he/she heard Resident #69 yell, stop that hurt and he/she went to see what occurred and saw Resident #387 twisting Resident #69's left forearm. During an interview on 12/31/24 at 2:35 P.M., showed Licensed Practical Nurse (LPN) A said: -He/She was working on 12/27/24 and both residents were outside of the 200 hall when he/she heard Resident #67 say ouch, you're hurting me. -He/She looked up and saw Resident #387 was holding Resident #69's left arm. -There was another nursing staff that was already separating the residents and had Resident #69 at the nursing station. -Resident #387 was headed back down the 200 hallway. -He/She completed a skin assessment on Resident #67 and saw the bruising on his/her left forearm and documented it in his/her medical record. The Nursing Assistant (NA) went to inform the Administrator and DON. During an interview on 1/2/25 at 9:03 A.M., NA A said: -Usually Resident #387 does not become aggressive unless residents or staff, are trying to pass him/her in the hall or in the dining area (anywhere there is a group of people). -Resident #387 will deliberately sit in the pathway so that residents cannot get around him/her and will refuse to move when they ask him/her to move. -Staff will then have to assist and move Resident #387 and if the residents or staff try to move him to get around him/her, Resident #387 will become physically aggressive. -Resident #387 has hit at him/her when he/she has tried to get him/her to move to the side so that a resident could pass in the hallway. During an interview on 12/31/24 at 1:50 P.M., the Director of Nursing (DON) said: -On 12/27/24 he/she was working and received a report that Resident #387 and Resident #69 were passing each other in the hall and they were tapping each other on the arm and Resident #387 grabbed Resident #69's arm and twisted it. -Nursing staff stepped in and separated the residents and a skin assessment was performed on Resident #69 and showed bruising on his/her arm. -Resident #387 does not like for people to be in his/her space and does not like to be in groups of people. -Resident #387 will place himself/herself in the middle of the hallway when other residents and staff have to try to get by him/her. -Resident #387 does not like to be moved. -After the incident occurred, he/she tried to interview Resident #387 and he/she did not think he/she understood what he/she was asking. He/She also interviewed Resident #69 and he/she said that it was all in good fun and that he/she did not think Resident #387 was trying to harm him/her. -Since this incident, Resident #387 has had physical aggression towards staff and another resident. During an interview on 12/31/24 at 2:52 P.M., the Administrator said: -He/She was in the facility on 12/27/24 and the DON told him/her about the incident between Resident #387 and Resident #67. -He/She thought that the nursing staff that initially moved Resident #387 out of the hallway was what made Resident #387 agitated initially. He/She said he/she tried to speak with Resident #387 and he/she did not respond at that time. -A couple hours later, the DON said the residents were on the 200 hall and staff saw Resident #387 grab Resident #69's arm causing bruising. Staff separated the residents. MO00247157

Based on observation and interview, the facility failed to maintain the floors in the dry goods storage room; maintain under and behind the ice machine free from food debris and grime; failed to maintain the ceiling vents and the fan free from a dust buildup; failed to maintain the milk that was served to residents in the 500 Hall at or close to 41 F (degrees Fahrenheit); and failed to maintain the toaster free from a buildup of crumbs at the bottom of the toaster. This practice potentially affected 77 residents who ate food from the kitchen. The facility census was 80 residents. 1. Observations on 11/1/24 from 6:04 A.M. through 8:29 A.M., showed: -The presence of food crumbs, including an old orange behind the canned goods storage -The presence of food crumbs in the corner close to the chest freezer in the dry goods storage room. -A buildup of dust on the ceiling vent over the food preparation table. -A buildup of grime and food debris behind the ice making machine. -A heavy buildup of bread crumbs at the bottom of the two-slice toaster. -The presence of dust on the fan in the kitchen. During an interview on 11/1/24 at 7:29 A.M., the Dietary Supervisor said: -The dietary staff should clean the dry goods store room on a regular basis. -He/She was surprised to see the shelves were not moved. -The shelves with the canned goods should have been moved so that dietary staff could get behind that area more thoroughly. During an interview on 11/1/24 at 7:33 A.M., the Dietary Supervisor said the housekeeping department was supposed to clean the floors in the area where the ice machine was located. During an interview on 11/1/24 at 8:27 A.M., the Dietary Supervisor said: -He/She has not developed a cleaning schedule for the toaster. -They have a cleaning list for the dietary staff, but he/she needed to outline the duties with all dietary staff. During an interview on 11/1/24 at 9:32 A.M., the Housekeeping Supervisor said it was the responsibility of both departments (dietary and housekeeping) to clean the floor, but it was very difficult to get behind the ice machine to clean the floor properly. During an interview on 11/1/24 at 11:35 A.M., the Administrator said he/she has seen housekeeping staff scrub the floors where the ice machine was located, but he/she should discuss a plan for cleaning that floor with the Housekeeping Supervisor and the Dietary Supervisor. 2. Observation on 11/1/24 at 7:42 A.M., showed the whole milk had a temperature of 50.1 F, when the temperature was measured after the Social Service Director poured the milk in a glass for measuring. During an interview on 11/1/24 at 7:46 A.M., the Activities' Director said he/she had not seen anyone form the dietary department at the 500 Unit to check temperatures of the foods. During an interview on 11/1/24 at 8:27 A.M., the Dietary Supervisor said: -No one was going to the 500 Unit to check the temperatures of the milk. -The milk was not maintaining the temperature that it is supposed for the entire time because the ice bath that the milk container sits in, melts.

Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices during wound care to prevent the potential of cross contamination for one sampled resident (Resident #9) who at risk for infection due to open wound on left buttocks area; failed to ensure enhanced barrier precautions (EBP- an approach to the use of personal protective equipment (PPE) to reduce the transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities) when transferring and emptying a urinary catheter (a flexible tube inserted through a narrow opening into the bladder for removing fluid) bag for one sampled resident (Resident #5), during personal care for three sampled residents (Resident #36, #68, and #59) and during a transfer for one sampled resident (Resident #19) and to ensure hand hygiene was practiced when administering medications to two sampled residents (Resident #101 and Resident #18) out of 22 sampled residents; and failed to ensure Tuberculosis (TB- a bacterial disease that mainly affects the lungs) screening was completed annually for two sampled residents (Resident #1 and Resident #68) out of five sampled residents and for 5 of 9 sampled employees. The facility census was 80 residents. Review of the facility's policy titled Enhanced Barrier Precautions dated 4/29/24 showed: -A sign indicated the enhanced barrier precautions should be placed on the resident's door and if it is a semi-private room, it should be labeled for which bed. -PPE should be readily accessible at all times, preferably near or inside/outside of resident/guest rooms, shower rooms, and Therapy Gyms. -There should be appropriate disposal containers in the resident/guest room and Therapy gyms, showers for removal of PPE. -EBP required donning of gowns and gloves during high contact resident/guest care activities that provide opportunities for transfer of MDROs to staff hands and clothing. -EBP was indicated for resident/guests with any of the flowing: --Wounds or indwelling medical devices (central lines, urinary catheters, feeding tubes, and tracheostomies). -EBP was employed while performing high contact resident/guest care activities which included: --Dressing. --Bathing/Showering. --Transferring. --Providing Hygiene. --Changing linens. --Changing briefs or assisting with toileting. --Device care. --Wound care. 1. Review of Resident #9's Significant Change of Condition Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/17/24 showed the resident: -Was severely impaired memory for long and short term. -Was at risk for pressure injury/ulcer (is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Review of the resident's Nursing note dated 10/5/24 at 3:48 A.M., showed: -Open wound on his/her left buttocks found by staff during cares. -Small open area was about the size of a dime. Review of the resident's Wound Care Plan updated 10/15/24 showed: -Had actual skin breakdown left inner buttock. -The resident was on Enhanced Barrier Precaution (Gown and glove are used during high contact resident care activities). Review of the resident's Physician Order Sheet (POS) dated 10/15/24 showed a Wound Order for a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) of sacral area (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) pressure injury, to the resident's left inner buttock. Review of the resident's Weekly Wound Assessment Report dated 10/22/24 at 4:21 P.M., showed the resident had a wound on left inner buttocks was open and pink. Observation on 10/29/24 at 9:37 A.M., of the resident's wound care showed: -The resident had signage on door for Enhanced Barrier Precaution, due to his/her wounds. -Regional Corporate Nurse with gloved hands, had unfasten and lowered the resident incontinent brief, then removed gloves washed his/her hands. -Resident incontinent brief was dry at that time. -The resident had a pea size open area on his/her left inner buttock. -The Wound Nurse cleansed the wound then applied cream to the resident's clean wound area. -Wound nurse removed the barrier and then placed the same used incontinent brief to covering the recently clean wound. During an interview on 10/29/24 at 10:13 A.M., Wound Nurse said: -He/She was not aware of the potential of cross contamination when reapplied the same used incontinent brief after completed wound care treatment. -He/She should had placed a clean unused brief on the resident help protect from potential of cross contamination of the clean wound area, since no dressing applied to cover the clean wound area. During interview 11/1/24 at 11:36 A.M., Director of Nursing (DON) and Regional Corporate Nurse said: -He/She would expect wound nurse to ensure have a new clean brief applied after the resident wound care was completed. -The clean brief applied would help protect the resident open wound from cross contamination from dirty to clean process. 51303 2. Review of Resident #59's quarterly MDS dated [DATE] showed: -The resident had some cognitive impairment that needed support from staff. -He/She had an indwelling catheter. -He/She required moderate assistance for toileting hygiene, shower/bathing, upper body dressing, lower body dressing and the putting on and taking off of footwear. Review of the resident's October 2024 POS showed enhanced barrier precautions during direct care related to foley catheter dated 12/14/23. Review of the resident's care plan start date 12/29/23 showed the problem of Foley catheter with an intervention to perform enhanced barrier precautions for foley catheter care. Observation on 10/28/24 at 8:28 A.M. a sign on the resident's door for Enhanced Barrier Precautions showed: -Everyone must clean their hands, including before entering and when leaving the room. -Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: --Providing hygiene. --Changing briefs or assisting with toileting. --Device care or use with central line urinary catheter, feeding tube, and tracheostomy. During an interview on 10/31/24 at 2:41 P.M., Licensed Practical Nurse (LPN) A said the process for foley catheter care included: -Wash hands, don gloves, complete catheter care, then perform hand hygiene prior to leaving the room. -He/She was not aware of EBP and was not aware staff were required to wear a gown while completing cares for residents on EBP. -He/She thought the sign was related to what to do if a resident had COVID (a new disease caused by a novel (new) coronavirus). -He/She did not wear a gown when completing the resident's catheter cares. During an interview on 11/01/24 at 11:31 A.M., the DON said: -He/She expected staff to perform Enhanced Barrier Precautions. -EBP would involve gown and glove use during high-contact resident care. -He/She was not aware staff had not used EBP for Resident #59 during catheter care. 21003 3. Review of Resident #19's quarterly MDS dated [DATE], showed: -The resident was alert and oriented with minimal confusion. -Had had no functional impairment in range of motion and used a walker for mobility. -Was dependent for toileting and required moderate assistance for upper and lower body dressing. Observation and interview on 10/30/24 at 1:15 P.M., showed: -There was a sign on the resident's door showing the resident was on EBP. The sign instructed the staff to stop and prior to entering the room the staff should wash or sanitize their hands, don gloves and a gown. -There was a personal protective equipment (PPE) cart containing gowns in the hallway. -The resident was laying down on his/her bed in his/her room. -Certified Nursing Assistant (CNA) B entered the resident's room and without washing or sanitizing his/her hands, gowning or gloving, he/she assisted the resident to sit up on the side of his/her bed. -CNA B then assisted the resident to the bathroom and back to his/her recliner. At 1:43 P.M., CNA B was sitting down beside the resident and was feeding him/her. -Once he/she finished feeding the resident, he/she took his/her room tray out of his/her room without washing or sanitizing his/her hands. During an interview on 10/30/24 at 1:24 P.M., LPN B said: -The resident was on EBP due to an abrasion on his/her elbow. -CNA B was supposed to wash or sanitize his/her hands prior to or upon entering the resident's room and prior to providing the resident with any assistance. -Because the resident is on EBP, CNA B should have sanitized his/her hands, put on a gown and gloves before entering the resident's room. -CNA B did not follow handwashing or EBP precautions. During an interview on 10/30/24 at 1:58 P.M., CNA B said: -Normally, upon entering a resident's room and prior to performing any cares, they are supposed to wash or sanitize their hands. -If the resident is on EBP, they are also supposed to put on gowns and gloves if they are going to have any physical contact with the resident. -Before exiting the resident's room they should discard their PPE and wash or sanitize their hands. -He/She was aware that the resident was on EBP and saw the sign on his/her door. -He/She did not use PPE or wash or sanitize his/her hands because he/she forgot to. 4. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with diagnoses including kidney disease with dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) use. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Was independent with mobility, dressing eating and toileting and needed supervision and touch assistance with bathing. Observation on 10/29/24 at 9:54 A.M., showed: -There was an enhanced barrier precaution sign on the resident's room door which instructed staff to stop, clean their hands before entering and upon leaving the room and wear gown and gloves for the following: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with device care. -There was a PPE cart in the hallway two doors down from the resident's room. -Upon entering the resident's room, CNA A was in the resident's room standing beside the resident who was uncovered and laying in his/her bed. -CNA A was not wearing a gown or gloves and said he/she was providing resident care. During an interview on 10/29/24 at 10:16 A.M., CNA A said: -He/She had been trained on EBP but it had been a while since he/she reviewed it. -He/She saw the EBP sign on the resident's door, but he/she really was just trying to get his/her bath completed. -He/She thought he/she was supposed to wear a gown and gloves when a resident is on EBP, but he/she would have to read up on it again to see what the protocol was. -He/She did not see a PPE cart outside of the resident's door but he/she did see there was one in the hallway. -The resident was probably on EBP because of his/her wounds. -He/She did not wear a gown or gloves prior to entering the resident's room and providing care but he/she would review the EBP protocol. Observation and interview on 10/30/24 at 11:05 A.M., showed LPN A said he/she was going to check the resident's dialysis site. LPN A obtained his/her stethoscope and gloves went to the resident's door and knocked. Without washing or sanitizing his/her hands and donning a gown or gloves prior to entering, LPN A entered the resident's room. The resident was laying on his/her back in bed and there was a bandage over his/her dialysis access site on his/her left arm. Once LPN A finished assessing the resident he/she removed his/her gloves and washed his/her hands. LPN A said: -Regarding EBP, the resident was on EBP due to his/her wounds. -If anyone is in contact with his/her wound during cares, they were to wear a gown. -Usually when someone is on EBP, anyone who is going to complete any resident care would need to wear a gown and gloves prior to contact with the resident. -He/She said she would need to clarify if he/she was supposed to put on a gown with any direct contact with this resident. -The nursing staff should wash or sanitize their hands upon entry into the resident's room and prior to exiting. -He/She should have washed or sanitized her hands upon entering, but he/she put on gloves without doing so. 5. Review of Resident #36's Face Sheet showed the resident was admitted on [DATE], with diagnoses including stroke with paralysis, muscle weakness and lack of coordination. Review of the resident's Care Plan updated 6/12/24, showed the resident needed assistance to complete daily activities of care safely. Interventions showed staff was to: -Provide extensive assistance with bed mobility. -Required total assistance with bathing dressing toileting and used a full body mechanical lift (a mechanical device that helps caregivers safely transfer people who have limited mobility) for transfers. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was alert and oriented without confusion. -Needed moderate to total assistance with mobility, transfers, bathing, dressing and toileting. Observation on 10/28/24 at 11:36 A.M., showed the resident was in his/her wheelchair in his/her room. CNA F was already in the resident's room and Nurse Assistant (NA) A brought the mechanical lift into the room. Both CNA F and NA A put on gloves without washing their hands and attached the lift sling to the lift (the resident was laying on the sling) then NA A lifted the resident while CNA F assisted with moving the resident and positioning him/her in bed. CNA F and NA A removed the sling from the lift. NA A moved lift out of the room. CNA F and NA A then pulled the resident's pants down to perform incontinence care. CNA F pulled out a trash bag and placed it on the resident's bed while NA A pulled several cleansing wipes from a container, removed the resident's brief and cleaned the resident using front to back one wipe one swipe method. Both CNA F and NA A rolled the resident to the side and NA A cleaned the resident's bottom using a one wipe one swipe front to back method. NA A then, without de-gloving, washing or sanitizing his/her hands, took a clean brief and placed it under one side of the resident. CNA F and NA A rolled the resident to the left and CNA F pulled the brief under the other side of the resident. They then fastened the brief and pulled the residents pants up. CNA F and NA A both discarded their gloves and washed their hands, turning off the water with a paper towel. During an interview on 10/30/24 at 1:58 P.M., CNA A said: -Normally, upon entering a resident's room and prior to performing any cares, they are supposed to wash or sanitize their hands. -They wash or sanitize their hands during care when they change gloves. -Before exiting the resident's room they should wash or sanitize their hands. During an interview on 11/01/24 at 11:36 A.M., with the DON, the Regional Nurse Consultant, and the Regional Quality Assurance (QA) Nurse, the DON said: -He/She would expect nursing staff to wash or sanitize their hands before or upon entering the resident's room. -Staff should perform handwashing or sanitizing upon entering the resident's room, during resident cares, between performing dirty to clean tasks and prior to leaving the resident's room. 46519 6. Review of Resident #5's face sheet showed he/she admitted to the facility with the following diagnoses: -Colostomy (when a piece if colon is diverted to an artificial opening in the abdominal wall) Status. -Presence of Urogenital (relating to both the urinary and genital organs) Implants. -Pressure Ulcer Stage III. Review of the resident's annual MDS dated [DATE] showed: -The resident had a catheter. -The resident had an ostomy. -The resident had a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. Observation on 10/29/24 at 9:03 A.M. of a wheelchair to bed transfer of the resident and emptied the resident's catheter bag completed by CNA C and CNA D showed both CNAs did not wear a gown the entire time they were completing the care of the resident. During an interview on 10/30/24 at 10:56 A.M. CNA C said: -He/She and CNA D had not worn gowns when performing the transfer and emptying the catheter bag during the resident's care. -He/She hadn't thought about putting on a gown and just entered the room due to being nervous. -EBP included wearing a gown and gloves during high contact resident care. -EBP were used to protect the resident. -Residents who have catheters, wounds, and colostomies should all be under EBP during high contact care. During an interview on 10/30/24 at 11:04 A.M. CNA D said: -After he/she and CNA C completed the resident's care, he/she realized that they forgot to put on gowns. -EBP were used for general infection control purposes and was unsure of any specifics to why a resident was on EBP. -Staff knew which residents were on EBP from a sign that was posted on the residents' door. -The facility had bins that held the necessary PPE, and they were stationed at the end of each resident hallway. During an interview on 10/31/24 at 1:30 P.M. the Infection Preventionist said: -He/She had been educated on EBP and so was the rest of the staff during an in-service. -He/She was unsure when the staff were last educated on EBP. -EBP was used for residents with portals for infections which included wounds, catheters, gastronomy tubes (a tube that is inserted through the wall of the abdomen directly into the stomach), and any other lines in general. -There were signs posted on each resident door that indicated the EBP and what the staff needed to wear in the room. -The sign also indicated the type of care that would indicate the use of the gown and gloves. -There was a cart that held the PPE on each resident hall. -The CNAs should have used EBP while performing the residents transfer and emptying the resident's catheter bag, which included the use of gloves and gowns. During an interview on 11/1/24 at 8:12 A.M. CNA A said EBP, which included the use of gowns and gloves, should be worn for any direct contact resident care. During an interview on 11/1/24 at 8:24 A.M. Registered Nurse (RN) A said he/she had not been trained on EBP and was not sure what exactly EBP indicated. During an interview on 11/1/24 at 11:36 A.M. the DON said: -EBP included wearing a gown and gloves during direct resident care. -There were signs posted on each residents' door that needed EBP and the sign would guide the staff on what to do. -Residents with wounds, catheters, indicated the need for EBP. -There was a PPE cart on each hall for the staff to utilize when EBP were needed. -The CNAs should have worn gowns and gloves during Resident #5's transfer and when they emptied Resident #5's catheter bag. 7. Review of the facility's policy titled Tuberculosis Screening dated 11/14/16 showed: -Upon admission, residents/guests should receive the purified protein derivative (PPD) two-step screening. -Residents/guests may receive an annual PPD test within one week of admission anniversary test. 8. Review of the following employee records showed there was no documentation showing these employees were given a two-step TB test upon hire or that the TB testing was not completed timely upon hire or that there was a previous TB test or X-ray to rule out TB had been completed prior to employment: -Employee A was hired 11/13/23 and his/her TB testing was started 2/5/24. He/She is still currently an employee. -Employee B was hired 7/9/24 and there was no TB test documented. He/She is currently an employee. -Employee C was hired 7/9/24 and there was no TB testing documented. He/She is currently and employee. -Employee D was hired 1/12/24 and his/her TB testing was started on 3/12/24. He/She is currently an employee. -Employee E was hired 5/20/24 and there was no TB testing documented. He/She is currently an employee. During an interview on 11/01/24 at 8:35 A.M., Financial Assistant/Human Resources said: -They completed an audit of the employee files in mid June 2024, and noticed there were some that were not completed and they tried to correct them. -Upon orientation, he/she had everyone complete the TB test step 1. -Nursing staff then complete the TB step 2 tests and they fill in the documentation. -If there were staff who had the first TB step completed and then there was no reading, and they had to start the testing over again because the nursing staff did not get it completed (this was why some were documented late). -They have not had a designated nurse that completed the TB testing for the past few months so whatever nurse that is available had to complete the TB testing and they were also supposed to track it to ensure both tests were completed. -They were not able to find the TB tests on three staff sampled and he/she did not know if anyone completed their TB tests or if they just cannot be located. During an interview on 11/01/24 at 11:36 A.M., with the DON, the Regional Nurse Consultant, and the Regional QA Nurse, the DON said: -The nurse was to complete TB at orientation and read it 72 hours afterward then they complete second step within 10 days of the first test. -There should not be a reason why TB was completed late. -The staffing coordinator was responsible for ensuring the TB is completed timely, but they have not had a Staffing Coordinator and so he/she and the Infection Control Preventionist had been trying to get the TB's completed and monitor to ensure both steps were completed. -They had recently hired a Staffing Coordinator. -They do keep the TB records in one binder and they complete them by month so they know who needs to have their follow up 8. Review of Resident #1's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's Physician Order Sheet dated October 2024 showed: -An order for Aplisol Solution (tuberculin PPD- used to test people for TB); five tuberculin (tub) unit/0.1 milliliter (ml); intradermal (situated, occurring, or done within or between the layers of the skin); Special Instructions: Yearly October PPD Test on October Third. -An order for Aplisol Solution five tub. unit/0.1 ml; read only; intradermal; Special Instructions: Yearly October PPD test results Annual on October Sixth. Review of the resident's Medication Administration Record (MAR) dated October 2024 showed: -The test was not administered because the resident had refused. -The results could not be read because the test was not administered. 9. Review of Resident #68's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's TB Test results on 10/31/24 showed the resident last received the test in May 2023. During an interview on 10/31/24 at 1:30 P.M. the Infection Preventionist said: -He/She had not kept a book or log of all resident TB test results. -He/She used to do TB test audits, but it had been a while since the last audit was completed. -He/She was unaware that Resident #1's TB test had not been completed. -He/She was unaware that Resident #68's TB test had not been completed in over a year. -Nursing Management was responsible for completing TB tests. -Residents were to be given a two-step test upon admission, then annually thereafter. -The nurse who was responsible for completing Resident #1's TB test should have re-offered the test or to have received an order from the facility's physician for a chest x-ray. During an interview on 11/1/24 at 8:24 A.M. RN A said: -Nurses were responsible for completing resident TB tests. -He/She was unsure of who ensured the resident TB tests were completed. -Resident TB tests needed to be done upon admission and then annually. -If a resident were to refuse the TB test, then he/she would call the doctor to get an order for a chest x-ray to be done. -If a resident was lasted tested for TB in May 2023, then the resident should have had the annual test completed by that point in time. During an interview on 11/1/24 at 11:36 A.M. the DON said: -Nurses were responsible for completing resident TB tests. -The interdisciplinary team ensured completion of resident TB tests. -Residents were to receive a two-step TB test upon admission and then annually thereafter. -He/She was unaware that Resident #1 had refused his/her TB test and that the TB screening had not been completed. -He/She was unaware that Resident #68's last TB test was completed in May 2023. -The nurse responsible for Resident #1's TB test should have gotten an order form the facility's physician for a chest x-ray. -Resident #68's TB test should have been done by that point in time. 50579 10. Review of a policy titled General Dose Preparation and Medication Administration, dated 12/1/07, showed: -Staff were to perform hand hygiene prior to beginning a medication administration/preparation. -Staff were not to touch medications during preparation or administration. -Medications that were dropped should be discarded. During an observation on 10/30/24 at 11:11 A.M., Certified Medication Technician (CMT) B administered a medication by mouth to Resident #101 in his/her room. After administration, CMT B returned to the medication cart, prepared two tablets of Acetaminophen (a pain reliever) 325 milligrams (mg) for Resident #9, and administered the medication in his/her room. No hand hygiene was performed from the beginning of the observation at 11:11 A.M. to the end of the observation at 11:25 A.M. During an interview on 10/30/24 at 11:25 A.M., CMT B said: -He/She forgot to sanitize his/her hands in between the administration of the medications. -He/She should have performed hand hygiene in between the medication administrations. 11. During an observation and interview on 10/31/24 at 8:59 A.M., CMT A began administering medications to Resident # 18. Hand hygiene was performed prior to preparing by mouth medications for the resident. CMT A prepared Aspirin (a pain reliever/anti-platelet aggregator) into the medication cup, then attempted to push a 5 mg Buspirone (a drug used to treat anxiety) tablet into the medication cup. The tablet missed the cup, landed on the medication cart and was picked up by CMT A with ungloved hands and placed into the medication cup. CMT A proceeded with the medication preparation and administered all ordered medications to the resident. -CMT A said he/she should not have touched the medication with his/her ungloved hand after it landed on the medication cart and placed it in the medication cup for infection control reasons. During an interview on 11/1/24 at 11:26 A.M., the DON said: -He/She would expect hand hygiene to be performed by all staff in between medication administrations. -He/She would expect staff to discard a medication that fell on to a medication cart and would not expect staff to pick up the medication with their hands and continue the administration.

