Every finding on record at Athene Nursing and Rehabilitation

Based on record review and interview, the facility failed to ensure one resident (Resident #1) was free from misappropriation of resident property when Housekeeping Supervisor (HS) and Certified Nursing Assistant (CNA) A used resident money for his/her personal use. The census was 155.The administrator was notified on 02/10/26 of the past noncompliance which occurred on 01/15/26. On 01/15/26, the administrator became aware of the staff to resident misappropriation of funds allegation involving Resident #1. Upon discovery, the facility immediately began an investigation, suspended the staff members, and in-serviced staff members on abuse, neglect, code of conduct, misappropriation, and exploitation. The deficiency was corrected on 01/17/26.1. Record review of Resident #1's personal bank statement for the month of 11/2025, showed the following withdrawals using Resident #1's debit card at River City Casino: Date Amount11/03/25 $1,009.0011/03/25 $709.0011/03/25 $209.00Total $1,927.00 Review of the Transactions Report by Card, dated 11/25/25, provided by the Town and Country (T & C) Police Lieutenant, showed withdrawals and/or attempted withdrawals at River City Casino using Resident #1's personal debit card on 11/03/25: Time Amount12:03:49 AM CST $1,009.0012:25:00 AM CST Exceeds Limit12:25:36 AM CST $709.0012:41:09 AM CST $200.00 Review of email correspondence on 01/19/26 at 2:53 P.M., showed T & C Police Department provided still photos with facial recognition of HS and CNA A entering River City Casino on 11/02/25 at 11:07:39 P.M. Review of the T & C Police Department Investigative Report 25-1258 - Supplement #2, showed Automated Teller Machine (ATM) transactions using Resident #1's debit card to attempt or make withdrawals on 11/03/25. Still photos of HS and CNA A were taken at the time of the fraudulent transactions. Review of Investigative Report 25-1258 - Supplement #4 Narrative, showed an interview between CNA A and Police Detective and Corporal. CNA A stated the following:-Confirmed his/her Driver's License picture was the one in the photo and the same license was used when playing Blackjack at River City Casino.-HS requested him/her to go to the car and get HS's Capital One card and pull out $1,000.-HS went to the ATM and withdrew more money.-Once HS and CNA A left, HS became stressed out and stated he/she needed to put the money back in his/her mother's account. -HS asked CNA A if he/she could borrow money and CNA A said no.-HS provided the Personal Identification Number (PIN) for the card to CNA A.-Identified both him/her and HS from the four still photos provided from the video footage supplied by the River City Casino. Review of email documentation on 01/19/26 at 2:53 PM, the Police Detective showed a video of HS and CNA A walking to a car in the River City Casino parking lot on 11/03/25 at 00:56:05 AM and driving away at 00:57:04 AM. Review of facility maintained documentation titled Athene Interview Questions, showed questions the Administrator asked HS and responses from HS on 01/15/26 at 1:58 PM; -Question - Have you ever been to the casino with CNA A, when was it and what time?Response - About two months ago, River City at nighttime.-Question - Who all went to River City Casino?Response - I told CNA A I was heading to River City.-Question - Did you take any money out of the ATM at the casino?Response - No, I came with money.-Question - Did you see CNA A take any money out of the ATM?Response - No, I texted her from the Black [NAME] table and asked if he/she had any cash and CNA A replied yes, but not a lot.During an interview on 02/13/26 at 1:34 P.M., the Police Lieutenant said this is an active investigation and Department of Health and Senior Services staff should not interview CNA A and HS. During an interview on 02/10/26 at 9:32 A.M., the Administrator said HS and CNA A were suspended pending investigation. Complaint 2718572