Based on interview and record review, the facility failed to obtain a signature for the authorization of the opening of a resident trust account for one sampled resident (Resident #50) and failed to obtain authorization signatures from sampled three residents (Residents #100, #41 and #62) to allow Supplemental Insurance Company A to withdraw funds from the accounts of those residents. This practice affected at least four residents who had resident trust accounts at the facility. The facility census was 80 residents. Review of the facility's Business Office and Internal Controls Policy and Procedure Manual, dated 10/22 showed: -Upon written authorization from the resident/guest or their agent, the facility must hold, safeguard, manage and account for the personal funds deposited with the facility. -Funds may be expended from the facility's Resident Trust Petty Cash or by a Resident Trust Check Request. -Anytime a transaction is made from the Resident Trust Fund, by request or by cash, it must be fully documented, supported by voucher or invoice, and approved by the resident, legal guardian, conservator or Power of Attorney (POA-- a legal document that allows someone to act on another person's behalf). 1. Review of Resident #50's authorization form (to open a resident trust account) showed the absence of the resident's signature or a signature from the resident's POA. The resident trust account was opened on 4/5/23. Review of written communication from the facility to the resident's POA dated 4/3/23 showed the POA returned the form back to the facility on [DATE] unsigned. During an interview on 10/29/24 at 10:58 A.M., the Financial Specialist said he/she did not believe any other outreach has been done to the resident's POA, since April of 2023. 2. Review of Resident #100's Resident Trust account records, showed: -A check for $636.00 dated 8/6/24, was written to Supplemental Insurance Company A for dental insurance premium. -A check for $159.00 dated 8/6/24, was written to Supplemental Insurance Company A for vision insurance. -No signatures by Resident #100 to allow Supplemental Insurance Company A to be able to obtain that money. During an interview on 10/29/24 at 9:52 A.M., the Financial Specialist said: -Resident #100 had a withdrawal of $636.00 on 8/6/24 for insurance premiums which were $159.00 each month for four months (4/24 through 8/24). -Another check was written for $159.00 on 9/3/24. -Another check was written for $159.00 on 10/1/24 -There were not any signatures by the resident in 4/24, at the beginning of the residents purchasing of services from Supplemental Insurance Company A and no signatures to authorize any transactions in 8/24. 3. Review of Resident #41's Resident Trust Account records showed: -On 8/2/24, a check for $236.00 dated 8/2/24, was written to Supplemental Insurance Company A for vision insurance, -On 8/2/24, a check for $636.00 dated 8/2/24, was written to Supplemental Insurance Company A for dental Insurance, - Review of Resident #41's Resident Trust records with the Financial Specialist, showed the absence of signature from Resident #41 on any of the forms which were dated August 2024 4. Review of Resident #62's Resident Trust Account records showed: -On 8/2/24, a check for $708.00 dated 8/2/24 was written to Supplemental Insurance Company A for vision insurance -On 8/2/24, a check for $636.00 dated 8/2/24 was written to Supplemental Insurance Company A for dental Insurance -The absence of a signature by Resident #62 to authorize Supplemental Insurance Company A to have those checks written. During an interview on 11/1/24 at 10:08 A.M. the Financial Specialist said: -After he/she reviewed the resident trust records of Residents #100, #41 and #62, he/she did not see there were signatures from any of those residents to authorize payments to Supplemental Insurance Company A. -Supplemental Insurance Company A signs up the residents but the company did not provide facility personnel with copies of the signed paperwork with the resident's signature. -The facility is supposed to obtain signatures from the residents when they first sign up with Supplemental Insurance Company A.

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) and/or the Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) for three sampled residents (Resident #78, #139 and #102) out of three sampled residents who were discharged from Medicare part A services. The facility census was 80 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) was issued when all covered Medicare services end for coverage reasons. -If the skilled nursing facility (SNF) believed on admission or during a resident's stay that Medicare would not pay for skilled nursing or specialized rehabilitative services and the provider believed that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters. -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have. -If the SNF provided the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider had met the obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Review of Resident #78's SNF Beneficiary Protection Notification Review form completed by Financial Specialist showed: -The resident discharged from Medicare Part A services on 6/23/24 and stayed at the facility. -The NOMNC had not been provided to the resident or the resident's responsible party because he/he had been using the incorrect form. 2. Record review Resident #138's SNF Beneficiary Protection Notification Review form completed by Financial Specialist showed: -The resident discharged from Medicare Part A services on 6/30/24 and stayed at the facility. -The NOMNC had not been provided to the resident or the resident's responsible party because he/he had been using the incorrect form. 3. Review of Resident #102's SNF Beneficiary Notification Review form completed by Financial Specialist showed: -The resident discharged from Medicare Part A services on 7/26/24 and went home. -The NOMNC had not been provided to the resident because the resident requested to go home. Review of the resident's electronic medical record showed no documentation the resident requested to self-discharge off Medicare Part A services. During an interview on 10/31/24 at 1:40 P.M. the Financial Specialist said: -He/She was responsible for providing the NOMNCs and SNF ABNs to the residents. -The residents were given a 48-hour notice prior to the Medicare Part A discharge date . -He/She would call the resident's responsible party and notify them over the phone 48 hours prior to the Medicare Part A discharge date . -In certain situations, the NOMNC and ABN will be given in advance. -He/She had been giving out the wrong NOMNC. -He/She thought the Medicare Part B form was the NOMNC form. -He/She had been trained to use the Medicare Part B form as the NOMNC form upon hire. -He/She gave the ABN form to the resident and/or resident responsible party. -He/She gives the form to every resident who is discharged or stay in the facility. -Resident #102 requested to discharge to home so the no forms were provided to the resident. -He/She could not locate any information in the resident electronic medical record showing the resident decided to discharge home.

Based on observation and interview, the facility failed to maintain the following resident rooms clean and free from a buildup of dust and food debris on the floors and walls: resident rooms 508, 207, 202, 201, 200, 301, 303, 302, 300, 403, 404, 401, 105, and 107. This practice potentially affected 24 residents who resided in those rooms. The facility census was 80 residents. 1. Observations with the Maintenance Director on 10/30/24, showed: -At 1:36 P.M., there was a heavy buildup of cobwebs (a web spun by certain spiders, often found in the corners of disused rooms) between the climate control unit and the night stand in resident room [ROOM NUMBER]. -At 2:37 P.M., there was a heavy buildup of cobwebs which stretched between the floor and the climate control unit. -At 2:40 P.M., there was a heavy buildup of food crumbs in he corner between the bed and the window in resident room [ROOM NUMBER]. -At 2:43 P.M., there was a buildup of dust on the fans in resident room [ROOM NUMBER]. -At 2:44 P.M., there was a buildup of debris including grass clippings and grime on the floor next to the climate control unit in resident room [ROOM NUMBER]. Observations with the Maintenance Director on 10/31/24, showed: -At 9:46 A.M., there was a buildup of debris such papers under the bed in resident room [ROOM NUMBER]. -At 9:48 A.M., there was the presence of debris under the beds in resident room [ROOM NUMBER]. -At 10:05 A.M., there was debris under the bed in resident room [ROOM NUMBER]. -At 10:14 A.M., a trash container with soiled items (adult briefs etc.) was stored in the 300 Hall shower room, which caused a pungent urine odor in that shower room. -At 10:31 A.M., there was an old plastic pink bedpan under the bed in resident room [ROOM NUMBER]. -At 10:34 A.M., there was a buildup of dust under the beds in resident room [ROOM NUMBER]. -At 10:47 A.M., there was a buildup of food crumbs and debris in the corner next to the bed closest to the door in resident room [ROOM NUMBER]. -At 11:21 A.M, there was a buildup of candy pieces behind the bed in resident room [ROOM NUMBER]. and -At 11:27 A.M., there was dust and debris under the bed in resident room [ROOM NUMBER]. During an interview on 11/01/24 at 9:06 A.M., the Housekeeping Supervisor said: -He/She has been the housekeeping supervisor since 6/24. -After seeing the buildup of cobwebs in resident room [ROOM NUMBER] , he/she said that the housekeepers go into rooms where the residents do not want the housekeeper to move their items so it was harder for the housekeepers to get into areas to clean properly. -The trash container should not be in the shower room, instead the trash container should be in the soiled utility room. -He/She noticed the buildup of cobwebs, the dead insects and dust behind the night stand in resident room [ROOM NUMBER]. -He/She noticed the buildup of plastic bags and debris behind nightstand in resident room [ROOM NUMBER]. -He/She noticed the pieces of candy and the buildup of dust on the floor in resident room [ROOM NUMBER]. -He/She noticed the dust buildup on the fan in resident room [ROOM NUMBER] and the housekeepers should clean the fan once per week. -He/She expected the housekeepers to do as much they can without hurting themselves and his/her department was short of a housekeeper for a period of time earlier in 2024. During an interview on 11/01/24 at At 9:15 A.M., Nursing Assistant (NA) A said the trash container should be in the soiled utility room. During an interview on 11/1/24 at 2:17 P.M., the Administrator said he/she did not know why that pink bedpan was under the bed in resident 403 and he/she did not know how long that pink bedpan had been there.

Based on observation, interview, and record review, the facility failed to maintain the hot water temperature at or below 120 F (degrees Fahrenheit) in the room of Residents #2 and #76 and in the room of Residents #26 and #77; failed to use a gait belt when assisting one sampled resident to ambulate (Resident #19) who was unsteady on his/her feet; and failed to ensure an initial smoking assessment was completed to establish a baseline for the ability of one resident to smoke, determine assistance as necessary, and ensure safe smoking habits were in place for one sampled resident (Residents #61) out of 22 sampled residents. The facility census was 80 residents. 1. Review of the temperature log dated 10/14/24, showed the following hot water temperatures: -In the 100 Hall the temperature was 102 F. -In the 200 Hall, the temperature was 102 F. -In the 300 Hall, the temperature was 104 F. -In the 400 Hall, the temperature was 105 F -In the 500 Hall, the temperature was 104 F. -The particular rooms on each hall were not identified. During an interview on 11/1/24 at 12:54 P.M., the Maintenance Director said he/she had not identified the particular rooms on each hall in hot water temperatures were checked. 2. Observation on 10/31/24 at 10:02 A.M., with the Maintenance Director, showed the temperature of the hot water heater for that hall, was set at 165 F and that hot water heater also served the laundry which was on that hall. During an interview on 10/31/24 at 10:03 A.M., the Maintenance Director said the hot water heater did not need to be set at that high of a temperature. 3. Review of Resident #2's quarterly Minimum Data Set (MDS--a federally mandated assessment tool completed by the facility for care planning) dated 8/20/24, identified the resident as: -A resident who needed minimal assistance for transfers and ambulation. -A resident who had moderate cognitive impairment. Review of Resident #76's quarterly MDS dated [DATE], identified the resident as -A resident who required substantial assistance for transfers and ambulation. -A resident who was severely impaired in cognitive skills for daily decision-making. Observation on 10/31/24 at 9:54 A.M. with the Maintenance Director, showed the temperature of the hot water in the room of Residents #2 and #76 was between 126-128.2 F, after the water from the faucet was allowed to flow for two or more minutes. Observation on 10/31/24 at 1:54 P.M., with Certified Medication Technician (CMT) A showed the temperature of the hot water in the Resident #76's and #2's room, was 129.7 F. During an interview on 10/31/24 at 1:55 P.M., CMT A said he/she did not know the water in that room was so hot after he/she washed his/her hands. Observations on 11/1/24 at 9:35 A.M., showed the hot water temperature in Resident #76's and #2's room was 128.4 F. 4. Review of Resident #26's quarterly MDS dated [DATE] identified the resident as: -A resident who was required no assistance from a helper in transfers. and ambulation. -A resident who had severe cognitive impairment. Review of Resident #77's quarterly MDS dated [DATE], identified the resident as -A resident who needed minimal assistance for transfers and had not performed any ambulation in the 7 days prior to the date of the MDS. -Resident who had severe cognitive impairment. Observation on 10/31/24 at 9:56 A.M. with the Maintenance Director, showed the temperature of the hot water in the room of Residents #26 and #77, was between 126.5 F, after the water from the faucet was allowed to flow for two or more minutes. Observation on 10/31/24 at 1:58 P.M., showed the temperature of the hot water in the Resident #26's and #77's room, was 129.5 F. Observations on 11/1/24 at 9:32 A.M., showed the hot water temperature in Resident #26's and #77's room was 130.0 F. 5. During an interview on 10/31/24 at 2:03 P.M., CMT A said: - Neither Resident #76 nor Resident #2 were able to get to the handwashing faucet on their own because both residents needed assistance in ambulating. - Resident #26 was able to ambulate without assistance but did not have enough cognitive ability to be able to mix the hot and cold water. - Resident #77 was able to ambulate to the handwashing faucet and had the cognitive ability to mix the hot and cold water at the faucet. ** At the times of the observations no residents attempted to go towards the handwashing faucet. During an interview on 10/31/24 at 2:07 P.M., Licensed Practical Nurse (LPN) A said: - Residents #76 and #2 were not able to get to the handwashing faucet on their own, because they needed assistance in transfers. - Resident #26 was capable of getting to the handwashing faucet on his/her own, but only had the cognitive ability to mix the hot and the cold on some days and on other days. He/she was not able to mix the hot and cold water. - Resident #77 had the cognitive ability to mix the hot and cold water on his/her own. 21003 6. A policy for gait belt use was requested but not received from the facility at the time of exit. Review of Resident #19's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Parkinson's Disease (a movement disorder of the nervous system that worsens over time) and blindness. Review of the resident's MDS dated [DATE], showed: -The resident was alert and oriented with minimal confusion. -Had had no functional impairment in range of motion and used a walker for mobility. -Was dependent for toileting and required moderate assistance for upper and lower body dressing. -Needed supervision to touching assistance to go from a siting to lying position, lying to sitting, sitting to standing, transfer to/from bed to chair, and transfer to/from the toilet. -Had no falls during the look back period. Review of the resident's Nursing Notes showed the resident had a recent unwitnessed non-injury fall on 10/28/24 and the resident sustained a skin abrasion to his/her right elbow. Review of the resident's Care Plan dated 4/12/27 and revised on 10/28/24, showed the resident required staff assistance with all cares due to visual disturbances and tremors, It also showed the resident had the potential for falls related to poor safety awareness and blindness. Observation and interview on 10/30/24 at 1:15 P.M., showed the resident was laying down on his/her bed in his/her room. Certified Nursing Assistant (CNA) B entered the resident's room and assisted the resident to sit up on the side of his/her bed. CNA B then pulled the resident's walker up to him/her and the resident was able to hold onto the walker as CNA B assisted the resident to stand without using a gait belt. Once the resident was standing, he/she said he/she needed to go to the bathroom and CNA B provided standby assist and direct assistance of the resident as he/she walked with his/her walker to the bathroom, as the resident became unsteady while walking. LPN B, who was watching CNA B assisting the resident to walk, went to get a gait belt and gave it to CNA B to put on the resident. The resident was in the bathroom at this time. During an interview on 10/30/24 at 1:24 P.M., LPN B said: -The resident normally was able to ambulate without any assistance with his/her walker, but he/she was having more shaking related to his/her Parkinson's disease today and needed the assistance to walk. -He/She went to get the gait belt when he/she did not see the resident wearing one while CNA B was assisting him/her. -CNA B should have placed a gait belt on the resident because he/she was physically assisting him/her with walking to the bathroom. During an interview on 10/30/24 at 1:58 P.M., CNA B said: -He/She went to the resident's room to feed him/her because the resident was shaking more and did not want to go to the dining room. -He/She assisted the resident to transfer to his/her walker and to the bathroom because he/she was unsteady on his/her feet. -He/She did not have a gait belt available at the time and there was no gait belt in the room so he/she did not use one. -He/She knew he/she should have used a gait belt when assisting the resident to stand and walk. During an interview on 11/1/24 at 11:36 A.M., with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and Regional Quality Assurance Nurse (RQAN), the DON said: -If the resident is ambulating independently, they would not need to wear a gait belt if they were only providing stand by assistance only. -If the nursing staff provide any hands on assistance with ambulation, they are to use a gait belt. -The nursing staff do not carry gait belts with them. -Each resident has a gait belt in their room that is designated for use with that resident and the gait belts are hanging in each resident closet. -He/She was made aware that the nursing aide had not worn a gait belt when assisting the resident and the nursing staff should have worn one. 51305 7. Review of the facility Smoking policy and procedure, dated 10/29/17 showed: -The facility must comply with federal, state, and local regulations regarding smoking in healthcare facilities. -There was no documentation showing how often staff were to complete smoking assessments for residents to ensure they could smoke safely. Review of Resident #61's Face Sheet showed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation) and tobacco use. Review of the resident's admission Progress Note dated 9/19/24 showed the resident was a current every day smoker. Review of the resident's admission MDS dated [DATE] showed the resident: -Was cognitively intact. -Used tobacco products. Review of the resident's Care Plan dated 10/2/24, showed: -The resident smoked cigarettes. -The staff were to instruct the resident about smoking schedule and rules. -The resident was to be observed while smoking by staff. Review of the resident's electronic medical record on 10/29/24 showed: -No documentation the facility staff had completed an initial smoking assessment. -There was no documentation showing the resident was able to safely smoke and abide by the facility smoking policy. During an interview on 10/28/24 at 11:42 A.M., the resident said he/she goes outside and smokes cigarettes five times a day. During an interview on 10/31/24 at 2:21 P.M., LPN C said: -Upon admission, he/she would ask the resident if he/she smoked cigarettes. -If the resident said yes, he/she would notify the Social Services Director (SSD) to complete a smoking assessment on the resident. -The SSD was responsible for completing all smoking assessment on the residents. -The smoking assessments were completed upon admission, quarterly or if there was a change in the resident's condition. -Resident #61 should have had a smoking assessment completed. -All residents that smoke cigarettes have a contract that was signed by the resident stating that he/she agreed to follow the facilities rules about smoking. During an interview on 11/1/24 at 9:16 A.M., the SSD said: -If a resident smoked cigarettes, he/she signed a contract agreeing to the rules. -Nurses were responsible for completing residents smoking assessments. -A resident would be assessed by the nurse to see if he/she could hold and light a cigarette safely. -The smoking assessments were done upon admission and every quarter. -The Director of Nursing or any nurse were responsible for the completion of the smoking assessment. -Resident #61 should have had a smoking assessment completed. During an interview on 11/1/24 at 11:36 A.M., the DON, RNC, and RQAN, the DON said: -A smoking assessment was needed to make sure the resident was able to smoke cigarettes without any concerns or if he/she would need some kind of protection like a smoking apron. -He/She would use the assessment to determine if the resident can smoke cigarettes safely. -The smoking assessments were completed upon admission and annually. -The nurses or nursing management were responsible for completing the smoking assessments. -The smoking assessments were completed by the interdisciplinary Team (IDT). -All assessments are kept electronically in the resident's medical record. -The RNC said: -If the resident was a smoker at the time of admission, he/she should have had a smoking assessment completed. -He/She would observe the resident to determine if he/she could smoke safely.

Based on observation, interview and record review, the facility failed to ensure physician's orders for a Continuous Positive Airway Pressure (CPAP a form of positive airway pressure ventilation in which a constant level of pressure greater than atmospheric pressure is continuously pumped into the lungs during spontaneous breathing) machine was on their Physician's Order Sheet (POS), care plan for one sampled resident (Resident #37); and failed to ensure respiratory face masks and tubing were kept covered when not in use for three sampled residents (Resident #68, #81, and #59) out of 22 sampled residents. The facility census was 80 residents. Review of the facility's Policy Continuous Positive Airway Pressure revised 6/15/16 showed: -CPAP should be administered under order of the attending physician. -Obtain physician order for the rate of flow/pressure setting for CPAP and frequency of use. -Mask/nasal pillows and flexible tubing should be washed, per manufacturers guidelines with mild soap and water, rinse thoroughly and air dry. Review of the facility's Policy Oxygen Administration dated 12/8/05 showed: -Oxygen (O2) cannula/mask should be stored in plastic bag when not in use. -Obtain physician order for the rate of flow and route of administration of oxygen (i.e. by tank, concentrator, nasal cannula, mask, etc.). 1. Review of Resident #37's Admission Face sheet showed the resident had a diagnosis of: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/19/24 showed he/she: -Was cognitively intact, able to make his/her needs and wants known. -Had no documentation that the resident required the use of a CPAP machine. Review of the resident's Care Plan dated 9/17/24 showed the resident: -Was receiving Oxygen Therapy. -Intervention include administer oxygen therapy as needed and ensure that supplies were always available. -NOTE: Did not have a care plan for the use and the care of CPAP machine and mask. Review of the resident's POS dated 10/1/24 to 10/31/24 showed he/she had the following orders: -Did not have a detailed physician's order for use and monitoring/care of the residents CPAP machine and supplies. -No documentation of the resident's use of the CPAP machine at bedtime or as needed. Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 10/1/24 to 10/31/24 showed: -Did not have a detailed physician's order for use and monitoring/care of the residents CPAP machine and supplies. -No documentation of the monitoring of the resident's use of the CPAP machine at bedtime or as needed. Observation on 10/28/24 at 8:20 A.M., showed the resident had a CPAP machine next to the bed on the dresser with a face mask laid on the resident bed uncovered. Observation on 10/29/24 at 12:33 P.M. showed: -A CPAP machine sitting on the dresser. Observation on 10/30/24 at 12:56 P.M., showed the resident had a CPAP machine sitting on the dresser, mask laid on bed uncovered. During an interview on 10/30/24 at 2:23 P.M. the resident said: -He/She wore the CPAP at night. During an interview on 11/1/24 at 8:16 A.M., Certified Medication Technician (CMT) A said: -The resident use CPAP at night. During an interview on 11/1/24 at 8:40 A.M., Certified Nursing Assistant (CNA) E said: -CPAP should have a physician order, he/she would refer to the nursing staff about the physician order and care for a CPAP machine. During an interview on 11/01/24 at 8:56 A.M., Registered Nurse (RN) B said: -He/she would expect to have physician's order for use of CPAP. Review of the resident's electronic record on 11/1/24 at 9:02 A.M., with RN B showed: -He/she did not find a physician order for Resident #37 use of CPAP machine and care of mask or supplies. -RCN said he/she did not find a physician order for CPAP. -RCN said he/she would expect to have detail physician order for use of CPAP machine and care for mask. Care plan updated with use and monitoring of the CPAP machine and supplies. During an interview 11/01/24 at 11:36 A.M., the Director of Nursing (DON) said: -Would expect to have a physician order for Resident#37 use of CPAP machine to include the settings, supplies needed for CPAP machine and the cleaning of face mask. -Would expect to have care plan to include resident use of a CPAP. 50579 2. Review of Resident #81's quarterly MDS assessment, dated 10/16/24, showed: -Diagnoses of COPD and chronic respiratory failure. -The resident received oxygen therapy but did not use a CPAP device. Review of the resident's POS, dated 11/1/24, showed no orders for oxygen administration or the use of a CPAP machine. Review of the resident's Care Plan, dated 10/21/24, showed: -The resident received oxygen therapy. -Staff were to change tubing per protocol. -No specifications to the rate or frequency of oxygen to be administered. Observation on 10/28/24 at 9:13 A.M., showed: -The resident in his/her room with oxygen being administered through a nasal cannula at 2 liters per minute. -A CPAP device near the resident's bed, with tubing that ran across the ground and a mask that rested uncovered on a tote near the resident's bed. -No dates on the oxygen tubing or CPAP mask/tubing. -No bags or areas to place the mask or tubing when not in use. 21003 3. Review of Resident #68's Face Sheet showed the resident was admitted on [DATE], with a diagnosis of sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep). Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Had a specialized treatment- a non-invasive ventilator (CPAP/bilevel positive airway pressure (BiPAP, a noninvasive breathing machine that helps people breathe when they have medical conditions that make it difficult). Review of the resident's POS dated 10/2024, showed physician's orders for: - CPAP/BiPAP setting and ensure distilled water is full in the reservoir at bedtime daily at 9:00 P.M. Review of the resident's Care Plan updated on 10/25/24, showed the resident had sleep apnea and used a CPAP/BiPAP at bedside. Interventions showed staff would: -Administer oxygen therapy as ordered. -Change the tubing per protocol. Observation on 10/28/24 at 8:39 A.M., showed the resident was not in his/her room. There was a CPAP/BiPAP machine sitting on the nightstand beside the resident's bed. The resident's face mask and tubing was left uncovered and laying on top of the resident's bed. There was a brown substance on the linen on the bed that was next to the face mask. Observation on 10/29/24 at 9:54 A.M., showed the resident was laying on his/her bed and nursing staff was preparing to provide care to him/her/ On the nightstand beside the resident's bed was his/her CPAP/BiPAP machine and the face mask and tubing was laying on top of it, uncovered. Observation and interview on 10/29/24 at 10:24 A.M., showed the resident's CPAP/BiPAP machine was still on his/her nightstand and the face mask and tubing was still laying on the machine, uncovered. The resident said he/she used the CPAP/BiPAP when he/she was sleeping at night and when he/she awoke, he/she placed the face mask on the machine. He/She said he/she did not usually have a bag for the face mask. 51303 4. Review of the resident undated Face Sheet showed his/her most recent admission was 12/14/2023 with a diagnosis of COPD. Review of resident's quarterly MDS dated [DATE] showed: -The resident had some cognitive impairment that needed support from staff. -He/She was receiving oxygen. Review of resident's POS for 10/1/24 to 10/29/24 showed an order for oxygen at 2 to 4 liters per minute per nasal cannula as needed for shortness of breath. Review of resident's care plan showed a problem of oxygen therapy with interventions to include: -Administer oxygen therapy as ordered. -Change tubing per protocol. Observation on 10/28/24 at 8:28 A.M. showed the oxygen tubing for the E-tank (a portable oxygen tank) was draped over the wheelchair and not bagged. Observation on 10/29/24 at 12:59 P.M. showed the oxygen tubing for his/her concentrator in the room drapped over the bedside table and was not bagged. Observation 10/30/24 at 9:09 showed the resident up in wheelchair with oxygen tubing to his concentrator on. The external filter to the concentrator was missing, and the concentrator had a buildup of dust and grime. Oxygen tubing for the E-tank was draped over wheelchair and not bagged. 5. During an interview on 10/29/24 at 10:16 A.M., CNA A said: -The CPAP face mask and oxygen tubing should be in a bag when it is not in use and they (staff) should label and date the bag. During an interview on 11/01/24 at 11:36 A.M., with the DON, Regional Nurse Consultant, and the Regional Corporate Quality Assurance (QA) Nurse, the DON said: -Oxygen tubing, face masks and CPAP/BiPAP supplies should be stored in dated bags when not in use to prevent contamination. -An order should be in the resident's record for oxygen therapy, CPAP use and changing the oxygen tubing and storage bags. -The night shift nurses were responsible for changing out the tubing weekly at night. -CPAP masks should be bagged when not in use and there should also be an order showing when the mask and bags are to be changed. -He/She expected the filters and concentrators were cleaned weekly on Wednesdays by night shift.

Based on interview, and record review, the facility failed to maintain documentation and ensure that Certified Nursing Assistants (CNAs), and licensed nursing staff had the appropriate competencies and skills check off completed annually and as needed. This had the potential to effect any resident care provided by care staff. The facility census was 80 residents. Review of the Facility assessment dated [DATE] showed: -The facility has staff skills and competencies to address the current and future needs of the facility's resident. -The facility had reviewed staff training and inservices program and determined that it is appropriate to provide the level and types of care needed for the resident population outlined in this assessment. The facility also reviewed staff competencies and skills sets and determined that competencies and skills sets for both staff and contractors were appropriate. 1. During the entrance conference on 10/28/24 at 9:07 A.M., the Administrator said: -The facility does not currently have an Assistant Director of Nursing (ADON). -The facility had residents with tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions), wounds, colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine), tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing), and dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). Review of employees annual inservices and training records from 10/1/23 to 10/31/24 showed the facility did not have documentation of the staff completed skill and competency check off records. On 10/31/24 at 1:56 P.M. request the facilities staff competency skills check off for sampled employees. During an interview on 11/1/24 at 8:16 A.M., Certified Medication Technician (CMT) A said: -He/She had completed a competency skills check off about 4-5 months ago. -He/She did not keep a copy for his/her record. During an interview 11/1/24 at 11:11 A.M., Director of Nursing (DON) and Licensed Practical Nurse (LPN) B said: -The facility did not have staffing coordinator at that time. -The staffing coordinator would have been responsible for coordination of competency and skills check off, and maintaining staff competence and skill check off documentation. -The DON and LPN B were assisting with staff scheduling and training as needed until new staff were hired. -Staffing coordinator would normally coordinate a skills lab to be completed annually and as needed. -DON said: he/she was not able to locate the staff competency and skills documentation at that time for all nursing, CMT, CNA competency and skill completed. -DON would expect the facility staff coordinator to ensure to maintain and secure staff competency and skills check off documentation that had been completed for that year. On 11/1/24 at 2:06 P.M., at the time of exit, the facility administration were not able to find documentation of facility staff competency and skill check off that had been completed.

Based on observation and interview, the facility failed to maintain the covers of cleanouts (an access point which provides access to the sewer or other plumbing line so that blockages can be removed) in a tight-fitting manner so the covers would not be a hazard to facility residents or staff located on the 100 Hall and on the 400 Hall. This practice potentially affected 31 residents who resided on those halls. 1. Observations on 10/29/24 at 1:23 P.M. and on 10/31/24 at 10:29 A.M., showed the cleanout cover outside of resident room [ROOM NUMBER] was loose when it was stepped on. During an interview on 10/31/24 at 10:30 A.M., the Maintenance Director said there has not been any work completed around that cleanout since he/she started his/her tenure at the facility in April 2024. 2. Observations on 10/31/24 at 11:31 A.M., showed the cleanout cover between 107 and 108 was loose when it was stepped on. During a phone interview on 11/6/24 at 3:08 P.M., the Maintenance Director said he/she expected the housekeeping staff who cleaned the floors in the hallways to notify him/her if one of those cleanout covers was loose.

Based on interview and record review, the facility failed to ensure a resident was included on his/her care plan meetings and care plan meeting invitations for two sampled residents (Resident #59 and #75) out of 22 sampled residents. The facility census was 80 residents. Review of the policy Person Centered Care Plans effective date 8/15/18 showed: -Preparation for Care Plan Committee Meetings: --The Registered Nurse or other designee should provide a list of resident/guest(s) names, dates, and times for care plan meetings two weeks in advance to other team members. This list also includes information as to the type of care plan review for each resident/guest, admission, quarterly, annual, or significant change in status reviews. --The Social Service Director (SSD, or other designee, should inform the resident/guest and families of the scheduled meeting by mailing the Notice of Schedule Plan of Care Conference to family members or legal representatives, as meeting notice. Family members and legal representatives should only be invited to attend, when permitted by the resident/guest, or when the party is legally responsible for making the health care decisions for the resident/guest. --The Interdisciplinary team (IDT) members should prepare for the care plan meeting by completing an assessment of the resident/guest and initiating care plan entries for problems or concerns related to the resident/guest as appropriate. -Conducting the Person-Centered Care Plan Meeting: --The team, including the resident/guest and their desired representatives, when possible, should present findings from assessments, using information from the Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan and discuss suggested new goals or approaches, as appropriate. Existing goals and approaches should be reviewed and revised as needed. Any input gained from the resident/guest should be recorded in the plan of care and the resident/guest participation should be recorded in the electronic medical record (EMR). --When the resident/guest is unable to attend, but able to comprehend the plan of care, a review of the plan should be conducted by the care plan designee. The resident/guest participation should be recorded in the EMR. --The care plan team should develop a comprehensive care plan for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s)medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and the resident/guest(s) goals and preferences, future discharge. --Each participant in the care plan meeting should document their involvement. 1. Review of Resident #59's undated Face Sheet showed his/her most recent admission was 12/14/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/7/24 showed the resident had some cognitive impairment that needed support. During an interview on 10/28/24 at 8:28 A.M. the resident said he/she was not aware of care plan meetings or involved in the setting of goals, and had not been invited to care plan meetings. Resident had not seen his/her care plan. He/She had two sons that were retired but did not provide help. He/She would like to participate in the care plan process. Review of the resident's care plan meeting invitation binder on 10/30/24 at 11:06 A.M. showed: -Care plan meeting invitations for 5/28/24, 8/7/24, and 11/13/24 were addressed to the resident's family member. No care plan meeting invitations were addressed to the resident. -No documentation the resident was presented a copy of these invitations to his/her care plan meetings. -No documentation of who attended the care plan meetings. 2. Review of Resident #75's undated Face Sheet showed his/her most recent admission was 4/7/24. Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 10/28/24 at 11:50 A.M. the resident said he/she had not been informed of care plan meetings, had not been invited to care plan meetings, or involved in the setting of goals but would like to be involved. He/She had not seen his/her individualized care plan. Review of the resident's care plan meeting invitation binder on 10/30/24 at 8:43 A.M. showed: -Care plan meeting invitations for 6/14/24, 7/31/24, and 10/10/24 were addressed to the resident's family member. No care plan meeting invitations were addressed to the resident. -No documentation the resident was presented a copy of these invitations to his/her care plan meetings. -No documentation of who attended the care plan meetings. 3. During an interview on 10/30/24 at 11:06 A.M. the SSD said: -Care plan meeting invitations were sent to the family. -Care plan meeting invitations are not sent out or given to the residents. -The Interdisciplinary Team (IDT) would speak to the resident to ask if there were concerns. -A care plan conference form would be signed to document the meeting by all who attended the meeting. -A care plan conference form was not located for Resident #59 or #75. During an interview on 11/01/24 at 08:43 AM. the MDS nurse said: -The Social Service Director would send the care plan meeting invitations. -The facility tries to include the resident and/or the responsible party. -The care plan meeting was attended by the MDS nurse, SSD and Business Office Manager (BOM), Activities Director (AD) would be there if there were an activity concern. The dietary manager was new and not attending at this time. -The care plan meetings were to be documented in the chart. -The SSD usually made a note documenting the care plan meeting. -He/She felt a skilled resident was involved in goal setting. -The IDT would ask a long-term care resident if they had concerns or wanted something different. -He/She reviewed the baseline care plan with new residents. -He/She did not review the comprehensive care plans with residents. During an interview on 11/01/24 at 11:31 A.M. the Director of Nursing (DON) said: -He/She expected residents to participate in the development and implementation of the person-centered care plan. -He/She expected residents to be involved in the establishment of goals. -He/She expected the residents were able to review their care plans. -He/She expected a member of the IDT would document the care plan meeting in the clinical chart. This was usually the SSD.