Based on observation, interview, and record review, the facility failed to ensure physician-ordered prescription medications were received timely from the pharmacy and administered as ordered, affecting one resident who did not receive an antipsychotic medication for one month and had documented increased behaviors, including a resident-to-resident incident (Resident #173), and another resident who did not receive an antibiotic medication (Resident #133). The sample was 47. The census was 166.Review of the Medication Reordering policy, revised 8/1/25, showed:-Policy: To accurately and safely provide or obtain pharmaceutically services including the provision of routine and emergency medication and biologicals in a timely manner to meet the needs of reach resident;-Explanation and compliance guidelines:--The facility will utilize a systematic approach to provide or obtain routine and emergency medications in order to meet the needs of each resident;--Acquisition of medications should be completed in a timely manner to ensure medication are administered in a timely manner;--Each time a nurse is administering medication and observes six of less doses left of one kind, that nurse will reorder the medication, time permitting;--In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the physician. 1. Review of Resident #173's closed medical record, showed:-re-admitted to the facility on [DATE];-Diagnoses included lung disease, schizophrenia (a brain disorder causing distorted reality with symptoms including hallucinations, delusions and disorganized thinking/speech and unusual behavior), anxiety, bipolar disorder (mental disorder including emotional highs and lows), insomnia (difficulty sleeping) and depression. Review of the resident's progress note, dated 1/24/25 at 5:28 P.M., showed the resident re-admitted to the facility. The physician notified, medications verified and faxed to the pharmacy. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident used psychotropic medications for behavior management;-Goal: The resident will be/remain free of complications;-Interventions: Administer medications as ordered and monitor effectiveness, discuss with the physician regarding the ongoing need for the medications, monitor and record behaviors. Review of the resident's physician order sheet (POS), showed an order, dated 1/24/25, for cariprazine (used to treat schizophrenia) 4.5 milligram (mg.). Take one capsule once daily. Review of the resident's progress notes, showed:-On 1/25/25 at 8:28 A.M., administration note, cariprazine 4.5 mg for schizophrenia, drug on order;-On 1/26/25 at 6:05 A.M., behavior note, the resident used the call light all night, requested medication he/she had already received of melatonin (used to help sleep). The resident yelled out and disturbed other residents and was asked to lower voice. The resident not easily redirected. The resident requested to assistance to be changed. Resident threatened to call emergency services to report he/she could not sleep;-On 1/26/25 at 9:00 A.M., an administration note, cariprazine 4.5 mg, on order;-On 1/27/25 at 9:30 A.M., an administration note, cariprazine 4.5 mg, on order;-On 1/28/25 at 9:18 P.M., an administration note:, cariprazine 4.5 mg, on order;-On 1/29/25 at 9:54 A.M., an administration note, cariprazine 4.5 mg, on order;-On 1/30/35 at 8:12 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 1/31/25 at 8:25 A.M., an administration note, cariprazine 4.5 mg, on order. Review of the resident's January 2025 Medication Administration Record (MAR), showed the order for cariprazine 4.5 mg. missed 7 out of 7 missed medication administration opportunities. Further review of the resident's progress notes, showed:-On 2/1/25 at 9:59 A.M., an administration note, cariprazine 4.5 mg, unavailable pharmacy contacted;-On 2/1/25 at 8:02 A.M., an administration note, cariprazine 4.5 mg, on order;-On 2/2/25 at 9:59 A.M., an administration note, cariprazine 4.5 mg, on order;-On 2/3/25 at 9:56 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/4/25 at 9:44 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/5/25 at 11:05 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/6/25 at 9:17 A.M., a behavior note, the resident reviewed for resident-to-resident altercation. Interventions put in place for psychology and psychiatry consult for coping skills;-On 2/6/25 at 10:30 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/7/25 at 7:28 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/9/25 at 10:27 A.M., and administration note, cariprazine 4.5 mg, unavailable;-On 2/11/25 at 8:58 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/13/25 at 10:31 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/14/25 at 10:27 A.M., an administration note, cariprazine 4.5 mg, drug unavailable;-On 2/15/25 at 9:27 A.M., an administration note, cariprazine 4.5 mg, drug on order;-On 2/16/25 at 10:40 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/19/25 at 9:05 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/20/25 at 10:32 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/22/25 at 10:37 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/23/25 at 9:31 