Based on interview and record review, the facility failed to ensure the correct code status was in place for one sampled resident (Resident #28) out of 22 sampled residents. The facility census was 80 residents. A policy related to advance directives was requested and was not received by the facility. 1. Review of Resident #28's face sheet showed he/she admitted to the facility on [DATE] with a diagnosis of Encounter for Other Orthopedic Aftercare. NOTE: The face sheet also showed that the resident did not have an advance directive or code status in place. Review of the resident's Physician Order Sheet (POS) dated [DATE] showed no order for an advance directive or code status. Review of the resident's care plan dated [DATE] showed the resident's advance directive or code status was not in the care plan. Review off the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident was cognitively intact. Review of the resident's Electronic Medical Record (EMR) on [DATE] at 10:34 A.M. showed the resident did not have an advance directive in place and no documentation of the resident's desire for a Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) code status. Review of the resident's paper chart on [DATE] at 2:22 P.M. showed the resident did not have an advance directive in place and no documentation of the resident's desire for a DNR code status. During an interview on [DATE] at 9:34 A.M. the resident said he/she had a code status of DNR. During an interview on [DATE] at 9:35 A.M. Family Member A said: -The resident was a DNR. -The resident's DNR status should be in the facility records. During an interview on [DATE] at 8:59 A.M. the Social Services Designee (SSD) said the resident was a full code, so the facility did not have any record of the resident's advance directive or desire for a DNR code status. During an interview on [DATE] at 8:03 A.M. Certified Nursing Assistant (CNA) A said: -The facility usually received a resident's advance directive and code status upon admission. -The nurses were responsible for ensuring the completion of the advance directive. -If a resident stated that they were supposed to be a DNR, then he/she would get the nurse or SSD. -A resident's advance directive could be found in the EMR or in a paper chart. -If a resident is a DNR then there should be an order in place. -He/She thought the resident was a full code (indicates the healthcare team should perform CardioPulmonary Resuscitation (CPR) - if needed). -The resident's advance directive and code status should be on his/her care plan. -He/She was unaware that the resident was supposed to be a DNR. During an interview on [DATE] at 8:14 A.M. Registered Nurse (RN) A said: -Nurses were responsible for ensuring the resident's correct advance directive and code status was in place upon admission. -A resident's advance directive could be found in the EMR or in a paper chart. -If a resident requested to be a DNR then he/she would discuss his/her code status with the resident to ensure that is what the resident wanted and get an order from the doctor. -An order should be in place for a resident who is a DNR. -He/She thought the resident was a full code. -If the face sheet showed There are no Advance Directives selected for this resident then that indicated the resident's code status was not in the EMR. -He/She was unaware that the resident did not have an advance directive in place and that the resident was supposed to be a DNR. -A resident's advance directive and code status should be on his/her care plan. During an interview on [DATE] at 11:36 A.M. the Director of Nursing (DON) said: -Nurses were responsible for obtaining a resident's advance directive and code status upon admission. -Advance directives and code status should be on all resident care plans. -If a resident wanted to be a DNR, then he/she would expect the nurses to ensure the resident could make his/her own decisions, get an order, and ensure the appropriate documentation was in place. -There was a banner in the facility's electronic medical record system that indicated what a resident's code status was. -There would only need to be an order in place in the resident's POS if the resident was a DNR. -He/She thought the resident was a full code. -He/She was unaware that the resident's advance directive had not been completed and that the resident was supposed to be a DNR.

Based on interview and record review, the facility failed to ascertain the resident's code status before initiating cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for one sampled resident (Resident #5) who was a do not resuscitate (DNR) status out of 5 sampled residents. On [DATE], Registered Nurse (RN) A found the resident without spontaneous respirations and pulse and started CPR. The resident was resuscitated after CPR was performed and was taken by Emergency Medical Services (EMS) to the hospital and subsequently died [DATE] after he/she was placed on comfort care. The facility census was 79 residents. The Administrator was notified on [DATE] at 11:25 A.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's Cardiopulmonary Resuscitation Policy, dated [DATE], showed: -Code Status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). -Original Do Not Resuscitate (DNR) Order (refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest) should be handwritten by a physician and then entered in the order system as these are not allowed to be telephone orders. -A faxed handwritten order by physician is acceptable. The original order should be maintained in the hard copy record in a plastic sleeve. -The DNR order is entered as a specific order type in electronic record as advance directive for quick reference in case of an emergency. Review of the facility's undated Protocol for Emergent care showed: -Call Stat to or Code Blue to location. -Do not leave the resident unattended. -Staff member should call for assistance. -Make sure enough staff members to assist with the resident and to make all necessary phone notifications and obtain crash cart, emergency equipment. -A staff member should access the electronic record immediately and verify the identification of the resident by electronic photograph and if there is an order for DNR. This order will appear as one of the first orders when sorting by order type. (Note does not indicate has to be a nurse or CMT). -In electric outage a hard copy photograph used for identification and hard copy DNR order on the chart. -The staff member (preferably nurse) that remains with the resident should get the resident prepared for resuscitation pending the determination of whether or not the resident has a current DNR order so that CPR can be immediately started if no DNR found. 1. Review of Resident #5's Admission Face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses of surgical wound, low back pain, paraplegia (an impairment in motor or sensory function of the lower extremities), history of pulmonary embolism (blood clot in lung), and seizures (is a sudden body or limb jerks that can involve the arms, head and neck). Review of the resident's Admission Data Collection, dated [DATE] at 3:50 P.M., showed the resident was oriented to person, time, and situation. Review of the resident's Base Line Care Plan, dated [DATE] at 2:04 P.M., showed the resident was a DNR, wishes no CPR. Review of the resident's Outside the Hospital DNR Order Sheet showed the form had been signed on [DATE] by the resident and his/her physician. Review of the resident's Physician Order Sheet (POS) showed the resident had a physician order dated [DATE] for DNR code status. Review of the resident's Care Plan for Living Will/Do Not Resuscitate status, dated [DATE], showed: -Goal for the resident was end of life wishes to be honored for 90 days (started [DATE]). -Respect the resident decision and assure that he/she may change his/her mind at any time concerning terms of living will/DNR. -Provide comfort measure and provide pain management as needed. -Inform other healthcare providers caring for the resident of his/her living will/DNR status. -Physician will review and uphold the resident's wishes stipulated in the living will. Review of the resident's facility Nursing Note, dated [DATE] at 2:56 P.M. which was documented by RN B, showed: -Around 11:30 A.M. on [DATE], the resident went unresponsive while in the bath house. -RN B arrived to see resident already lowered to ground from wheelchair and RN A performing CPR. -When RN B arrived at bath house at 11:32 A.M., he/she took command of recording the event. -At 11:34 A.M., the resident had a return of spontaneous circulation (ROSC, is the resumption of sustained perfusion cardiac activity associated with significant respiratory effort after cardiac arrest). -The resident was placed on oxygen (O2) at a rate of 15 liters via a non-rebreather mask, oxygen saturation (O2 stats- measures how much oxygen is carried by the hemoglobin in your blood) were at 95% with O2 in place, and a heart rate of 105. -EMS arrived at 11:39 A.M., the resident was sent to the hospital for evaluation and treatment. -The resident's family member was notified of the event. -Note: There was no documentation the resident was a DNR status. Review of the resident's facility Summary of Events, dated [DATE], showed: -The resident was in the shower/bath house with two Certified Nursing Assistants (CNA) when the resident went unresponsive. -CNA A instructed CNA B to go get the charge nurse. -The nurse arrived at the bath house and a Code Blue (activated if a patient or individual is found unconscious, without a pulse, or not breathing) was called overhead. -The resident was lowered to the ground and the nurse began performing CPR and staff called the emergency phone number (911). -The facility summary timeline of the events: --Approximately at 11:28 A.M. the resident became unresponsive. --At 11:32 A.M., one round of chest compressions with Ambu-bag (refers to a type of device known as a bag valve mask, which is used to provide respiratory support to patients). --At 11:34 A.M., the resident's DNR status found in orders in his/her electronic record. --At 11:34 A.M., the resident chest compressions stopped due to ROSC achieved. --The resident's O2 sats 66% at room air (the average O2 sats level are from 95 to 100%.) and heart rate of 121 (the normal heart rate between 60 and 100 beats/minute). --At 11:38 A.M., resident placed on oxygen at rate 15 liters per minute via a non-rebreather mask (a special medical device that helps provide resident with oxygen in emergencies) --At 11:39 A.M., O2 sats 95% with oxygen in place and heart rate of 105. --At 11:39 A.M., Emergency Medical Services (EMS) arrived at the facility. Review of the resident's EMS report, dated [DATE] at 11:34 A.M., showed. -EMS received call from the facility related to a resident in cardiac arrest-death. -EMS, fire and rescue arrived at the facility at 11:37 A.M. -At 11:40 A.M., the resident vital signs were taken with findings of heart rate (pulse) of 100 beats per minute, respiratory rate of 11 (an average normal rate of ,d+[DATE] per minute), O2 sats 96% with oxygen in place, the resident had oxygen administered at flow rate of 15 liters per minute, and the resident had improved with use oxygen. --The resident had no eye movement when assessed by EMS staff, no motor response and no verbal/vocal response. -At 11:52 A.M., the resident departed the facility by EMS. --At 11:58 A.M., the resident opened his/her eyes to verbal stimulation, obeys commands appropriate response to stimulation. -At 12:06 P.M., the resident arrived at the hospital. Narrative: dispatched to facility in regard to a cardiac arrest with CPR in progress. -EMS unit in route and updated on the patient, he/she had regained a pulse and now spontaneously breathing. Update no longer breathing, -An update the resident DNR status had been located. -EMS unit arrived on scene. Resident found lying supine on the floor in the shower room. Located off the 500 hallways under the care of facility staff. --Facility staff reports that while attempting to shower the resident, he/she became unresponsive and slumped over. --Facility staff initiated CPR when resident was found with no pulse and no breathing observed. --CPR was being performed by facility staff until the resident's DNR code status was located. --The resident was unconscious and unresponsive with a Glasgow Coma Scale (GCS, is a system to score or measure how conscious you are at) of 3, he/she had a patent airway with apparent agonal (uneven) respiration at a rate of approximately ,d+[DATE] breaths per minute. --The resident skin pink, warm and moist. The resident pupils equal and reactive to light. -While attempting to contact online medical control for orders to transport determination, the resident began to have normal respiration and began to open his/her eyes and look around the room. -Due to sudden increase in GCS and Level of Consciousness (LOC) transport decision were made for hospital. -The resident was moved to a stretcher and secured in semi-Fowler (head elevated laying down) then moved to the ambulance and secured. Review of the resident's Hospital History and Physical Assessment (H&P), dated [DATE], showed: -The hospital received a copy of the resident's DNR status signed on [DATE]. -Family members were ok with comfort care only for the resident, to include use of a Bilevel Positive Airway Pressure (known as BPAP, or BiPAP, is a machine that helps you breathe) machine. -Had a diagnosis of cardiac arrest (heart attack) which was witnessed while he/she was in shower room at the nursing home. -CPR started by facility staff, even though the resident was a DNR status. Automated External Defibrillator (AED, a portable device that analyzes the heart's rhythm and delivers an electric shock to restore a normal heartbeat in cases of sudden cardiac arrest) was used. -The resident was transferred to Emergency Department (ED) from the care facility. -The resident had purposeful movement, but not yet following staff commands. -The resident had Acute Hypoxic (lack of oxygen to brain) and respiratory failure (a serious condition makes it difficulty to breath on your own). Review of the resident's hospital Physician Discharge Record, dated [DATE], showed: -The resident was admitted to the hospital on [DATE]. -The resident had a witnessed cardiac arrest at his/her skilled facility on [DATE]. He/She had signed Outside the Hospital DNR form, but was resuscitated regardless. He/she arrived at our facility requiring BiPAP. -He/she had a cardiac arrest event, witnessed while he/she was in the shower at nursing home. -CPR was started, though the resident was an DNR. The facility also used an AED. -While at the hospital, Resident #5 was able to speak for himself/herself and clearly asserted that he/she did not want any further care. -The hospital plan was to transition the resident to hospice care, but he/she passed away prior to this occurring. -On [DATE], the resident passed away at the hospital. During an interview on [DATE] at 11:07 A.M., CNA B said: -On [DATE] at around 11:30 A.M., CNA A was about to shower the resident. -He/she had gone into the shower room to grab supplies for another resident. -CNA A and he/she had noted the resident's head had dropped to his/her chest. -He/she said something to CNA A that there was something wrong with the resident. -CNA A called out the resident's name, with no response. -CNA A then instructed CNA B to go get a nurse and he/she left to notify RN A. -Other nursing staff also arrived at the shower house to assist in the medical emergency. -He/she left the area to attend to another resident after he/she notified the nurse. During interview on [DATE] at 12:27 P.M., RN A said: -He/she was CPR certified. -On the morning of [DATE] the resident was feeling well enough and wanted to take a shower. He/she went to the shower room with CNA A, where the resident then become unresponsive. -RN A was notified by CNA B, and immediately went to assess the resident in the shower room. -The resident was found unresponsive to sternal chest rub and shaking shout. -He/she requested staff members (LPN B and CNA A) to call Code Blue and to obtain the AED and Crash cart (contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency). -With assist of three other staff members lowered the resident to ground and he/she started performing chest compressions, CPR. -Another nurse (LPN C) went to check the resident's code status and informed RN A and other nursing staff present the resident was a DNR. -He/she stopped performing CPR after the resident had spontaneous breathing and pulse return. -Legally he/she could not stop performing CPR once he/she started CPR. He/she could only stop CPR if the resident became responsive or EMS arrived to take over resident care. -He/she was aware after performing CPR for a resident with a DNR, that he/she was going to be sent home until further investigation. -His/her immediate thought was not about the resident's code status or wishes, only his/her response to an unresponsive resident and the emergency room nurse reaction kicked in and he/she started chest compressions after finding the resident had no breathing and no pulse. -He/she should have checked for the resident's code status before performing CPR. -The residents' code status were located in residents electronic record under POS and could also be found in the resident's medical hard chart, documented on the POS and usually a purple form with the resident's DNR form signed and dated by the physician and resident. During an interview on [DATE] at 11:15 A.M., Licensed Practical Nurse (LPN) A said: -On [DATE] he/she heard the Code Blue and responded to the shower house. -RN A assessed the resident, found he/she was unresponsive, not breathing and had no pulse. -He/she assisted RN A ad LPN B with lowering the resident to the ground. -RN A had already started chest compressions. -RN A was the resident's assigned nurse for that day. -Another nurse (LPN C) entered the shower house and said the resident was DNR, stop CPR. -The resident had started to breathe and had a pulse. -He/she would expect the resident code status be checked prior to initiation of CPR. Review of the facility Witness Statement by LPN B dated [DATE] showed: -At approximately 11:30 A.M. on [DATE], he/she was informed by LPN C the facility had a Code Blue to the shower house on 500 hallway. -As he/she was heading to the shower house, the administrator and LPN C were grabbing the crash cart. -When he/she arrived to the shower house, he/she noted LPN A , Registered Nurse RN A and the CNA A were already on scene and RN A had already started chest compressions. -The nursing staff transferred the resident to the ground. -The Administrator called EMS while RN A continued chest compressions. -He/she attached the AED pads to the resident's chest. -At around that time I heard LPN C stating the resident was a DNR and looked up to see LPN C showing us the hard chart with the DNR order paper work. -At around the same time the resident started breathing again, we got a set of vital signs, and then EMS arrived. -Paramedics took over the resident's care and transported the resident to the hospital. During an interview on [DATE] at 11:38 A.M., LPN B said: -On [DATE] at around 11:30 A.M. he/she was informed by LPN C of a Code Blue and heard Code Blue shower room. -The Administrator and LPN C grabbed a crash cart and headed toward the shower house by 500 hallway. -When he/she arrived CNA A, RN A, and LPN A were in the shower room and RN A had started chest compressions while the resident was in his/her wheelchair. -He/she and other nursing staff lowered the resident to ground with the use of a mechanical lift. -The Administrator went to call EMS, while RN A continued CPR. -He/she attached the pad for the AED. The resident had oxygen placed and then started using the Ambu bag. -The Assistant Director of Nursing (ADON) was the timekeeper for the event and called out times as needed. -At that time, he/she heard LPN C say the resident was a DNR. -Around this time the resident started breathing again and the nursing staff obtained a set of vital signs as EMS staff arrived and took over the resident's care. -He/she would expect the resident code status to be verified prior to performing CPR. -The resident code status could be found by looking in his/her electronic record and then in the hard chart. -The facility SSD had a binder with all resident DNR forms signed by the physician. Review of the facility Witness Statement by LPN C dated [DATE] showed: -At approximately 11:30 A.M. on [DATE], he/she was standing at the Nursing desk when he/she heard Code Blue to the shower house called overhead. I repeated the page to LPN B. -LPN B headed to the shower house and LPN C headed to get the crash cart with the Administrator. -Upon reaching the shower house on the 500 hallway, a crash cart was on site. -The 500 hall charge nurse and multiple staff members were already present. -He/she looked into the shower house to see staff lowering the resident to floor and the nurse (RN A) had started chest compressions. -Someone called for oxygen, so I assisted unwrapping tubing and handed the to tubing to another nurse. -He/she then heard someone ask if code status was confirmed. -At that time, he/she sent Certified Medication Technician (CMT) A to grab the resident's hard chart. -Another staff member called EMS while another staff attempted to reach the resident's spouse. -CMT A returned with the resident code status, he/she called out that the resident was a DNR to the rest of nursing staff present. -The resident had then began breathing on his/her own with noted pulse. -CPR was stopped. EMS arrived to facility and transported the resident out of the facility. During an interview on [DATE] at 11:22 A.M., LPN C said: -On [DATE], heard Code Blue overhead. -He/she had grabbed the crash cart heading to the shower house. -Had plenty of nursing staff in the room assisting the resident. -He/she handed the O2 tubing and then sent the CMT to get the resident's medical record. -He/she reviewed the resident's hard chart for a physician order for DNR status, and found the resident's purple DNR order in the chart. -He/she notified nursing staff the resident was a DNR and to stop chest compressions. -RN A stopped CPR when the resident began to breath on his/her own and have a pulse. -EMS arrived about the same time. -He/she left the area to gather transfer paperwork to send with the resident to hospital. -The resident's DNR status should have been found in his/her electronic medical record under physician orders and could also be found in the resident's hard chart, located in current printed POS. -Located in the hard chart, should be the resident's purple DNR form, signed by the resident and his/her physician. During an interview on [DATE] at 2:03 P.M., the Admission Coordinator said: -He/she had gone to visit the resident at the hospital on [DATE]. -The resident was found on the Intensive Care Unit (ICU) unit at the hospital. -The resident did not have O2 in place during the visit. He/she was alert and talkative at the time the visit. -He/she did not ask the resident about his/her feeling related to CPR being performed. -The resident had been referred to Hospice Care Services and hospital Social Service Worker (SSW) was assisting family with finding care. -He/She received a call about ,d+[DATE] minutes after he/she left the hospital, that the resident had passed away. During an interview on [DATE] at 2:25 P.M., the Hospital SSW said: -He/she was talking with the hospital physician who said the resident came to the hospital after cardiac resuscitation was successful. -The physician and hospital had received the resident current DNR status, and the resident was placed on cardiac care monitoring only. -The hospital Physician reported he/she had talked with the resident and he/she said Why am I here, I should not be here. (Related to his/her wishes of DNR status.) -The resident did not want to return back to the facility, due to the facility initiated CPR not following the resident's end of life wish. During an interview on [DATE] at 11:56 A.M., Hospital Physician B said: -The resident expressed his/her intent of not wanting CPR performed while at the hospital. -The resident came in with the Out of Hospital DNR form. -The resident was admitted to the hospital to provide comfort care only. -He/she was made aware the facility had initiated CPR even though the resident had a code status of DNR. -The resident passed away at the hospital on [DATE]. During an interview on [DATE] at 2:18 P.M., Physician A said: -He/she was the resident's physician. -He/she was made aware of the change of condition and the incident related to not following the resident's wishes for DNR. -It was reported the facility staff could not find the resident DNR status right away and started chest compressions, CPR. -He/she felt it could have been worse, if the facility found out the resident was full code and did not start CPR. -He/she felt the facility should ensure a better system was in place for obtaining or access resident code status. -The resident passed away at the hospital. During an interview on [DATE] at 3:09 A.M., Director of Nursing (DON) said: -He/she would expect the nursing staff to follow facility policy for verifying DNR status by checking the resident's electronic record first for current DNR physician order. -The resident DNR status can also be found in the residents' hard chart under current printed physician order sheet and front of the chart purple form, signed by resident and the resident physician. -He/she would expect the nursing staff to obtain the resident code status before initiation of CPR chest compression. -He/she would expect nursing staff to complete initial assessment of the resident by checking for responsiveness, pulse and breathing, while another nurse would obtain and check code status before initiation of CPR. -RN A was aware of Resident #5's code status. He/she entered the resident's DNR code status physician order into his/her electronic record on [DATE]. -RN A's instincts were to ensure he/she immediately addressed the resident's medical emergency which the resident was without a pulse, not breathing, and was unresponsive. -RN A's thought was the resident not breathing and had no pulse, he/she needed start chest compressions (CPR). During interview on [DATE] at 11:36 A.M., CMT A said: -He/she was not aware if CMTs had access to the resident physician orders to review the resident code status. -He/she would have obtained the resident's hard chart for the resident code status and given to the nurse to review. -He/she was not shown how to find the resident code status in physician orders in the electronic records. During an interview on [DATE] at 11:40 A.M., LPN D said: -He/she would assess the resident and have another nurse or CMT find the resident code status. -To find a resident DNR status he/she would go into the electronic charting to find the DNR orders. -He/she not sure if the CMTs had access. After review of the facility electronic records, the CMT was able to access the resident physician orders. During an exit interview on [DATE] at 12:20 P.M., the DON said: -Licensed nursing staff was required to be CPR certified and would be responsible for initiating CPR after nursing staff had checked and verified the resident code status. -CPR should not be initiated until verified the resident end of life wishes or DNR status. -CMTs and nursing staff should have access to check code status in the resident electronic record under physician orders. -CNAs would be instructed to grab the hard chart for the nursing staff to find and verify the resident's code status. -He/she would expect CMTs and nursing staff to have the capability and knowledge to know how to locate the resident code status in the electronic medical record, to find printed copy signed DNR form and the physician order located in the resident medical hard chart. During an interview on [DATE] at 12:30 P.M., the Administrator said: -He/she would expect nursing staff to follow the facility policy and verify the resident code status before initiation of chest compressions or CPR. -The first nurse assessing the resident while the second nurse checked the resident code status. -RN A did not verify the resident code status prior to initiation of CPR. -RN A was not thinking about having to check the resident's code status first. -RN A's first reaction when he/she responded to residents' emergency, was to be assessed, the resident required immediate emergency care and he/she initiated CPR due to the resident was unresponsive, not breathing and had no pulse. He/she was not thinking about checking code status first. Note: At the time of the survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. The facility put measure in place to ensure the deficient practice with CPR would not recur. 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. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint# MO 00233192