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/24/25 at 10:00 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/25/25 at 9:57 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/26/25 at 10:42 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/27/25 at 11:02 A.M., an administration note, cariprazine 4.5 mg, unavailable;-On 2/28/25 at 10:16 A.M., an administration note, cariprazine 4.5 mg, unavailable;-No documented notifications to the physician regarding missed doses of cariprazine. Review of the resident's February 2025 MAR, showed the order for cariprazine 4.5 mg. missed 24 out of 28 missed medication administration opportunities. During an interview on 1/12/26 at 12:15 P.M., Pharmacy Representative W said the pharmacy last dispensed the medication on 3/13/25 as a 14-day supply. The medication is expensive and that is why a 14-day supply is sent. The facility did not send in a prescription for the medication to the pharmacy in January 2025, following the resident's re-admission. The facility did not send an order until March 2025, and that is when a 14-day supply was sent routinely. 2. Review of Resident #133's medical record, showed diagnoses included alcoholic cirrhosis of the liver (hardening of the liver resulting in dysfunction) and hepatic encephalopathy (brain disease or damage caused by liver failure). Review of the resident's December 2025 MAR, showed:-An order, dated 12/6/25, for rifaximin (an antibiotic use to treat hepatic encephalopathy) 550 mg, give one tablet twice a day for 14 days;-Rifaximin not documented as administered 12/6/25 through 12/19/25. During an interview on 1/12/26 at 11:56 A.M., Pharmacy Representative W said the resident's rifaximin was not sent because it required an out-of-pocket expense of $1600.00. The pharmacy needed either payment from the facility or from the resident because it was not covered by the resident's health plan. During an interview on 1/12/26 at 12:01 P.M., Nurse Practitioner (NP) J said he/she was notified by nursing staff that the resident's Rifaximin was not covered by the resident's health plan and was asked if there was an alternative that was less expensive. NP J informed the nursing staff member that all the liver medications are expensive and that the rifaximin needed to be dispensed. NP J was not informed that the medication was not administered to the resident. During an interview on 1/13/26 at approximately 12:15 P.M., the Administrator said he was not aware that the resident did not receive his/her rifaximin. Generally, if a medication is expensive, the facility will reach out to the physician and pharmacy to see if there is an alternative that is less expensive. The Administrator said the facility would have paid for the resident's rifaximin. 3. During an interview on 1/13/25 at 11:32 A.M., Certified Medication Technician (CMT) Z said if a medication is not present in the medication cart, staff should check the bottom drawer for overflow medication. If the medication is not available, the charge nurse should be notified. The CMT's nurse should notify the pharmacy and ensure the medication will be delivered. If the medication is not delivered, the pharmacy and physician should be notified within 48 hours. 4. During an interview on 1/13/26 at approximately 12:15 P.M., the Administrator said he would expect staff to reach out to himself or the Director of Nurses and inform them of a resident's missing medication and not continue to document that it was not administered. 25663522713484

Based on interview and record review, the facility failed to follow current infection control best practices and facility infection control policy for three of 47 sampled residents who were receiving antibiotic therapy. Concerns were noted with the indications for use in the antibiotic orders for all three residents (Residents #69, #166 and #26). The facility census was 166. Review of the facility's Antibiotic Stewardship Program Policy, revised 7/2/25, showed:-The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the Infection Preventionist (IP). The IP utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms;-The program includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols include nursing staff assessments of residents suspected to have an infection, the use of the CDC (Center for Disease Control and Prevention, a federal health agency designed to prevent the spread of resistant infections)'s Surveillance data and definitions, all prescriptions for antibiotics shall specify dose, duration, and indication for use;-Antibiotic orders obtained upon admission, whether new admission or readmission to the facility shall be reviewed for appropriateness;-Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness. 1. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/25, showed:-Diagnoses included Alzheimer's disease, diabetes, heart failure, and muscle weakness;-Moderately impaired cognition. Review of the resident's Physician's Order Summary (POS), dated 1/2026, showed:-An order, dated 11/22/25, Gentamicin Sulfate (antibiotic) external cream 0.1 %, apply to affected area topically at bedtime related to need for assistance with personal care;-The antibiotic medication did not have any indications for use. 2. Review of Resident #166's quarterly MDS, dated [DATE], showed:-Diagnoses included dementia, major depressive disorder, anxiety, and chronic kidney disease;-Moderately impaired cognition. Review of the resident's POS, dated 1/2026, showed:-An order, dated 12/9/25, Cefadroxil (antibiotic) oral capsule 500 milligram (mg), Give one capsule by mouth two times a day for antibiotic for three months;-The antibiotic medication did not have any indications for use. 3. Review of Resident #26's medical record, showed:-re-admitted : 11/15/25;-Suprapubic catheter (hollow tube placed through the abdomen into the bladder to drain urine) related to bladder dysfunction;-Diagnoses included amyotrophic lateral sclerosis (ALS, a terminal progressive neurodegenerative disease attacking motor neurons, causing gradual muscle weakness, twitching and loss of control), bipolar disease (emotions ranging from high to low), muscle wasting and atrophy (muscle loss), dysphagia (difficulty swallowing) and bladder dysfunction. Review of the electronic physician order sheet (ePOS), showed:-An order, dated 11/15/25: Doxycycline (antibiotic) 100 mg tablet. Take one tablet twice a day for urinary tract infection;-The order did not include an end or stop date. Review of the November and December 2025 MAR, showed:-An order, dated 11/15/25: Doxycycline (antibiotic) 100 milligram (mg) tablet. Take one tablet twice a day for urinary tract infection;-Noted administered as ordered November and December 2025;-The order did not include an end or stop date for the antibiotic. Review of the January 2026, MAR, showed:-An order, dated 11/15/25: Doxycycline (antibiotic) 100 mg tablet. Take one tablet twice a day for urinary tract infection;-Noted administered as ordered daily during the survey January 2026;-The order did not include an end or stop date for the antibiotic. During an interview on 1/13/26 at 12:15 P.M., Assistant Director of Nursing (ADON) Y said when the nurse received an antibiotic order, he/she should verify a stop/end date for the antibiotic use. Long term antibiotic use can result in antibiotic resistance. The facility has experienced management changes, and he/she is not sure who the infection preventionist is or how antibiotic tracking is occurring. 4. During an interview on 1/13/26 at 10:01 A.M. Registered Nurse (RN) G said all residents on antibiotics are tracked by the facility IP, and should have orders that include a stop date, and an adequate indication for use of the antibiotic. Continuation of antibiotic therapy when an infection is not present or is not reacting to the antibiotic can promote the spread of drug-resistant organisms. 5. During an interview on 1/13/26 at 9:21 A.M. RN N, who serves as the facility IP, and Regional Nurse Consultant O said the facility has an antibiotic tracking log that ideally should be reviewed daily by the facility IP and the Interdisciplinary Team (IDT) during morning meetings. The infection control program also has facility mapping techniques identifying infections by organism. At the time of the interview, the facility IP and RN Consultant O were unaware of any residents receiving long term antibiotics. Antibiotic orders for all residents should have an adequate indication for use and a stop date. Currently, the facility IP and RN Consultant O are working on education with staff to ensure that antibiotic orders are transcribed accurately and with correct indications for use and listed stop date. It is important to ensure antibiotics orders are audited to prevent the spread of drug-resistant infections. 6. During an interview on 1/13/26 at 1:41 P.M. the facility Administrator and Director of Nursing (DON) said they would expect all residents on antibiotics in the facility to have both an adequate listed indication for use of the antibiotic and a stop date indicating when the resident should discontinue the antibiotic.