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 67 residents. Record review of the facility's Abuse, Neglect, Misappropriation and Suspicious Injuries of Unknown Source policy, dated February 8, 2018 showed: -Residents have a right to be free of abuse. -Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately (not inadvertently or accidentally), not that the individual must have intended to inflict injury or harm. A cognitively impaired resident that intentionally hits another resident may be considered abusive. -Physical abuse included hitting, slapping, pinching and kicking. -Mental abuse included verbal or nonverbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation or degradation. -The facility will report reasonable suspicions of a crime against a resident to local law enforcement per Elder Justice Act (EJA - signed into law on March 23, 2010, the EJA applies to seniors aged 60 and older and promotes prevention, detection, intervention and prosecution of abuse/neglect and exploitation to protect elders with diminished capacity.) The reporting requirement is on each individual employee of the facility. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance. -Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), single episode. -Mood disorder (a group of conditions in which a disturbance in the person's mood is the main underlying feature) due to known physiological condition with depressive features. Record review of a previous internal abuse investigation by the facility, dated 2/16/21 showed a summary showing a facility resident (Resident #3) reported Resident #1 hit him/her with his/her cane three times, twice in the bottom of his/her wheelchair and once on his/her back over a disagreement involving a television remote control. Resident #1 denied hitting Resident #3 at first and then said he/she would do it again. Resident #1 was sent for a psychological evaluation. Record review of the resident's Behavior Care Plan, dated 2/16/21 showed: -The resident could be impulsive, aggressive and easily provoked when frustrated. -Interventions implemented on 2/16/21 included: ---Placing the resident where frequent observation was possible ---Remove the resident from public area when disruptive. ---Discuss options for proper channeling of anger. ---Observe and document agitation, disruptive and aggressive behaviors and watch for escalation. ---Maintain safe personal boundaries. -On 2/25/21 an intervention was added for Therapy to evaluate for safety and use of a rolling walker. -On 11/5/21 an intervention was added to ensure the resident does not have access to a walking cane. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/10/21 showed the resident: -Was moderately cognitively impaired. -Had no inattention, disorganized thinking or altered level of consciousness (such as vigilance or lethargy). -Had no mood issues. -Had no physical or verbal behaviors towards others or any other behaviors (pacing, hitting self or disruptive sounds). -Walked independently with a walker. -Was independent in Activities of Daily Living (ADLs - bed mobility, transfers, locomotion and hygiene). -Had no upper or lower extremity impairment. Record review of Registered Nurse (RN) A's nursing note, dated 11/5/21 at 4:56 A.M. showed: -Cussing and yelling was heard from the nurses' desk coming from the resident's room at 4:00 A.M. -Certified Nurse Assistant (CNA) A went to the room to investigate and called to the nurse to come immediately. -CNA A reported he/she found the resident at his/her closet trying to put a cane back in his/her closet. -The resident's roommate (Resident #2) stated the resident repeatedly hit him/her on his/her left forearm with the cane. -When CNA A attempted to take the cane from the resident, he/she tried to hit CNA A with it. -The resident was removed from the room and placed in the day room under constant observation. -The Assistant Director of Nursing (ADON) was notified at 4:07 A.M., a message was left for the Director of Nursing (DON) at 4:13 A.M., a message was left at 4:21 A.M. for the Social Services Director (SSD), and the MDS Coordinator took the incident report. Record review of the MDS Coordinator's nursing note, dated 11/5/21 at 6:17 A.M. showed: -He/she was notified by RN A of an altercation between the resident and his/her roommate that occurred at 4:00 A.M. It was reported the resident was standing at his/her roommate's bedside, striking him/her with a cane on the wrist and forearm. A CNA requested assistance to remove the cane from the resident's hand and a separate CNA escorted the resident to the day room. -At 4:30 A.M. he/she conducted an interview with the resident who was awake, alert, oriented to person, place, and situation. The resident reported he/she went to his/her closet to get his/her cane, went around the curtain dividing the room, hit his/her roommate. Staff came in and took the cane. The resident reported his/her roommate had been calling him/her names and cussing and stated his/her roommate was a son of a [OBSCENITY] and a mother [OBSCENITY] . -The resident's vital signs (body temperature, pulse (heartbeat rate) and respiration (breathing) rate and blood pressure (the force blood is pushed through the arteries to the rest of the body) were obtained. -The resident was in no apparent distress. -The resident had previous altercations and was informed the DON would evaluate the situation and further evaluation might be necessary. The resident replied he/she didn't give[OBSCENITY]and didn't want to stay at the facility. -A decision was made to send the resident to the hospital. Record review of the resident's SSD note, dated 11/5/21 at 9:53 A.M. showed the SSD spoke with the resident's responsible party who was notified the resident had been sent out to the emergency room (ER). The responsible party was informed the resident would be separated from his/her roommate upon his/her return to the facility. Record review of the resident's DON nursing note, dated 11/5/21 at 10:16 A.M. showed the physician was notified at approximately 6:10 A.M. of the resident hitting his/her roommate with a cane. An order was received to send the resident to the ER for possible psychiatric admission. 2. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] (paralysis of the legs and lower body caused by injury or disease), unspecified. -Monoplegia (paralysis of one limb or region of the body) of upper limb (arm) following cerebral infarction (a stroke, occurring as a result of disruption of blood flow to the brain) affecting right dominant side. -[CONDITION(S)] (a surgical procedure in which a piece of colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon) status. Record review of the resident's Behavior Care Plan, dated 9/27/18 showed the resident frequently refused to turn in bed, take his/her medications, take showers and allow staff to clean and change him/her. There was no mention of the resident having physically or verbally aggressive behaviors towards other residents. Record review of the resident's Activities of Daily Living (ADL) Care Plan, dated 8/7/21 showed: -The resident required staff assistance with ADLs such as shaving, dressing, oral care and bathing. -The resident required a mechanical lift for transfers. Record review of the resident's Significant Change MDS, dated [DATE] showed the resident: -Was moderately cognitively impaired. -Had no inattention, disorganized thought processes, or altered level of consciousness. -Had no mood issues. -Had no verbal or physical behaviors towards others or any other behaviors. -Required extensive assistance of two staff persons for bed mobility, transfers, dressing, and toileting needs. -Had an upper extremity impairment on one side and lower extremity impairment on both sides. -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Had an indwelling catheter (a tube which drains urine from the bladder into a bag outside the body). -Was receiving hospice care (services for the terminally ill with a focus on quality of life). Record review of the MDS Coordinator's progress notes, dated 11/5/21 at 4:52 A.M. showed: -On 11/5/21 at 4:25 A.M. the resident was interviewed at bedside and reported: --Resident #1 approached his/her bed with a cane in hand and struck him/her repeatedly on the left upper extremity, four to five times at the wrist level and once or twice in the mid forearm area. --When Resident #1 came around the curtain and started hitting him/her with the cane he/she called out for help and cussed at Resident #1 to get him/her to stop. --The CNA came in, followed by the nurse and Resident #1 was escorted out of the room. --His/Her wrist was tender, but he/she didn't want pain medication. -A check for injury showed an erythematous (reddened) area on the lateral (furthest from the middle of the body) wrist five centimeters (cm) by five cm and radial (thumb) side of the mid forearm 3 cm by 4 cm. Dermis (skin) remains intact and unraised. Vital signs were obtained and a full skin assessment was completed with no further areas or markings of concern. -The resident was informed the DON had been notified and said he/she felt safe at the moment. -The resident refused an ice pack and didn't want medical attention and was informed medication for discomfort would be available upon request. Record review of RN A's nursing note, dated 11/5/21 at 5:58 A.M. showed: -Swearing was heard from the resident's room. -CNA A saw the resident's roommate (Resident #1) placing a metal cane back in his/her closet. Resident #2 said he/she was being hit with the cane. -The cane was taken to the nurses' station and Resident #1 was brought to the day area and placed under constant supervision. -Resident #2 said he/she was hit on the left forearm and had mild pain. -Reddened areas on forearm was immediately observed. -Calls were placed to the ADON at 4:07 A.M., messages were left for the DON at 4:13 A.M. and for the SSD at 4:21 A.M. At 4:24 A.M. the incident was reported to the MDS Coordinator who was at the facility by then. Record review of RN A's nursing note, dated 11/5/21 at 10:08 A.M. showed no changes in the resident's status and the resident denied pain at the time. Record review of the DON's nursing note, dated 11/5/21 at 10:18 A.M. showed the physician was notified on 11/5/21 at 6:10 A.M. of the resident being hit on the arm while in bed. Nursing staff were advised to monitor the reddened areas to the left forearm. There were no new orders. 3. Record review of the facility's internal abuse/neglect investigation, started 11/5/21 showed: -A summary of the resident to resident abuse/neglect incident showed: --Resident #1 said he/she heard his/her roommate (Resident #2) call him/her profanities. He/She became agitated and hit Resident #2 with a cane he/she had stored in his/her closet. He/She also stated he/she would do it again. --Resident #2 said he was lying in bed when he/she saw his/her roommate (Resident #1) approach him/her with a cane and start hitting him/her. Resident #2 raised his/her arm to block the cane from hitting his/her head and he/she was hit on the left forearm. Profanities were exchanged and staff intervened quickly. --Resident #1 was immediately put on one to one supervision and the metal cane was removed from his/her possession. --An order was obtained to send Resident #1 for psychiatric evaluation with admission to the Behavioral Health Unit. --Resident #1 was readmitted to the facility on [DATE] to a private room with one on one supervision and monitoring for medication effectiveness. Social Services will continue to seek placement in another facility. No further behaviors. --Findings were that Resident #1 did hit Resident #2 with a metal cane causing bruising to Resident #2's left forearm. -Contributing factors to the incident included: --Incompatibility of the two roommates. Recommendations/interventions to prevent reoccurrence was to move Resident #1 to a private room upon return to the facility following his/her hospital stay. --Cognition of aggressor. Recommendations/interventions were for an inpatient psychiatric stay for medication evaluation. --Accessibility of cane. Recommendations/interventions were to remove the cane from Resident #1's possession. -Employees on duty in the unit at the time of the incident were RN A, CNA A and CNA B. Employees who arrived to the facility soon after the incident were the MDS Coordinator and the DON. -CNA A's written statement, dated 11/5/21 at 4:50 A.M. showed: --He/She was standing at the nurses' station when he/she heard Resident #2 yelling profanities and heard a clicking sound. --He/She ran to Resident #1's and Resident #2's room to find Resident #1 trying to hide his/her cane in his/her closet. --Resident #2 stated Resident #1 repeatedly hit him/her with his/her cane. --He/She asked Resident #1 for the cane which he/she refused to give up voluntarily. The cane was taken from the resident and brought to the nurse. -CNA B's written statement, undated, showed: --At approximately 4:00 A.M. he/she heard repeated yelling of mother [OBSCENITY] and son of a [OBSCENITY] . --CNA A went to the room thinking Resident #2 needed something or was in pain. --He/She heard CNA A say give me that cane. --He/She ran to the room and found Resident #1 near his/her closet with a cane. --When asked why he/she hit Resident #2? Resident #1 said that son of a [OBSCENITY] needed it and admitted to hitting Resident #2 multiple times with the cane. --Resident #2's wrist was notably red. -RN A's testimony stated he/she heard a resident's voice coming from the 400 hallway. CNAs A and B headed down the hallway to investigate. The CNAs reported Resident #2 was hit by Resident #1 with a cane and when the CNAs tried to remove the cane from Resident #1, he/she swung at CNA A. The cane was immediately removed and Resident #1 was removed from the room and placed on one to one supervision. -The investigation included the progress notes written by the DON, ADON, MDS Coordinator and RN A completed on 11/5/21 for Residents #1 and #2. -Also included in the investigation package were the facility's abuse/neglect policy/procedure; education that had been started on 11/5/21 of the facility's abuse/neglect policy; interviews with nine additional interviewable residents who all said they had not been abused by another resident; and documentation signed by 30 staff members who had been asked if they had knowledge of any abuse/neglect towards a resident, which the 30 staff members all denied. 4. During an interview on 11/5/21 at 11:19 A.M. the DON said Resident #1 was at the ER. A referral was sent for a psychological evaluation. He/She was told the resident met the criteria for inpatient psychological treatment because of malicious intent towards his/her roommate. The resident had been treated at the hospital in February 2021 due to a previous incident in which he/she hit another resident with his/her cane. During an interview on 11/5/21 at 12:40 P.M. Resident #1 said: -This was the first physical altercation he/she had with Resident #2. -He/She hit Resident #2 because he/she got aggravated. It was sort of impulsive. His/Her roommate kept bothering him/her. If he/she coughed, Resident #2 coughed louder. He/She told his/her roommate if he/she kept on he/she would beat him/her up. Resident #2 kept on. -He/She couldn't get any sleep because of the noise his/her roommate was making. Before the morning of 11/5/21 when his/her roommate would make a noise he/she would tell his/her roommate to shut up. It was just verbal before. -He/She had a cane in his/her closet and hit his/her roommate with the cane maybe five or six times. His/Her roommate was holding his/her hands up and he/she hit him/her on the fingers hard enough to be painful. He/She didn't think he/she caused any injury. Resident #2 did not hit him/her back. His/Her roommate was lying in his/her bed. -He stole the cane from the rehabilitation area a couple of months ago to walk with, but was afraid if he/she used the cane it would be taken from him/her. None of the staff noticed he/she had the cane in his/her closet. -He/She had a different kind of cane a long while back, but the facility took his/her cane away and he/she never got it back. The cane was taken away several months ago because another resident accused him/her of hitting him/her with his/her cane, but he/she never hit the resident with his/her cane. -He/She wouldn't hit his/her roommate if he/she had to do it again because it landed him/her at the treatment center. He/She wanted to be at the facility because he/she was on the list to see the dentist and didn't want to miss getting seen. During an interview on 11/5/21 at 1:15 P.M. the Social Worker at the inpatient psychological center said: -Resident #1 was in the psychiatric hospital in February 2021. -On the first day of the resident's previous psychological admission on 2/16/21 the resident reported being at the hospital due to the idiot from the skilled nursing facility whom he/she hit with his/her walking stick. After the first day of hospitalization he/she denied hitting the resident. -While hospitalized the resident would argue with other patients over television programs. He became upset about a remote control during the previous hospitalization which he/she tried to take to his/her room. Staff had to take it and the resident angrily went to his/her room, cursing at staff. -The resident was upset he/she didn't have his/her cane while at the hospital. -The resident was placed on [MEDICATION(S)] (an anticonvulsant usually prescribed to treat seizures or nerve pain) 100 milligrams (mg) three times daily and was discharged back to the skilled nursing facility on 2/25/21. During an interview on 11/5/21 at 2:15 P.M. the Medical Records Director said: -Residents #1 and #2 had been roommates several months with no issues. -Resident #2 was very soft spoken and had no history of verbal or physical aggression. -The staff hadn't figured out how the resident got the most recent cane. He/She always uses his/her rolling walker and goes everywhere throughout the building. -The rehabilitation room is kept open all day. During an interview on 11/5/21 at 2:54 P.M. Certified Medication Technician (CMT) A said: -If Resident #1 is antagonized he/she will become defensive. If he/she doesn't hear someone well he/she might think they are saying something else and will yell at them. He/She had never seen the resident physically aggressive. -Resident #2 just lays in his/her bed and doesn't say much, sleeping most of the time. -He/She had never know the two to have a verbal or physical altercation before. During an interview on 11/5/21 at 3:05 P.M. Resident #2 said: -He/She didn't think Resident #1 was ever verbally or physically aggressive before the morning of 11/5/21. -He/She didn't know why Resident #1 was upset. Resident #1 hit him/her on the left forearm three or four times. He/She did not hit his/her fingers. -He/She was caught by surprise and he/she had no idea what precipitated the aggressive behavior. -He/She put his/her left arm up to block the hits. The blows felt sharp when Resident #1 hit him/her but he/she hadn't needed pain medication because of it. -When asked why he/she only used one arm to block the blows Resident #2 showed the surveyor his/her right hand which was contractured and said he/she had limitations with the use of his/her right arm. -He/She didn't get out of bed anymore. -He/She was afraid Resident #1 would hit him/her again and didn't want him/her as a roommate in the future. During an interview on 11/5/21 at 3:15 P.M. CNA C said: -He/She had never heard of Resident #1 and #2 having an altercation before. -It was not typical for Resident #2 to cuss. -He/She had only known Resident #1 to walk around with a walker and didn't know the resident had a cane in his/her room. During an interview on 11/5/21 at 3:25 P.M. the ADON said: -He/She knew from shift reports Resident #1 has had verbal outbursts such as when someone's television is too loud or there is commotion he/she will yell about the noise. He/She had never seen the resident verbally or physically act out against anyone. -He/She had only seen the resident use a walker and not a cane and didn't know he/she had one. -He/She hadn't seen changes in either Resident #1 or Resident #2's behaviors for months. Observation on 11/5/21 between 3:35 P.M. and 3:40 P.M. showed: -The therapy room was open and there were no therapy staff in the room. Equipment was not secured in a locked cabinet. -There were five canes, four aluminum and one wooden, leaning against a wall. Four crutches were also leaning against a wall. Four wheelchair leg rests were lying on the therapy exercise steps. Two more were lying on a toilet seat which was on top of a walker. There were four wheelchairs, two metal reachers, and several weights. During an interview on 11/5/21 at 3:46 P.M. CNA B said: -Sometimes Resident #2 will hit himself/herself when he/she needs pain medications. He/She heard a hitting sound and assumed Resident #2 was hitting himself/herself. He/She also heard Resident #2 yelling out son of a [OBSCENITY] and mother [OBSCENITY] . Resident #2 is normally very soft spoken. -CNA A went to the residents' room and he/she heard CNA A yell give me that cane. -When he/she arrived in the room Resident #1 was trying to put the cane back in his/her closet and try to hide it when CNA A was asking him/her to give the cane to her. When asked why he/she hit his/her roommate Resident #1 said that son of a [OBSCENITY] needed it and would not explain more. -He/She had never seen Resident #1 with a cane before. -Resident #2 would not instigate a conflict. The hitting seemed very unprovoked. -He/She had never known Resident #1 to have [CONDITION(S)] or paranoia. -He/She heard others say Resident #1 has verbally snapped at them and the resident called him/her a [OBSCENITY] once when he/she tried to redirect him from the kitchen, but he/she had never seen Resident #1 be physically aggressive. During an interview on 11/5/21 at 4:25 P.M. CMT B said he/she was very familiar with Resident #2 who was not verbally or physically aggressive and did not instigate altercations. During an interview on 11/5/21 at 4:40 P.M. RN A said: -He/She heard yelling and what he/she thought was Resident #2 smacking himself/herself which he/she did when in pain. -CNA A was heading to the residents' room. He/She told CNA A to tell Resident #2 he/she was coming with his/her pain medication. When CNA A arrived to the room he/she yelled get down here now. -By the time he/she arrived to the room the incident was over. -The cane was removed from the room. -He/She had only seen verbal aggression from Resident #1 when he/she was asked to do something he/she didn't want to do. -Resident #2 is extremely quiet and doesn't say anything to anyone. -Resident #1 doesn't sleep much. Both residents had their televisions on a low volume. Resident #1 is very hard of hearing and it was doubtful he/she could hear his/her roommate's television. -The resident used to have a wooden cane. It was taken away after a prior incident involving hitting a different resident with his/her cane. The cane Resident #1 had with him/her on 11/5/21 was aluminum. -CNA A reported Resident #1 tried to hide the cane in his/her closet and when CNA A asked for the cane Resident #1 tried to hit CNA A with it; however, he/she got hold of the cane. When CNA A grabbed the cane Resident #1 just let go of it. -Resident #1's behavior was totally unexpected. During an interview on 11/5/21 at 5:03 P.M. the MDS Coordinator said: -Upon his/her arrival to work at 4:25 A.M. that morning, RN A told him/her staff heard a ruckus and a bang and then heard Resident #2 yelling for help and also say you son of a [OBSCENITY] and you mother [OBSCENITY] . RN A asked CNA A to see if the resident needed pain medications. -CNA A tried to take the cane from Resident #1 when he/she got to the room. CNA B assisted in getting the resident to let go of the cane and then encouraged Resident #1 to come out of the room and ushered him/her to the sitting area near the main nurses' desk. -He/She interviewed Resident #2 first to see if he/she was injured and to reassure him/her. Resident #2 said Resident #1 just came around the corner and started hitting him/her. He/She and Resident #1 had words for a few days. Resident #1 was instigating things and would call him/her a son of a [OBSCENITY] and get mad at him/her for having his/her television on. Resident #2 didn't say if he/she reported the two of them having words for a few days. He felt unsafe when being hit with the cane. He/She was hit four or five times. He/She was frightened by Resident #1 beating him/her. It took him/her by surprise. He didn't want Resident #1 to be his/her roommate again. -The arm did not need an X-ray. It was hardly pink. He/She asked the resident if he/she wanted medical treatment or pain medication which the resident declined. The resident said the area hit was tender. -He/She interviewed Resident #1 who said Resident #2 called him/her a son of a [OBSCENITY] . He/She went to his/her closet and got the cane and beat Resident #2. Resident #1 referred to his/her roommate as a dirty son of a [OBSCENITY] and said he/she would beat his/her roommate again worse if he/she had the chance and would kill him/her. Resident #1 acknowledged hitting Resident #2. -He/She didn't know how Resident #1 got the cane which was kept in his/her closet. The resident didn't say where he/she got it or how long he/she had it. -Resident #1 has impulsive tendencies. He/She can be verbally aggressive. At times he/she had increased agitation. -Resident #2 doesn't have behaviors that instigate aggression from others. -Resident #1 was informed he/she would need a psychiatric evaluation. -The police were not called because Resident #1 did not continue to threaten or show violence. Observation on 11/8/21 at 9:58 A.M. showed Resident #2 had light purple bruising on the left outer wrist approximately ¾ inch diameter. Above that was light purple bruising approximately 1 ¼ inch diameter. On the outer forearm was a very faint reddish bruise approximately 4 inches long by 2 ½ inches wide with faint bluish bruising on the outer length of the edges. During an interview on 11/8/21 at 10:00 A.M. Resident #2 said: -He/She was awake and watching television in the early morning of 11/5/21. Resident #1 didn't say anything about his/her television being on. He/She never asked him/her to turn off his/her TV. -The dividing curtain was shut behind his/her head and to his/her left side except for an approximate three foot opening. When he/she saw Resident #1, he/she was at the end of the curtain near the opening. He/She never heard Resident #1's footsteps. Resident#1 didn't have a walker, only the lightweight metal cane in his/her hand. -Resident #1 moved to within two foot of him/her and started hitting him/her immediately. The strikes on his/her arm were aggressive and very intentional. He/She felt like Resident #1 was trying to hurt him/her. -Had staff not come in, he/she thinks Resident #1 wouldn't have stopped because he/she wasn't stopping when he/she yelled at him/her to do so. -He/She was afraid when Resident #1 kept hitting him/her that he/she would be injured. He/She was completely caught off guard and taken by surprise and was afraid for his/her safety. -He/She was afraid to be in the room any more with Resident #1. -His/Her arm was sore to the touch. An X-ray was not taken of the arm. -The police were not contacted and did not speak to him/her. During an interview on 11/8/21 at 11:41 A.M., the DON said: -He/She was not aware of any conflicts between Resident #1 and Resident #2 before the morning of 11/5/21. They had been roommates for several months, since probably January 2021. He/She never knew them to banter back and forth and Resident #2 had never reported feeling afraid of Resident #1 before the early morning of 11/5/21. -Resident #2 has always been quiet before this incident. He/She will sometimes talk out in a normal tone of voice, but not loudly or constantly and Resident #1 was never known to be bothered by that before. -He/She didn't know if Resident #1 was aware of the consequences of his/her behavior. That awareness might fluctuate. -He/She didn't know where Resident #1 got the cane, how long it had been hidden in the closet, or why he/she was hiding the cane in his/her closet. He/She hadn't asked those specific questions prior to the resident going out to the ER. -It was not typical of Resident #2 to call anyone names. -Resident #2 said he/she wasn't hurt and declined an ice pack and didn't want any pain medications following the incident. -Staff are educated to report abuse. Fear was an example of emotional abuse. Intentional harm would be considered abusive if repetitive. -He/She thought Resident #1's behavior was a knee jerk reaction to what he/she perceived as Resident #2 calling him/her a mother [OBSCENITY] and son of a [OBSCENITY] . --He/She had only heard Resident #2 curse one time. He/She was talking to himself/herself in a normal volume and he/she happened to be outside Resident #2's door. He/She thought Resident #2 had hallucinations that caused him/her to do that. -He/She thought Resident #1 could have hurt or scared Resident #2. -The facility typically did not contact the police with resident to resident abuse unless they can't get a situation under control. The police were not contacted because as soon as Resident #1 was separated from Resident #2 there were no further incidents and they were working on getting Resident #1 psychiatric evaluation and treatment. -The facility planned to put the resident in an area where he/she would have increased supervision upon his/her return from inpatient treatment, but the facility had not yet determined what the increased supervision would entail. He/She, other nurses, and the SSD, had discussed the resident might benefit from moving to a less populated facility. -When interviewed, Resident #1 voiced no remorse whatsoever. He/She said if the SOB did that again he/she wouldn't hesitate to strike him/her again. -The physician did not feel an X-ray was necessary for Resident #2 at this time, but an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/8/21 at 12:25 P.M. the Physician said: -Resident #1 was sent for psychiatric evaluatio