Based on interview and record review, the facility failed to ensure advance directive/code status forms (a legal document, often a Do Not Resuscitate (DNR) order, that tells medical professionals not to perform cardiopulmonary resuscitation (CPR) if the heart and breathing stop) were documented, updated, and reviewed annually, in accordance with the expectations of the Director of Nursing (DON) and Administrator, for 7 sampled residents (Residents #1, #6, #12, #17, #39, #55, and #176). The sample was 47. The census was 166.Review of the Residents' Rights Regarding Treatment and Advance Directives policy, revised [DATE], showed:-Policy: To support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advanced directive;-Definitions: Advance directive is written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated;-Explanation and compliance guidelines:-On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive;-The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive;-Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff;-The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities;-The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions;-During the care planning process, the facility will identify, clarify and review with the resident of legal representative whether they desire to make any changes related to any advanced directives;-Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions;-Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care;-The facility will use the process as provided by state law for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes. 1. Review of Resident #1's request concerning life prolonging procedures form, dated [DATE], showed:-CPR: Yes;-Use of respirators or ventilators: Yes;-Blood transfusions: Yes;-Administration of medications other than those necessary to prevent infection, provide comfort or alleviate pain: Yes;-Signed by the resident and the physician. Review of the resident's medical record, showed:-re-admitted to facility on [DATE];-Diagnoses included irregular heartbeat, bipolar disorder (a chemical disorder that causes emotional highs and lows), heart disease, kidney disease, depression, muscle weakness, high blood pressure;-A physician order, dated [DATE], for full code. Review of the resident's care plan, revised [DATE], showed:-Focus: The resident has a full code status;-Goal: The resident/power of attorney (POA) will be informed of the right to complete advance directives to direct medical care and make treatment goals known;-Interventions: Advance directives and resident wishes will be honored. Further review of the resident's medical record, showed no updated signed code status election form since 2020. 2. Review of Resident #6's code status form, dated [DATE], showed:-Full resuscitation: I understand full resuscitation means that if my heart stops beating or if I stop breathing, all medical procedures to restart breathing or heart function will be initiated all measures will be taken including CPR, calling 911 (emergency services) and emergency intravenous fluids and medications;-Signed by the resident and a registered nurse on [DATE]. Review of the resident's medical record, showed:-re-admitted to the facility on [DATE];-Diagnoses included diabetes, high blood pressure, depression, muscle wasting, schizophrenia (irregular thoughts), difficulty swallowing, and communication deficit. Review of the resident's care plan, revised [DATE], showed:-Focus: The resident has a full code status;-Goal: The resident and POA will be informed of the right to complete advance directive to direct medical care and make treatment goals known;-Interventions: Advance directives and resident wishes will be honored. Further review of the resident's medical record, showed no updated and reviewed signed code status form since 2023. 3. Review of Resident #12's electronic medical record (EMR), showed:-admitted to the facility on [DATE];-Diagnoses included diabetes, chronic kidney disease, heart disease, and heart failure;-A running ribbon at the top of the EMR included the resident's code status, listed as full code;-A physician order, dated [DATE], for full code;-A care plan, in use at the time of survey, showed the resident full code status;-A scanned copy of the resident's code status form showed DNR, signed by the resident and representative on [DATE]. Review of the 3rd Floor Terrace code status book on [DATE] at 10:18 A.M. showed a three-ring binder with copies of code statuses for residents on the hall. A DNR code status form signed by the resident's representative on [DATE] and signed by the hospice physician on [DATE] in the code status book. 4. Review of Resident #17's EMR, showed:-A scanned copy of the resident's code status form showed DNR, signed by the resident on [DATE], signed by the resident's representative on [DATE], and signed by the physician on [DATE];-admitted to the facility on [DATE];-Some cognitive impairment;-Diagnoses included unspecified dementia, neurocognitive disorder with Lewy Bodies (progressive brain disorder characterized by abnormal protein clumps affecting movement, behavior, and mood), schizophrenia, and Alzheimer's Disease;-A physician order, dated [DATE], for DNR. Review of the resident's care plan, in use during the survey, showed the resident had a DNR code status. Interventions included the resident completed a DNR advanced directive and had an active DNR physician order. Review of the 3rd Floor Terrace code status book on [DATE] at 10:18 A.M. showed a three-ring binder with copies of code statuses for residents on the hall. No code status for the located in the code status book. 5. Review of Resident #39's code status form, dated [DATE], showed:-Full resuscitation: I understand full resuscitation means that if my heart stops beating or if I stop breathing, all medical procedures to restart breathing or heart function will be initiated all measures will be taken including CPR, calling 911 (emergency services) and emergency intravenous fluids and medications;-Signed by the resident and a witness on [DATE]. Review of the resident's medical record, showed:-An order, dated [DATE] for full code;-re-admitted to the facility on [DATE];-Diagnoses included lack of coordination, abnormal gait, communication deficit, muscle weakness, neuropathy (loss of feeling in feet and legs), and heart failure. Review of the resident's care plan, revised [DATE], showed:-Focus: The resident has a full code status;-Goal: The resident will be informed of the right to complete advance directives to direct medical care and make treatment goals known;-Interventions: Advance directive and resident wishes will be honored, advance directives completed and placed in the front of the chart to ensure timely access and a copy placed in financial records, the resident will be informed of any changes in condition and benefits, risks, and possible choices of treatment, the physician will be notified of the resident's wishes and any needed physician order will be obtained. Further review of the resident's medical record, showed no current signed code status form. 6. Review of Resident #55's code status form, dated [DATE], showed: -DNR: I understand that DNR means that if my heart stops beating or if I stop breathing, no medical procedures to restart breathing or heart functioning will be initiated. No measures of resuscitation will be taken, including no CPR initiated and not calling 911; -Signed by the resident and a witness on [DATE]. Review of the resident's medical record, showed:-admitted to the facility on [DATE];-A physician order, dated [DATE], showed DNR code status;-Diagnoses included schizoaffective disorder, borderline personality disorder, bipolar disorder, dementia, depression, difficulty swallowing, and communication deficit. Review of the resident's care plan, revised [DATE], showed:-Focus: The resident has a DNR code status;-Goal: The resident will be informed of the right to be complete advanced directive to direct medical care and make treatment goals known;-Interventions: The advance directive will be honored, advance directives completed and placed in the front of the chart to ensure timely access and a copy placed in financial records, the physician will be notified of the wishes and orders will be obtained. Further review of the resident's medical record, showed no signed code status form after [DATE]. 7. Review of Resident #176's medical record, showed:-Initially admitted to the facility on [DATE];-A physician order, darted [DATE], for full code;-A hospital Discharge summary, dated [DATE], showed code status listed as default full code, needs discussion;-re-admitted to the facility on [DATE];-Diagnoses included irregular heartbeat, protein-calorie malnutrition, diabetes, and muscle weakness. Review of the resident's care plan, revised on [DATE], showed:-Focus: The resident has a full code status;-Goal: The POA will be informed of the right to complete advance directives to direct medical care and make treatment goals known;-Interventions: Advance directive and wishes will be honored, advance directives completed and placed in the front of the chart to ensure timely access and a copy placed in the financial records and the physician will be notified of the resident wishes. Further review of the resident's medical record, showed no signed code status form. 8. During an interview on [DATE] at 9:51 A.M. Certified Nurse Aide (CNA) L said when looking for a resident's code status, staff first look in the EMR to see if a resident is a full code or DNR. DNR orders should be updated every six months or if there is a change in condition that necessitates a new code status order. Code statuses should be reflected accurately in residents' care plans, as front-line staff such as CNA's often consult resident care plans to determine care needs. 9. During an interview on [DATE] at 10:01 A.M. Registered Nurse (RN) P said staff are instructed to check the EMR to identify if a resident is a full code or DNR. If the EMR is unavailable or not working, a code status book is located at the desk with active code statuses for all residents on the hall. Advanced directives should be updated when a significant change happened. He/She expected code status orders to be accurately reflected in care plans. 10. During an interview on [DATE] at 9:21 A.M. RN N, the Infection Preventionist (IP), and Regional Nurse Consultant (RNC) O said staff should consult the EMR to determine a resident's code status. They should review the physical code status book located at each nurse's station if the medical record system is down. RN N and RNC O said resident code statuses should be accurately reflected in resident care plans, as the CNAs often review and consult the care plans to direct resident care. Code statuses should be updated when there is a change in condition or per company policy. 11. During an interview on [DATE] at 1:50 P.M., the Administrator and DON said at the time of admission, re-admission, and upon a change in condition, the admission nurse is responsible to ensure a current code status election is obtained, entered on the POS and added onto the care plan. The resident's code status should be reviewed yearly and at each care plan meeting and should be documented in the resident's medical record. The code status form should be signed yearly by the resident or responsible party and the physician.