Based on interview and record review, the facility failed to ensure a resident was free from neglect when facility staff failed to appropriately assess and respond to one sampled resident (Resident #1), who had a recent [CONDITION(S)] and two stent placements. On 4/3/21 the resident had frequent and ongoing complaints of chest pain in the early hours of the morning to Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) A. Facility staff did not notify the physician or the paramedics. As a result of the lack of notification, the resident notified a family member who contacted local paramedics. Upon arrival at 6:00 A.M., paramedic assessment found the resident had elevated blood pressure and elevated pulse. The resident was taken to the hospital and found to have a 100% occlusion of one stent resulting in another [CONDITION(S)]. The facility census was 63 residents. The Administrator was notified on 4/7/21 at 12:11 P.M. of an Immediate Jeopardy (IJ) which began on 4/3/21. The IJ was removed on 4/7/21, as confirmed by surveyor onsite verification. Record review of the facility policy for Change in Medical Condition updated October 1, 2010 showed: -The purpose of the policy was to keep the physician, who was in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident representatives informed of the resident's medical condition so they may direct the plan of care as needed. -The notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there was a change in the resident's condition. -Change in condition was defined as a significant change in the resident's status, a need to alter treatment significantly, or a decision to transfer the resident out of the facility. -An example of a change in condition included new pain. -The facility nurse should document the symptoms and observations associated with the change in condition, the date and time of the contact with the physician and family member or legal representative. Record review of the facility policy for Pain Management and Assessment last updated March 1, 2011 showed: -The purpose of the policy was to detect the presence of pain, determine the frequency and intensity of pain, and identification of effective pain management interventions to help to avoid adverse outcomes that impact the resident's functional status and quality of life. -Pain assessments presented unique problems in the elderly, as the resident could have exhibited physiologic, psychologic and cultural changes associated with aging. -Many health care providers mistakenly considered pain to have been a normal part of aging. -An on-going assessment of pain utilizing either a numeric scale of 1-10 or a verbal descriptor scale was to have been conducted daily and with evidence of new or worsening pain. -Pain could cause suffering and lead to functional decline. -The resident should be asked to describe the pain on a scale from 1-10, show the location of the pain, and asked if anything made the pain better or worse. -If the resident's pain was not controlled by the current treatment, the physician should be notified. 1. Record review of Resident #1's Inpatient Diagnosis, Assessment and Plan dated 3/30/21 showed: -The resident had a [CONDITION(S)]. -He/she had two stents (a tube-like device placed by a physician and used to keep the artery open) recently placed. -He/she also had congestive heart failure (CHF a disease which causes fluid to build up around the lungs making it difficult to breathe). Record review of the resident's face sheet showed the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Peripheral Vascular Disease (PVD, inadequate flow of blood to the extremities). -Heart failure. -[CONDITION(S)]. -[CONDITION(S)] Heart Disease (AHD, a hardening of the arteries). -Presence of cardiac stents. Record review of the resident's temporary care plan dated 3/31/21 showed: -No mention of cardiac disease. -No mention of having pain. Record review of the resident's Physician's Order Sheet (POS) dated 3/31/21 showed the resident had been prescribed oxycodone (a narcotic medication used to treat severe pain) 5/325 milligrams (mg) tablet every three hours as needed for pain. Record review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., showed the resident received one Oxycodone 5/325 mg tablet for pain. Record review of the resident's vital sign and pain history showed: -On 4/1/21 at 4:14 A.M., pain level was a three on a scale of 0 - 10 with zero being no pain and 10 being the worst pain and vital signs were within normal limits. -On 4/2/21 at 12:24 A.M., pain level was a zero and vital signs were within normal limits. Record review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., showed the resident received one Oxycodone 5/325 tablet for pain. Record review of the resident's nurse's notes dated 4/3/21 at 2:46 A.M., showed: -He/she had been medicated for severe abdominal pain. -The nurse's notes did not say what time the pain medication had been administered. -The resident continued to complain of severe abdominal pain. -A Kidney, Ureter and Bladder (KUB an X-ray study that assesses the organs of your urinary and gastrointestinal systems. Used to diagnose urinary disorders and causes of abdominal pain) x-ray had been completed, but the nurse's notes did not say when. -Results of the KUB showed modest fecal residual which could have meant clinical constipation. -The resident had stated that he/she did not think that one pain pill was going to do any good and continued to complain of severe pain. -The resident stated that he/she was going to call Medicare and 911 if nothing was done for his/her pain. Record review of the resident's vital sign and pain history dated 4/3/21 at 2:47 A.M., showed the resident's pain level was a 10 on a scale of 0 - 10 and his/her blood pressure and pulse were elevated. Record review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., showed: -The resident received one Oxycodone 5/325 tablet for pain. Record review of the resident's discharge Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff and used for care planning) dated 4/3/21, showed the resident: -Had no issues with his/her mood. -Had no behaviors. -Had PVD. -Had shortness of air when walking, bathing, transferring, sitting up and lying flat. -Had received pain medications as needed. Record review of the paramedic's Pre-hospital Care Billing Report dated 4/3/21 at 5:51 A.M., showed: -The paramedics were dispatched to the facility after a call from a third party regarding a resident with an unknown problem. -The paramedics arrived at the facility and the facility staff did not answer the phone calls from dispatch or the emergency personnel which delayed allowing the emergency personnel access to the resident. -Once inside the facility, the emergency personnel reached the resident who was sitting up in his/her bed in obvious distress. -The resident was alert and oriented and reported that he/she had been having chest pain and shortness of air for more than three hours. -The resident reported to the paramedics that the facility staff had been refusing to help him/her. -The resident finally called his/her family member who called emergency personnel. -While on site, the facility staff dismissed the resident's concerns in front of the paramedics stating that the resident was just constipated. -The resident was then placed on the ambulance stretcher and transported to the emergency room . Record review of the resident's nurses notes dated 4/3/21 showed there was no nurse's note completed at the time the resident was transferred to the hospital around 6:00 A.M. on 4/3/21. During an interview on 4/3/21 at 8:16 A.M., Paramedic A said: -He/she received a call from dispatch about 5:50 A.M., on 4/3/21 for a nursing home resident having chest pains and a possible [CONDITION(S)] from a third party family member. -The paramedics arrived within five minutes of being dispatched. -Dispatch reported they had attempted to call the facility for additional information with no answer. -Upon arrival on scene, the paramedics went to the doors off the 500 hall where usually an emergency button could be pushed and the doors would open, however, those doors were locked. -Certified Nurse Aide (CNA) A opened the door and the paramedics explained why they were there. -License Practical Nurse (LPN) A at the other end of the hall yelled, 'he/she is a F-ing' liar, with several other resident room doors open. -When the resident spoke to the paramedics, he/she said he/she had chest pain and it felt like the same pain of his/her [CONDITION(S)] three weeks ago. -LPN A said the resident had no chest pain and that he/she was just constipated and had x-ray the night before. -When asked for the resident paperwork, LPN A said there was nothing wrong with the resident and the paramedics did not need any paperwork, refusing to provide the paramedics with the requested resident paperwork. -The resident presented alert and oriented, and the paramedics asked if the resident was his/her own responsible party to which LPN A responded that the resident had a family member as the responsible party and further stated that the paramedics did not need to contact the resident's family. -The resident then provided the phone number for the family member who was contacted by the paramedics and agreed to have the resident transported to the hospital. -Paramedic A said the situation felt adversarial and assessment showed it was in resident's best interest to go to the hospital. -The resident's responsible party told the paramedics that he/she had been calling the facility for three hours and received no answer. During an interview on 4/3/21 at 10:30 A.M., Director of Nursing (DON) A said: -The resident had been admitted to the facility on [DATE] for rehabilitation. -He/she was at the facility on 4/3/21 and said the resident had been having abdominal pains on 4/2/21. -At around 4:30 A.M. on 4/2/21, LPN A called the physician and received new orders to increase the resident's [MEDICATION(S)] (a mediation used to assist with abdominal cramping) from twice daily to four times a day for cramps and pain. -A KUB x-ray was ordered and showed modest fecal residual. -The resident was given pain medication. -He/she followed up with the resident around 7:23 P.M. on 4/2/21 and LPN A said the treatment was effective. -He/she then received a call around 6:25 A.M. on 4/3/21 telling him/her the resident called 911 and went to the hospital. -He/she knew nothing about the resident having chest pains. -He/she thought the resident went to the hospital for abdominal pain. -The staff did not know that the paramedics had been called. -Usually when the facility called 911, a staff member waited by the door to let the paramedics into the facility. -All doors were locked at night for resident safety. -Paramedics can push a button during the day to get in, but not at night. During an interview on 4/3/21 at 9:00 A.M., the resident's family member said: -The resident was in the rehabilitation unit at the facility for a foot injury involving missing toes. -The resident presented to the hospital on 4/3/21 between 6:30 A.M. and 6:45 A.M. -The resident reported his/her pain began around 3:00 A.M., on 4/3/21 and he/she repeatedly pressed his/her call light, but no one came to his/her room. -An unknown staff member finally came and said, No, you're fine, and walked away, failing to address the resident's concerns. -This went on for approximately two hours. -The resident kept asking to go to the hospital, but the facility staff would not call for paramedics. -Around 5:00 A.M. on 4/3/21, the resident called his/her family member, telling him/her that he/she felt as if he/she was having another [CONDITION(S)] but no one at the facility would answer his/her call light or call for paramedics. -The resident's family member told the resident to call 911, but he/she said he/she could not, so the resident's family member called the paramedics for the resident. -The resident's family member tried to call the facility but no one answered. -The paramedics arrived at the facility, but when they got there, they could not get in the facility door. -The paramedics tried to call the facility but no one would answer. -The paramedics had to wait outside until they finally found someone to let them into the facility. -The family member stated at that point, the resident's chest pains had been going on for close to five hours. -The family member said he/she had to give the paramedics permission to take the resident to the hospital even though the resident was alert, oriented, and able to make his/her own decisions. -The resident was having a [CONDITION(S)] and was admitted to the hospital. During an interview on 4/5/21 at 9:40 A.M., Hospital Registered Nurse (RN) A said: -The resident came to the hospital emergency room (ER) on 4/3/21 around 7:00 A.M. -He/she went straight to the cardiac catheterization laboratory (a room in the hospital where minimally invasive procedures are done to diagnose heart disease) prior to being admitted to the hospital. -The resident presented to the ER with right sided chest pain and abdominal pain. -The ER staff placed a urinary catheter (a tube inserted into the bladder and used to drain urine) and drained 1,200 milliliters (ml) of urine out of the resident's bladder. -The resident had just had a [CONDITION(S)] three weeks earlier and had two cardiac stents placed then. -When the resident had the cardiac catheter placed into his/her heart, he/she had one of his/her cardiac stents completely occluded, causing the resident to have another [CONDITION(S)]. -The resident was also constipated, but that had been treated since he/she was hospitalized and was resolved. -The resident should have been immediately transported to the hospital as soon as he/she complained of pain so that he/she could have been treated in a timely manner. -If the resident was complaining of high abdominal pain, that could have been sternal (breast bone) pain which could have been cardiac related. During an interview on 4/5/21 at 10:50 A.M., the resident said: -He/she had been complaining to LPN A and CNA A about chest pain for several hours in the early morning of 4/3/21. -LPN A did not believe that he/she needed to go to the hospital. -He/she told LPN A that his/her chest pain level was at a nine to a 12. -He/she first had abdominal pain and then his/her anxiety level got high and the chest pain began. -LPN A told him/her that he/she was just constipated. -LPN A told him/her that he/she was given medication for the constipation which should help the pain. -He/she was also complaining that he/she felt like he/she had to urinate, but could not. -LPN A said that he/she had two wet briefs and urine in his/her urinal so he/she should not have to urinate any more. -The resident asked to go to the hospital and LPN A said he/she did not need to. -He/she asked CNA A to give him/her the Administrator's phone number so he/she could get some help. -CNA A agreed, but never brought him/her the phone number. -He/she eventually got a hold of his/her family member who called 911 to get the resident to the hospital. -The resident told LPN A and CNA A, if they did not get him/her to the hospital, he/she was going to die. -When the paramedics arrived at the facility, he/she heard the paramedics beating on the door and then he/she heard an unknown staff member say, The son-of-a-[OBSCENITY] called the fire department on us! -The resident felt that he/she was lucky to be alive. -LPN A told him/her that all the resident wanted was pain pills. -The resident was afraid to have LPN A assist him/her with having a bowel movement as he/she had told the resident earlier that he/she should be pushing harder and the resident felt that was dangerous as he/she had just had a [CONDITION(S)] three weeks earlier and the resident did not think it would be safe for him/her to strain too hard to move his/her bowels. Record review of the resident's nurse's notes dated 4/5/21 at 12:05 P.M., but not shown as being a late entry showed: -Paramedics had arrived at the facility at the 500 hall fire exit door at 6:00 A.M. -The paramedics said the resident was having a [CONDITION(S)]. -LPN A showed the paramedics to the resident's room and went to look for DPOA paperwork which had been requested by the paramedics. -LPN A was unable to locate the DPOA paperwork. -LPN A gave report to the paramedics and showed them the results of the resident's KUB. -LPN A told the paramedics that the resident had not complained of chest pain. -The resident had only complained that the hospital sent him/her to the facility while constipated and that the abdominal pain had been happening off and on for the past several weeks, causing the resident to need stronger pain medication. -The paramedic took the report to the other emergency responder staff and showed them the KUB report. -The paramedics then stated that the resident's family wanted the resident to go to the hospital and the resident was transported there. During an interview on 4/5/21 at 1:46 P.M., Medical Director A said: -If a resident was complaining of chest pain, the facility should immediately send the resident to the hospital. -If the situation was not emergent, the facility should call the physician or the Nurse Practitioner on call. -If the situation was emergent, he/she would expect the facility to call 911. -He/she had not seen the resident yet, as the resident had just been admitted to the facility and he/she had not been to the facility to see residents since his/her admission. During an interview on 4/5/21 at 5:40 p.m., the resident's family member said: -He/she got a call from the resident stating he/she had been having chest and abdominal pain for over three hours and the nurse was not doing anything to help him/her. -The resident wanted to go to the hospital and based on his/her symptoms, and given he/she had a [CONDITION(S)] with two stents placed just three weeks prior, the family member agreed that the resident should be transferred to the hospital. -He/she tried to call the facility several times and no one answered, so he/she called the police department and they transferred him/her to Emergency Medical Services (EMS). -EMS said they would send paramedics out immediately. -The paramedics called him/her once they arrived at the facility to make sure he/she was okay with sending the resident to the hospital. -The paramedics told him/her that they had a delay in transporting the resident because they could not reach the facility by phone and it took some time to get any facility staff to answer the unit door. During an interview on 4/6/21 at 1:15 P.M., LPN A said: -The resident had complained of abdominal pain, but he/she was constipated and they were treating it. -The resident never complained about chest pain at any point during the shift. -The resident never said he/she had any anxiety. -The resident was complaining about the hospital sending him/her to the facility constipated. -LPN A was not aware that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -If the resident had complained about chest pain he/she would have taken vital signs and called the physician. -The physician had changed the resident's medication for his/her stomach pain the day before. -The resident said he/she was going to call Medicare or 911 if he/she did not get his/her abdominal pain resolved. -He/she felt the resident was seeking pain medication. During an interview on 4/6/21 at 2:25 P.M., Registered Nurse (RN) A said: -He/she was just coming on the day shift the morning of 4/3/21. -He/she was not there when the resident was transferred, but LPN A had told him/her that the resident was drug seeking. During an interview on 4/6/21 at 2:40 P.M., RN B said: -He/she took care of the resident one time while he/she was at the present facility. -He/she knew the resident well from having cared for him/her at another facility. -The resident was not drug seeking and in fact, the resident frequently waited too long to ask for pain medication and his/her pain got out of control. -If the resident was complaining of pain, especially after having pain medication, the resident must have been in distress. During an interview on 4/6/21 at 3:16 P.M., CNA A said: -The resident never said anything about chest pain on 4/3/21 during the night or early morning. -He/she was told by LPN A that the resident was just seeking pain medication and was constipated. -He/she did not remember the resident asking for the Administrator's phone number. -If someone other than a staff member called 911, the staff would not know to answer the door to let them in. During an interview on 4/7/21 at 10:00 A.M., the Administrator and DON said: -They felt as though the resident did not have chest pain as all of the facility staff said the resident was only complaining of abdominal pain. -The staff caring for the resident should have been aware that he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 to a D level at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO 579