Based on observation, interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff observed a resident on the floor and failed to tell anyone, leaving the resident on the floor (Resident #183), and when staff left one resident without pants, leaving him/her exposed in the hallway (Resident #69). In addition, the facility failed to ensure the men and women's shower rooms on 3 Long Unit were in working order, preventing residents on that unit from using the shower room on their hall for an undetermined about of time, including one resident (Resident #147) who became aggressive due to his/her lack of access to showers. The sample was 47. The census was 166. Review of the facility's admission Agreement, dated, showed:-Right to a dignified existence: Be treated with consideration, respect, and dignity, recognizing each resident's individuality;-Freedom from abuse, neglect, exploitation, and misappropriation of property;-Freedom from physical or chemical restraints;-Quality of life is maintained or improved;-Exercise rights without interference, coercion, discrimination, or reprisal;-A homelike environment, and use of personal belongings when possible;-Equal access to quality care;-Security of possessions;-You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals. 1. Review of Resident #183's medical record, showed:-admitted to the facility on [DATE];-Diagnoses included difficulty swallowing, muscle weakness, diabetes, seizures and fall history. During an observation and interview on 1/13/26 at approximately 1:15 P.M., the surveyor walked past the resident's room. The resident was observed on the floor, on his/her buttocks with the wheelchair against his/her back. Housekeeper G observed in the resident's bathroom. The surveyor told Housekeeper G that the resident was on the floor, on his/her buttocks, and asked if he/she was going to tell anyone. Housekeeper G threw up his/her hands and said No and continued to spray cleanser on the toilet. During an interview on 1/13/26 at 11:59 A.M., the Housekeeping Supervisor said the housekeeper should have followed facility policy and reported the resident's fall to nursing staff immediately upon noticing the resident on the ground. The housekeeper should not have continued cleaning after becoming aware the resident was on the floor. During an interview on 1/13/26 at 1:50 P.M., the Administrator and Director of Nursing (DON) said if staff observe a resident on the floor, they are expected to immediately notify the nurse. Staff should not continue to work without notifying someone that a resident is on the floor. 2. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/25, showed:-Diagnoses included Alzheimer's disease, diabetes, heart failure, and muscle weakness;-Moderately impaired cognition;-Dependent on staff for dressing his/her lower body. Observation on 1/13/26 at 6:56 A.M., showed the resident sat in his/her wheelchair in the hallway. He/She wore a shirt and brief. The brief was undone, exposing the resident's genitals. Another resident walked by the exposed resident in the hallway. During an interview on 1/13/26 at 7:51 A.M., Certified Nurse Aide (CNA) H said all residents should be clothed or at least covered when in public areas. The resident's genitals being exposed in the hallway was a dignity concern. During an interview on 1/13/26 at 10:08 A.M., Licensed Practical Nurse (LPN) I said the resident is unable to dress him/herself and requires assistance from staff. He/She expected for residents to be clothed and covered in public spaces. During an interview on 1/13/25 at 2:34 P.M., the Administrator and DON said residents' genitals should be covered in public spaces. 3. Review of Resident #147's medical record, showed: -admitted on [DATE];-Room on 3 Long Unit;-Diagnoses included hemiplegia (paralysis that affects one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, heart failure, anxiety, and high blood pressure. Review of the resident's care plan, in use during survey, showed:-Focus: Resident has an Activities of Daily Living (ADL) self-care performance deficit related to left sided hemiparesis and hemiplegia;-Interventions included substantial/max assistance with bathing/shower. Observations during the survey from 1/6/26 through 1/12/26, showed the 3 Long Unit's men's and women's shower rooms with a taped piece of paper on each door that showed, This area is under construction. Do not enter. During an interview on 1/6/26 at 12:50 P.M., the resident said he/she cannot take a shower on his/her unit. His/Her shower days are Mondays and Thursdays. The men shower at night and the women during the day. Review of the