Based on observation, interview and record, the facility failed to ensure a resident with a history of falls from bed received adequate supervision, care and interventions to keep him/her safe from injury and emotional harm after he/she had numerous falls, including a fall from his/her bed after which he/she yelled out in a distressed manner and was found lying on the floor mattress next to his/her bed, face down, with his/her head stuck between the floor mattress and bedframe, resulting in redness on his/her neck and face, and he/she continued to vocalize in a distressed manner for 30 minutes after he/she was found, and to notify the resident's physician and guardian for one sampled resident (Resident #49); to complete an incident report and investigation after a resident had a fall for two sampled residents (Resident #49 and #63); and to complete an incident report and investigation when a resident had his/her foot caught during a staff assisted transfer resulting in complaints of pain for one sampled resident (Resident #64) out of 17 sampled residents. The facility census was 68 residents. Record review of the facility Change in Medical Condition or Resident policy dated 10/1/10 showed: -The purpose of the policy was to keep the physician who is in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident decisions and other resident representatives informed of the resident's medical condition so they may direct the plan of care as needed. -Notification of the physician, legal representative, or interested family member should occur promptly according to Federal regulations, when there is a change in the resident's condition. -Change in condition is defined as: --An accident involving the resident which results in injury and has the potential for requiring physician intervention. --A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions of clinical complications). --A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to communicate a new form of treatment). -Assess the injury or change in condition and determine whether it is an emergency medical situation or a non-emergency situation. -Contact the physician and family/legal representative for an emergency at the time the event occurs whatever time of day or night. -In non-emergency, call during normal office and daylight hours. --If a non-emergency situation occurs after 5:00 P.M. or on a weekend or holiday, the physician is contacted the next day or at the schedule requested by the physician, but no later than the next day. -When possible, non-emergency calls are consolidated with routine calls. -The 24 Hour (a shift to shift communication between licensed nurses to update residents' conditions and care needs and document any changes in residents' status) shift report can be used as a reminder for an oncoming shift to notify a physician and/or family member. -The Director of Nursing (DON) may be consulted for assistance determining the urgency of calls. -Document the symptoms and observations associated with the change in condition, the dated and time of contact with the physician and family member/legal representative. -Notes also should include comments on the care provided by nursing personnel. -The 24 Hour report served as a reminder to report any change in condition to the oncoming shift. -Further assessment may be warranted with certain permanent changes in condition. -The plan of care may be altered to reflect a change in condition where new goals and approaches are developed. Record review of the facility Incidents and Accidents policy dated 8/26/20 showed: -The purpose of the policy was to keep the resident's environment as free of accident hazards as possible. -Prompt reporting and response to accidents was to occur. -Examples of incidents included resident fall/found on floor. -Handling accident occurrences included- --The resident should not be moved unnecessarily until his/her condition has been assessed --Assess the resident for pain, range of motion, bruising, bleeding and lacerations (a skin/tissue cut or tear). --Access the resident for neurological signs (assessment for problems with nerve, spinal cord, or brain function) as appropriate. --Notify the physician, obtain orders for care, including any indicated diagnostics (use of a device or substance used for the analysis or detection of diseases or other medical conditions). --Notify family of the accident, status and orders for the residents care. -Remember, fractures in the elderly, particularly the immobile or contracted (reduction in normal joint range of movement caused by drawing together/shrinking of muscles/tendons) elderly, cannot readily be detected visually; frequently the elderly do not experience pain or deformity (misshape) immediately after a fracture. -Interventions should be documented in the nurse's notes and the incident noted on the 24 Hour Report. -An incident/Accident report should be completed. -Develop a brief investigation plan, include obvious interviewees, questions to be asked and information to be gathered. -Be sure to include documentation of interviewee and interviewer, with date, time and place on the statement. -Be sure to note if interview was face to face or by phone; it is preferable to interview face to face whenever possible. -Initiate and investigation. 1. Record review of Resident #49's Face Sheet showed he/she was admitted to the facility on [DATE] and his/her diagnoses included: -History of falling. -[CONDITION(S)] (an impairment in motor or sensory function of the lower half of the body). -Unspecified convulsions (seizures). -Muscle contractures (muscle tightening or shortening causing a deformity resulting in pain and loss of movement of joints). Record review of the resident's hospital medical records dated 7/11/19 showed: -He/she was non-verbal. -He/she had a history of strokes and a motor vehicle accident (MVA) in 2013 with axonal injury (the tearing of the brain's long connecting nerve fibers that happens when the brain is injured as it shifts and rotates inside the bony skull; it usually causes coma and injury to many different parts of the brain) with severe neurological deficits. -Diagnosis, Assessment and Plan included that he/she had agitation (anxiety or nervous excitement), was on as needed (PRN) [MEDICATION(S)] (antianxiety medication), and was at high risk of climbing out and falling out of bed. Record review of the residents annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/20 showed: -He/she was cognitively impaired. -He/she had absence of spoken words. -He/she had behavioral symptoms. -He/she required extensive two person assistance for bed mobility. -He/she was totally dependent on two or more staff for transfer. -He/she had non-verbal sounds of pain. -He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls). Record review of the residents Falls Care Area Assessment (CAA - the process of focusing on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored) for his/her 3/20/20 comprehensive assessment showed: -He/she received antipsychotic, antianxiety, antidepressant and opioid (formerly known as narcotic) medications. -History of falling was blank, physical performance limitations was blank. -Internal risk factors included incontinence, [CONDITION(S)], [CONDITION(S)], cognitive impairment, and anxiety. -Environmental factors was blank. -Analysis of findings contained a statement that the resident was dependent for transfers from two staff and a mechanical lift, he/she was known to slide out of bed at times, he/she was unable to make his/her needs known and his/her bed was in the lowest position with mats on the floor. -Note: there was no documentation of the frequency of finding him/her out of his/her bed, of alternatives considered to keep the resident safe, of a potential for him/her to become stuck/wedged by his/her bed frame and no evidence of a complete analysis of causative factors related to his/her falls. Record review of the resident's care plan reviewed on 4/26/20 showed: -He/she would had a need for safety and would be kept away from aggressive residents. -He/she had a potential for complications related to anticoagulant (blood thinner) therapy. -He/she had a potential for complications related to anxiety state. -Staff were to explain care and procedures before and during care, provide support and reassurance as needed, and observe for nervous, anxious fidgeting behaviors. -He/she had [CONDITION(S)], contractures, was unable to perform self-care and required total assistance from staff. -There were no interventions address his/her specific need for individualized assistance devices and number of staff needed to transfer (move from one surface to another surface) him/her. -He/she had a potential for falls related to moving about in his/her bed and wiggling in his/her chair. -Staff were to observe his/her need for additional assistive devices/positioning devices, keep his/her bed in the lowest position and provide a mattress beside his/her bed. -He/she often rolled onto the mattress beside his/her bed and then onto the floor. -Staff were to monitor him/her at all times when he/she was up in his/her wheelchair so that he/she did not wriggle to the end of his/her chair and cause it to tip forward. -Note: There were no individualized interventions to keep the resident safe and free from bodily/emotional harm from falls and/or from his/her body being entrapped by his/her bed. Record review of the resident's Nurse's Progress Note dated 5/31/20 at 5:21 P.M. showed: -The licensed nurse heard the resident yelling out in a distressed manner and found him/her laying on his/her mattress next to his/her bed, face down with his/her head stuck between the mattress he/she was laying on and the frame of his/her bed. -The licensed nurse got a Certified Nursing Assistant (CNA) who helped safely get the resident back into his/her bed. -The resident was crying and seemed to be extremely upset. -The licensed nurse consoled the resident and was able to calm him/her. -The licensed nurse then completed an assessment and noted that the resident had red markings on the right side of his/her neck, his/her chin, and the right side of his/her forehead from his/her hairline just past his/her eyebrow and to his/her right cheek; no open areas were noted. -The resident then was resting peacefully in his/her bed. Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively impaired. -He/she had absence of spoken words. -He/she had behavioral symptoms. -He/she required extensive two person assistance for bed mobility. -He/she was totally dependent on two or more staff for transfer. -He/she had non-verbal sounds of pain. -He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls). Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively impaired. -He/she had absence of spoken words. -He/she had behavioral symptoms. -He/she required extensive two person assistance for bed mobility. -He/she was totally dependent on two or more staff for transfer. -He/she had non-verbal sounds of pain. -He/she had not had falls since completion of the previous MDS (Note the resident had experienced falls). Record review of the resident's Physician's Orders Sheet (POS) dated 10/2020 showed his/her physician ordered: -[MEDICATION(S)] (antianxiety medication) 0.5 milligrams (mg), one tablet twice daily for anxiety/agitation/restlessness. -[MEDICATION(S)] (muscle relaxer and an [MEDICATION(S)] medication) 20 mg, one tablet four times daily for spasm of muscle. -[MEDICATION(S)] ([CONDITION(S)] medication) 100 mg twice daily for convulsions (seizures). -[MEDICATION(S)] (opioid pain medication) 5-325 mg every eight hours for pain. -[MEDICATION(S)] (antipsychotic medication) 5 mg daily for mood disorder. Observation of the resident on 10/20/20 at 9:14 A.M. showed: -His/her room door was closed. -Upon knocking, then opening his/her room door, he/she was observed lying on the mat on the floor next to his/her bed. -He/she was alert, dressed and moving his/her head, right arm and right leg. Observation of the resident on 10/20/20 at 11:29 A.M. showed: -His/her room door was closed. -Upon knocking, then opening his/her room door, he/she was observed lying on his/her room floor near his/her sink. -His/her bed was in the lowest position and a mattress was on the floor next to his/her bed. -He/she was alert and moving his/her head, right arm, and right leg. During an interview on 10/21/20 at 10:36 A.M. the Administrator said: -He/she was not aware that on 5/31/20 at 5:21 P.M. a licensed nurse heard the resident yelling out in a distressed manner and found him/her laying on his/her mattress next to his/her bed, face down with his/her head stuck between the mattress he/she was laying on and the frame of his/her bed and that the licensed nurse assessed the resident and noted that he/she had red markings on the right side of his/her neck, his/her chin, and the right side of his/her forehead from his/her hairline just past his/her eyebrow and to his/her right cheek. -He/she was not aware of the incident. -To her knowledge, no incident report was completed regarding the incident and no investigation of the incident was completed. -He/she would expect an incident report when something like that occurred. -The resident's care plan did not address a potential for injury related to the resident's bed/bed frame, the mattress next to the resident's bed, the resident moving to the floor from his/her bed. -He/she would look to for any investigation and incident report that might have been completed. During an interview on 12:13 P.M. LPN A said: -On 5/31/20 he/she heard a noise, entered the resident's room and found the resident on the floor. -The mattress on the floor was moved away from the resident's bed. -The resident's head was stuck under his/her bed frame middle bar. -He/she got a CNA to assist him/her, then he/she looked at the resident's head under his/her bedframe metal bar to see if it was safe to move the bed frame up. -He/she then had the CNA move the bedframe up with the electronic control. -He/she then assessed the resident. -The resident was vocalizing in a distressed manner. -He/she and the CNA transferred the resident to his/her bed using his/her sling. -The resident continued to vocalize in a distressed manner for a half hour while he/she remained with the resident consoling him/her. -He/she did not recall telling anyone regarding finding the resident's head stuck under his/her bed. -He/she did not remember who was on duty or what day of the week this occurred; it was a long time ago. -He/she would typically notify the Assistant Director of Nursing (ADON) or DON regarding resident incidents. -In this resident case, he/she would not need to notify anyone of finding the resident on the floor or of this resident having his/her head under his/her bed frame because the resident did that on his/her own, it was a behavior. -He/she found the resident on the floor several times each 12 hour shift he/she worked. -He/she did not do anything other than transferring the resident back to his/her bed and checking the resident for injuries, bleeding, and if he/she needed to have incontinence care. -The number of times he/she found on the floor during shifts he/she worked varied from four to six times. During an interview on 10/22/20 at 12:58 P.M. CNA G said: -He/she sometimes worked the resident's hall. -He/she found the resident on his/her floor two to three times a shift. -When he/she found the resident on his/her floor, he/she got another CNA and transferred the resident back to his/her bed and then told the nurse the resident was on his/her floor. -It was in the resident's care plan that he/she rolled out of his/her bed and to put him/her back in his/her bed. During an interview on 10/22/20 at 1:02 P.M. Nursing Assistant (NA) F said: -He/she had found the resident on the floor with his/her head wedged under his/her bed and could not move him/her. -This occurred in the past several months, he/she could not remember the date. -He/she moved the resident's bed up with the bed control and freed his/her head. -He/she then went and got a CNA and transferred the resident back to his/her bed. -He/she then told the nurse the resident's was on the floor with his/her head wedged under his/her bed. -Normally he/she found the resident on the floor about six to eight times during his/her eight hour shift. -When he/she found the resident on the floor, he/she put him/her back in his/her bed; this was in his/her care plan; he/she would then tell the nurse. -About three licensed nurses had told him/her to check on the resident frequently because he/she would get his/her head under his/her bed. -He/she checked on the resident about every hour. During an interview on 10/22/20 at 1:24 P.M. Registered Nurse (RN) A said: -He/she had sometimes worked on the resident's hall and found him/her on the floor about two times a shift. -The resident's bed was kept in the lowest position. -He/she had found the resident with his/her head under his/her bed frame - his/her head was not wedged in the bed frame; his/her head was on the floor, under his/her bed frame, but not touching his/her bed frame. -He/she was able to easily move the resident. -On that occasion, he/she was not working on the resident's hall, a CNA had told her the resident was on the floor and he/she went to the resident's room. -The resident was not injured, had no red marks and was not screaming. -He/she told the charge nurse for the resident's hall, LPN A that the resident on had been on the floor. During an interview on 10/22/20 at 2:16 P.M. Housekeeping Staff (HS) A said: -He/she worked full time. -He/she cleaned the resident's room once each day. -He/she found the resident on his/her floor about two times weekly. -He/she told a CNA or a licensed nurse when he/she found the resident on his/her floor. During an interview on 10/22/20 at 2:16 P.M., the ADON said: -He/she did not know much about the resident's history. -Every five minutes the resident scooted out of his/her bed, it was his/her choice. -The resident scooted on the floor, off the mat next to his/her bed and into rooms across the hall from his/her room. -When staff find the resident on the floor they should see if he/she needed incontinence care. -He/she had heard the resident at one time had squirmed under his/her bed; he/she did not recall that his/her head was stuck under his/her bed or that he/she had an injury, just that he/she was under his/her bed, that he/she had wiggled under his/her bed. -He/she expected that when staff found the resident under his/her bed, they first get a licensed nurse to determine if the resident had any injuries, then figure out the best way to get her out from under his/her bed. -He/she would not necessarily expect that if staff found the resident under his/her bed they would report that to management staff if he/she had no injuries; redness had to be reported to management. -If the resident was stuck/wedged under his/her bed and then screamed for a half hour, that did not necessarily need to be reported to management staff. -Staff were to notify management during regular working hours or call management after regular working hours if a resident fell , if a resident was sent out to a hospital, if facility staff had any questions; any resident injury of any kind needed to be reported to management staff; anything for which an incident report would be completed required notification to facility management staff. -When the resident wiggled out of bed, that was not a fall because it was intentional, he/she had seen the resident intentionally wiggle out of his/her bed. -He/she had never seen the resident roll out of bed; he/she would scoot to the edge of his/her bed and then push off, that was how he/she moved around his/her room. -If the resident was stuck under his/her bed that would require an incident report. -If the resident could not get out from under his/her bed by himself/herself, he/she would expect an incident report and for staff to notify management, if management was in the building, if management was not in the building, incident reports were slid under the DON's door. -If a resident had a gross (very obvious) injury or had to be sent out to a hospital after hours, management was to be notified. -Phone calls to physicians and family depended on the nature of what had occurred with the resident, typically after normal work hours if the resident had no injury, follow up phone calls would be made the next day. -Management followed up on incidents, the following day if after normal working hours, by assessing the nature what occurred, if nursing notes were completed, if the doctor needed to be notified the physician is notified would be notified during this follow-up, if the resident had a gross injury, the doctor and family would be notified. -He/she thought if he/she were involved in a discussion of the resident having his/her head under his/her bed, he/she would ask if there was anything the facility needed to do differently. -Falls investigations are done with incident reports; part of the DON review is a review of the resident's care. -In the time he/she had worked at the facility, there had been no changes to the resident's care to his/her knowledge. -As long as there was any furniture, such as a bedside table in the resident's room, there was always the potential for the resident to get caught on those. -He/she did not think anything different could be done to keep the resident safe. During an interview on 10/22/20 at 1:52 P.M. the DON said: -He/she was not aware the resident had his/her head under his/her bed frame and his/her bed had to be raised to move his/her head from his/her bed frame. -He/she had wanted to remove the resident's bed frame but could not get agreement that it was an acceptable alternative. -He/she wanted the resident's bed frame gone to keep the resident from hurting himself/herself, like for residents with [CONDITION(S)] (a progressive brain disorder that causes uncontrolled movements) who have just mats on their floor and walls. -The resident moved around on his/her floor, he/she intentionally moved from his/her bed to his/her mat and off his/her mat; he/she moved around on his/her floor. -When the resident moved from his/her bed to his/her mat and to his/her floor it was not treated like a fall. -He/she had called someone at Department of Health and Senior Services (DHSS) Central Office, someone and Centers for Medicare and Medicaid Services (CMS), and a neurological center and was unsuccessful finding alternatives to the resident having a regular bed frame. -There had been no changes to the resident's care in some time. -He/she would like to get rid of the resident's bed frame because it may cause problems, the resident might be hurt; the resident could get his/her head stuck in his/her bed frame. During an interview on 10/23/20 at 9:47 A.M. CNA G said: -He/she had worked on the resident's hall a handful of times since May, 2020 and was familiar with him/her. -When he/she worked on the resident's hall, he found the resident on his/her mat or on his/her floor a couple of times in his/her eight hour shift. -To him/her this was the resident's way of saying something was wrong; his/her movement was him/her trying to get staff's attention. -He/she did not think the resident could follow instructions from staff. -He/she had never seen the resident with any of his/her body parts under his/her bed frame and he/she never heard the resident had been stuck under his/her bed or that his/her bed needed to be raised up to get him out from under his/her bed. -When he/she transferred the resident back to his/her bed, he/she got help from another staff person, usually another CNA and used the soft sling to lift the resident. -He/she had never seen the resident trying to move from one location to another location, he/she had only seen the resident having movement to get staff's attention. -When he/she found the resident out of his/her bed, he/she told the charge nurse he/she found him/her on his/her mat or floor and what he/she did for the resident; for example, he/she would tell the charge nurse he/she found the resident on his/her floor and he/she changed the resident's wet brief, or whatever else he/she did for the resident. During an interview on 10/23/20 at 9:56 A.M., CNA H said: -The resident scoots himself/herself out of his/her bed onto the mattress kept on the floor next to his/her bed or onto the floor. -The resident was unable to say words. -The resident scooted himself/herself; he/she thought this was him/her moving just to be moving. -Some days the resident moved himself/herself out of his/her bed every ten to 15 minutes and some days just one time or not at all during an eight hour shift. -A couple of years ago, he/she once found the resident hollering and with his/her head under his/her bed frame, not stuck and he/she had a little redness on his/her forehead. -He/she had never heard the resident's bed had to be raised to free his/her head. -Facility staff had discussed getting a vail bed, but that was not allowed for the resident. -He/she did not think the resident could get under his/her bed frame because it was kept all the way down to the floor; if his/her bedframe was not all the way down to the floor, he/she possibly could get his/her head under the frame of his/her bed. The head of the resident's bed was usually kept up. -He/she usually checked on the resident every half hour to make sure he/she was safe. -He/she liked to keep the resident's room door open. -He/she thought the resident's room door should be kept open and on 10/22/20 he/she asked the DON and the DON agreed the resident's door should be kept open. -All the staff knew to go down to the resident's room (which was the last room on his/her hall, furthest away from the nurses' station) and check on him/her to see if he/she was in his/her bed. -He/she had seen the resident once in a while shake his/her head yes; no one knows how much he/she understands. During an interview on 10/23/20 at 10:11 A.M. CNA D said: -Until the day prior he/she had not heard of the resident having his/her head stuck under his/her bed. -More often than not, when he/she went to the resident's room, he/she found the resident on his/her mat or on his/her floor. -The resident used his/her foot to spin; he/she did not know why the resident did that, he/she only knew the resident had been in a car accident and that was how she was afterward. -It was in the resident's care plan to keep a mattress next to the resident's bed. -When he/she found the resident out of his/her bed, he/she would get someone to help him/her transfer the resident back to his/her bed with the resident's soft sling and checks to see if he/she needs incontinence care; every time, he/she would then immediately tell the charge nurse that he/she had transferred the resident back to his/her bed from the mattress next to his/her bed or from the floor. During an interview on 10/23/20 at 10:17 A.M. Certified Medication Technician (CMT) A said: -He/she worked all his/her eight hour shifts on the resident's hall. -If he/she heard noises from the resident's room, he/she would go in and check on him/her. -He/she found the resident on his/her floor at least four times each shift he/she worked; he/she would first tell the charge nurse and the charge nurse would go the resident and assess him/her. -He/she would then get an additional CNA to help her transfer the resident back to his/her bed with his/her soft sling. -He/she had not seen and was not aware of the resident having his/her head under his/her bed. -The resident likes to be mobile; he/she could move purposefully and could shake his/her head yes or no; if he/she wanted to end up in a location, he/she could scoot to what location he/she wanted. -Everyone is reminded to keep an eye on him/her about every hour to see if he/she wants something; he/she would get fidgety and would wiggle for a reason, that he/she is hungry, wet or in pain. -He/she had been told to keep the resident safe. -No one had told him/her the resident got his/her head stuck. During an interview on 10/23/20 at 10:43 A.M. CNA C said: -He/she had found the resident on the floor on 10/23/20. -Sometimes he/she did not find the resident on the floor at all and other days he/she found the resident on the floor several times. -When he/she found the resident on the floor, he/she would get another CNA and they would use the residents sling to put him/her back in his/her bed. -They would then check to make sure he/she was dry and comfortable. -He/she always told the charge nurse that he/she had found the resident on the floor; usually he/she would say the resident was on the floor again each time he/she found the resident was on the floor. -He/she had never seen the resident with any body parts under his/her bed; he/she would find the resident on the mattress net to his/her bed or on the floor in the middle of his/her room. -He/she knew the resident wiggled a lot; he/she did not believe the resident could move from point A to point B - just that he/she moved just to move. -He/she had seen red marks on the resident from him/her moving on the floor. -The resident uses one foot to move and ends up moving around in circles. Observation on 10/23/20 at 12:03 P.M. showed: -The resident's room door was closed and he/she was heard screaming in a distressed manner. -Upon entering the resident's with CMT A and CNA H the resident was found in bed pushing on the wall with his/her right foot as his/her body moved to the mattress next to his/her bed. -He/she moved himself/herself from the mattress to the floor and then moved himself/herself by pushing on the wall and floor with his/her right foot; it was not clear if the movement was purposeful. -The ADON came to the resident's room, assessed him/her and the three staff transferred the resident to his/her bed with his/her soft sling. During an interview on 10/23/20 at 2:10 P.M. the resident's physician said: -He/she was not aware the resident had gotten his/her head wedged under his/her bed. -He/she knew the resident for about five to six years. -The resident always went from the bed to the floor and was basically on the floor all of the time. -The resident continually crawled all over the place. -He/she expected an incident report to be completed when the resident got his/her head wedged under his/her bed. -It was not a good thing if the staff had found the resident and his/her head wedged under his/her bed and his/her head had to be released from the bed. -He/she was not sure what type of interventions could be used for the resident. -The resident had a traumatic brain injury (TBI) and was a very difficult resident. -The resident was always crawling on the floor and this was unavoidable. Observation and interview on 10/23/20 at 2:49 P.M. showed: -The resident's room door was closed and noise was heard. -Upon knocking on the resident's room d

Based on observation, interview and record review, the facility failed to have a system in place to ensure that when a Hospice (end of life care) nurse finds a wound and writes wound care orders that the facility has communication with the Hospice nurse to implement those new wound care orders and notifies the resident's physician in a timely manner, to assess the resident's skin accurately to show the current status of the resident's unstageable pressure ulcer from 11/27/17-12/6/17, which delayed the treatment of [REDACTED]. to float the resident's heels to prevent further breakdown for one sampled resident (Resident #33) out of 17 sampled residents. The facility census was 61 residents. Record review of the facility's Protocol for Certified Nursing Assistant (CNA) and Licensed Nurse (LPN/RN) Skin Inspections Guidelines dated 10/1/10, showed: -Identify any skin concerns in residents immediately and implement early interventions. -CNAs will conduct body inspections of residents at risk for pressure sores on a weekly bass. -CNA skin inspection results will be documented on the body audit sheet or in the Smart Charting beside the appropriate resident's name. -Any skin concerns identified by the CNA will be reported to the assigned Licensed Nurse immediately. -The CNA will document the Nurse it was reported to on the body audit sheet or record in the Smart Charting. -All body audit sheets will be shared with assigned Licensed Nurse and the Licensed Nurse will submit the sheet toe the Director of Nursing (DON)/designee. -CNA body audit sheets will be maintained in the DON office or 90-days in a QA binder if manual sheets and reviewed by the DON if electronic. -The body audit sheets will be reviewed by the Treatment Nurse/designee for new skin concerns and finding will be presented at the QA Skin Sub-committee. -The Treatment Nurse/designee will review for appropriate measures taken and report at morning meetings. -Licensed Nurses will conduct body inspections of residents at risk for pressure sores on a weekly basis. -Licensed Nurses will conduct body inspections on all residents on a weekly basis, per schedule. -The DON will ensure that a weekly schedule is developed and implemented. -Licensed Nurses will document findings of inspections on the Medication Administration Record [REDACTED]. -Any skin concerns identified by a Licensed Nurse will be reported the Treatment Nurse immediately for evaluation and treatment orders. If the Treatment Nurse is not available, the Nurse identifying the concern should evaluate the wound and notify the physician for initial treatment orders. Record review of the facility's Pressure Ulcers Policy dated 10/1/10, showed: -Residents at greater risk for development of pressure ulcers include, but are not limited to the following: --History of pressure ulcers; --immobility/bed mobility problems; --decreased functional ability; --under-nutrition/malnutrition; --hydration deficits; --associated diagnosis/co-morbidities; and --skin changes. -The Wound Flow Record should be completed when pressure ulcers are found on admission/readmission or identified after admission. -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; physician's orders for care should be recorded. -The physician should be encouraged to document the [DIAGNOSES REDACTED]. -The status of the pressure ulcer should be documented on the Wound Flow Record weekly. -The Dietary Manager should be consulted to assist with interventions; actions are recorded in the dietary progress notes. -Observations pertinent to the resident's skin status should be recorded in the nurse's notes. -The interdisciplinary plan of care communicates care instructions to staff. -The Interdisciplinary team consists of DON/designated RN, Wound Care Nurse, Restorative Nurse designee, and Dietary Manager. Other disciplines may participate as needed. 1. Record review of Resident #33's admission face sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]; -Secondary Malignant neoplasm of bone ([MEDICAL CONDITION]); -Muscle weakness; -[MEDICAL CONDITION] (paralysis/weakness affecting one side of the body); -[MEDICAL CONDITION] ([MEDICAL CONDITION] disorder) and -Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's Comprehensive Care Plan dated 9/23/17 and revised on 12/6/17 showed: -The resident had an actual right heel wound noted on 12/6/17; -Audit skin per schedule; -Inspect skin for changes daily; -Specialty mattress; -Heel protectors on bilateral heels at all times and -Monitor Nutritional intake. Record review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) dated 10/21/17 showed he/she: -Had a BIMS (brief interview for mental status) score of 15 indicating the resident was cognitively intact; -Weighed 178 pounds with no weight loss; -Had no unhealed pressure ulcers; -Had no pressure reducing device was used in the bed or chair; -Was not on a turning or positioning program; -Had no nutrition or hydration interventions and -Received no pressure ulcer care and no applications of ointments or medications to his/her feet. Record review of the resident's Skin Audit Report dated 9/22/17 through 11/16/17 showed no new skin problems noted. Record review of the resident's bath sheets from 11/6/17-12/25/17 showed: -11/6/17, 11/13/17, 11/20/17, 12/4/17, 12/18/17, and 12/25/17 showed yes marked for the question Is skin clear and intact? and -No areas of concern was marked on the body diagram. Record review of the resident's Nurse's Notes dated 11/16/17 showed: -Weekly skin audit order in place to be performed on Mondays and -The nurse performed a skin audit with no new skin issues noted. Record review of the resident's New Skin Audit Report Roster dated 11/16/17 - 11/20/17 showed no new skin problems noted. Record review of the Hospice Nursing Bi Weekly Comprehensive Update Visit Report dated 11/27/17, showed: -Chief complaint/problem: Impaired skin integrity; -New orders: Clean wound to right heel with wound cleanser, apply skin prep, and cover with a foam dressing. Change two times weekly and as needed; -Suspected deep tissue injury (SDTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue) to right heel. Area is black in color; -Educated on heel floating. CNA verbalized understanding and -Weight loss. Record review of the Hospice Interdisciplinary Care Plan dated 11/27/17, showed: -Unstageable pressure ulcer to right heel measuring 6.4 centimeters (cm) wide by 4 cm long with SDTI; -Necrotic (dead) skin; -Surrounding skin soft; -Cleanse, apply skin prep, cover with foam and secure. Change two times weekly and as needed if compromised; -Heel protectors; -Coordinated care with the Nursing Facility and -The physician was notified. Record review of the resident's Skin Audit Report dated 11/28/17 - 12/1/17 showed no new skin problems noted. Record review of the resident's Skin Audit Report dated 12/1/17 - 12/4/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/4/17 - 12/5/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/5/17 - 12/6/17 showed no new skin problems. Record review of the Hospice Interdisciplinary Care Plan dated 12/6/17, showed: -Unstageable pressure ulcer to right heel measuring 6.4 centimeters (cm) wide by 4 cm long with 100% eschar (dry scab); -Deteriorated; -Surrounding skin soft and intact; -Cleanse if soiled with wound cleanser and spray with [MEDICATION NAME] (A liquid film that forms a breathable, transparent, protective coating on the skin) daily; -Heel protectors and -Low air loss mattress. Record review of the resident's Wound Assessment Report dated 12/6/17, showed: -A new unstageable pressure ulcer to the right heel identified on 12/6/17 (Hospice identified the area on 11/27/17); -Measurements: 8 cm in length by 8 cm in width, which indicated the wound was larger than it was measured last on 11/27/17 nine days later and -100% eschar. Record review of the resident's Skin Audit Report dated 12/6/17 - 12/7/17 showed no new skin problems. Record review of the resident's Nurse's Notes dated 12/7/17 showed: -Resident noted to have an unstageable deep tissue injury to the right heel measuring 4 cm in diameter with 100% eschar. (this measurement is different than the measurement on 12/6/17); -Area hard when palpated; -Hospice at bedside and aware; -Hospice ordered a low air loss mattress; -Resident already had heel protectors in place; -Physician contacted and was made aware and -Received an order to skin prep heel every shift and continue heel protectors. Record review of the resident's Nurse's Notes dated 12/7/17, showed the resident on low air loss mattress at that time, educated staff to ensure draw sheet was between the resident and the mattress at all times. Record review of the resident's Skin Audit Report dated 12/7/17 - 12/8/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/8/17 - 12/9/17 showed no new skin problems. (The resident has an STDI to his/her right heel) Record review of the resident's Physician's Progress Note dated 12/8/17 (two days after the facility documented date of finding the unstageable, 100% eschar covered pressure ulcer to the resident's right heel) showed: -The resident was seen by the physician; -No loss of memory or confusion; -No fever/chills, night sweats or significant weight loss; -Musculoskeletal: Range of Motion (ROM) is limited, generalized weakness, severe low back pain with movement; no joint swelling or redness. No documentation of the right heel pressure ulcer; -The rash to the resident's left upper extremity and bilateral lower extremities was non-palpable, non blanchable purpura - most involved on the left foot; -Extremities: Warm, no lower extremity [MEDICAL CONDITION]; no mention of the right heel pressure ulcer and -Right heel pressure ulcer was not documented under Problem List. Record review of the resident's Skin Audit Report dated 12/14/17 - 12/15/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/15/17 - 12/19/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/19/17 - 12/20/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/20/17 - 12/21/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/21/17 - 12/22/17 showed no new skin problems. Record review of the resident's Skin Audit Report dated 12/22/17 - 12/27/17 showed new skin problem noted except for the entry 12/22/17 at 12:15 P.M. then rest of entries showed no new skin problems noted. Record review of the resident's Physician's Progress Note dated 12/27/17, showed: -The resident was seen by the Nurse Practitioner; -Resident has declined significantly but still rallies every few days with mental clarity for a short time; -No loss of memory or confusion; -No fever/chills, night sweats or significant weight loss; -Musculoskeletal: Range of Motion (ROM) is limited, generalized weakness, severe low back pain with movement; no joint swelling or redness. No documentation of unstageable, 100% eschar covered pressure ulcer to right heel; -Extremities: Warm, no lower extremity [MEDICAL CONDITION]; no mention of the right heel pressure ulcer and -Right heel pressure ulcer was not documented under Problem List. Record review of the resident's January 2018 POS showed: -Cleanse right heel with wound cleanser, spray with [MEDICATION NAME] no sting barrier daily and apply heel protectors. Dated 12/6/17; -Admit to Hospice for [MEDICAL CONDITION] with metastasis to spine; -No physician's order noted for skin assessments and -No physician's order noted for the use of a special mattress (Low air loss mattress). Record review of the resident's January 2018 Medication Administration Record [REDACTED] -Skin Audit to be done weekly; record 0 for no new skin problems and 1 for new skin problems. Follow up in notes. Dated 11/16/17 and -Mondays 1/1/18 and 1/8/18 had a check mark in the box but no number indicating if there was a new skin problem or not. Record review of the resident's Wound Assessment Report dated 1/3/18, showed: -An unchanged unstageable pressure ulcer to the right heel that had been identified on 12/6/17; -Measurements: 8 cm in length by 8 cm in width and -100% eschar. Observation on 1/3/18 at 1:10 P.M. showed: -The resident lying supine in bed with his/her padded heel socks in place and his/her heels lying on the bed and -His/her heels were not floated on a pillow and there was not a pillow in the bed or floor by the bed that could have fallen or moved. Observation on 1/4/18 at 10:36 A.M. showed: -The resident lying supine in bed with his/her padded heel socks in place and his/her heels lying on the bed and -His/her heels were not floated on a pillow and there was not a pillow in the bed or floor by the bed that could have fallen or moved. Observation on 1/5/18 at 9:05 A.M. showed: -The resident lying supine in bed with his/her padded heel socks in place and his/her heels lying on the bed and -His/her heels were not floated on a pillow and there was not a pillow in the bed or floor by the bed that could have fallen or moved. Record review of the resident's Skin Audit Report dated 1/5/18 - 1/8/18 showed no new skin problems noted. Observation on 1/8/18 at 10:56 A.M., showed: -The resident was lying supine in bed with heel cushion socks in place and bilateral heels lying on the bed and -His/her heels were not floated and no pillow or cushion was noted in or around bed for the floating of heels. Observation on 1/8/18 at 2:49 P.M., showed: -Entire bottom of the resident's right heel was covered in dark eschar; -The resident was lying supine in bed with heel cushion socks in place and bilateral heels lying on the bed; -The resident's heels were not floated and no pillow or cushion was noted in or around bed for the floating of heels; -The resident stated it hurts when the Wound Nurse removed the socks and replaces the socks and - The Wound Nurse notified the charge nurse the resident was in pain and charge nurse provided the resident with as needed (PRN) [MEDICATION NAME] (liquid narcotic pain medication). During an interview on 1/9/18 at 9:08 A.M. the DON said: -The facility does not have a contracted wound treatment company coming into the facility to see the residents with wound, just the facility's wound nurse sees the residents with wounds and -He/she does not trust the wound care companies. During an interview on 1/10/18 at 10:21 A.M., the resident said no one puts his/her feet on a pillow, they usually lay them on the bed. During an interview on 01/10/18 at 10:26 A.M. CNA C said: -There is nothing the CNA does for the wound on the resident's right heel; -He/she thinks the resident does wear boots, he/she said he/she would be right back and left to go look; -The resident does have heel protectors, booted socks; -We elevate his/her head only no need for his/her legs or feet to be elevated or floated; -He/she would ask the Charge Nurse if he/she had any questions on resident cares; -Only the Charge Nurse has access to the care plans and -The resident is a fall risk and the bed is supposed to be in low position, this is the only intervention he/she is aware the resident has. During an interview on 01/10/18 at 11:16 A.M., the Hospice CNA said: -Hospice found the right heel wound and notified the facility it was there and -Hospice obtained the order for and provided the heel protectors. During an interview on 01/10/18 at 11:26 A.M. LPN G said: -He/she is not sure who found the right heel wound; -The right heel wound was purplish black when it was found; -Staff is supposed to turn the resident every two hours; -The resident received heel protector socks and a low air loss mattress after the right heel wound was found; -He/she is not sure if the physician or nurse practitioner have ever looked at the wound; -They facility does not have a shower aide on Wednesdays; -No residents have complained about not getting a shower; -Bath aid will usually tell the nurse if there is a new wound or skin issue and -He/she has not seen the CNA skin inspection report before. No one has ever handed him/her one of these forms before. During an interview on 1/10/18 at 12:10 P.M., the Wound Nurse said: -He/she was the wound nurse at the beginning of the year in 2017 and the company decided they didn't need a wound nurse so he/she then worked the floor as the night charge nurse; -He/she was given three days of training at the beginning of the year; -He/she had been back as the wound nurse full time since the second week of December 2017; -He/she was the charge nurse the day hospice found the right heel wound; -He/she was not aware the hospice nurse found the wound on 11/27/17; -He/she did not inform anyone; -He/she was not aware the hospice nurse had documented in his/her notes on 11/27/17 that the wound had been found; -No one signs the hospice nurse notes/documentation before they leave for that particular hospice agency; -He/she is not sure if anyone reads the hospice nurse notes because the hospice nurse will usually tell the staff if there is an issue or a new order; -The resident was declining at that time and had been refusing repositioning; -He/she does not know if staff documented the resident refusals; -He/she is not sure if the physician has seen the wound, he/she had not looked at it with him/her present; -He/she believes the Nurse Practitioner sees the wound weekly; -Hospice does not want the resident to wear any other type of heel protectors and -Staff should be floating the resident's heels off the bed. During an interview on 1/10/18 at 1:47 P.M., the DON said: -The resident's condition has been up and down since he/she has been in the facility; -No one observed the left heel wound prior to it being found by hospice; -He/she can see the resident decline quickly and the wound go straight to eschar with the resident's current nutritional, physical and mental status; -He/she would have expected staff to document the wound only if they had seen it; -He/she would not have expected staff to find the wound prior to it being unstageable with full eschar because it can happen so quickly; -No one is in charge of reading or monitoring the Hospice Nurse documentation because he/she always notifies the Charge Nurse and the DON of any issues or new orders; -The regular Hospice Nurse was on vacation at the time the wound was found and the replacement did not notify the staff he/she had found the wound and -Staff should have reviewed the Hospice Nurse documentation because the facility was not notified resulting in a full week delay in treatment of [REDACTED]. During an interview on 1/12/17 at 10:12 A.M., the resident's physician said: -He/she believes the wound was unavoidable due to the resident's co-morbidities and health decline but the resident's heels should be floated off the bed at all time when the resident is in bed and he/she needs to be notified of any change in condition.