resident's progress note, dated 1/8/26 at 4:27 P.M., showed the resident became increasingly agitated this shift and became verbally aggressive with several staff after requesting a shower. This writer offered to assist resident with shower and after several attempts from staff, resident refused, stating that the facility does not like men, and he/she is not sufficient enough to do the shower. This writer and Assistant Director of Nursing (ADON) educated resident that he/she would able to the get the assistance needed in the shower, and his/her next shower day is Monday. Resident continued to refuse, will continue to monitor for change in condition. During an interview on 1/8/26 at 5:03 P.M., the resident said he/she had one shower in the past five weeks. He/She never took a shower on 3 Short Unit because there were women taking their showers in the evening, even though it was supposed to be men in the evenings. He/She blew up at corporate staff who said he/she would receive a shower. He/She wants a shower. During an interview on 1/8/26 at 11:47 A.M., Housekeeper R said the 3 Long Unit shower rooms just went under construction due to a leak in the shower room on The Loop Unit. During an interview on 1/9/26 at 9:42 A.M., Licensed Practical Nurse (LPN) S said the men and women's shower rooms on 3 Long Unit had out of service signs for at least a couple of months. The residents from 3 Long Unit use the showers on 3 Short Unit, which are functioning properly. The residents on 3 Long Unit keep their same shower days. They go by the shower list, so it is not men at night or women during the day. The rooms on the units are divided up on the shower schedule. All residents are scheduled for showers twice a week. Resident #147 receives his/her showers in the evening. He/She becomes aggressive if he/she does not get his/her shower. To his/her knowledge, LPN S believed the resident receives his/her showers. During an interview on 1/12/26 at 3:07 P.M., the Administrator said he was not aware the men and women's shower rooms on the 3 Long Unit were of order. Observation and interview on 1/12/26 at 3:34 P.M., showed the Director of Maintenance removed the signs on the 3 Long Unit men's and women's shower rooms that read, This area is under construction. Do not enter. The Director of Maintenance said that the showers are working on 3 Long Unit. There was a flood on The Loop Unit and they recently repaired a crushed underground pipe. It was repaired the week before, with work completed on 1/2/26. He did not have a chance to inform staff the shower rooms were working. During an interview on 1/13/26 at 7:42 A.M., CNA P said the shower rooms on 3 Long Unit had been out of order since he/she worked at the facility. The residents on 3 Long Unit were using the showers on 3 Short Unit. He/She had not been informed the showers were working and the maintenance signs were removed. During an interview on 1/13/26 at 7:49 A.M., Certified Medication Technician (CMT) V said the showers on 3 Long Unit had been out of order for four years. He/She had not been informed the showers were working and the maintenance signs were removed. During an interview on 1/13/26 at 8:21 A.M., the resident said he/she had given up on receiving a shower. He/She did not receive a shower on Monday, 1/12/26. He/She believed the men are not able to shower and the facility is discriminating against men. He/She refused last week because the water was cold. Staff make residents feel guilty for wanting a shower and then they say, Wait until your next shower day. Observation and interview on 1/13/26 at 8:28 A.M., showed the Director of Maintenance walked into the men and women's shower rooms on 3 Long Unit to ensure they were not out of order. The sinks and showers were turned on and water came out of the spouts. The Director of Maintenance said that the showers are working. The reason some staff may not have been aware was because those shower rooms were out of order when he started working at the facility. During an interview on 1/13/26 at 12:37 P.M., the DON said she was not aware that the shower rooms on 3 Long Unit were no longer out of order. The residents on 3 Long Unit use the showers on 3 Short Unit. Staff can report needed repairs by completing a work order for Maintenance. They can also notify the Housekeeping Supervisor. She was not aware of Resident #147's issues with having access to a shower. During an interview on 1/13/26 at 1:50 P.M., the Administrator said he expected residents to be treated with dignity and respect. He was not aware of the showers not working or not being used. He expected maintenance staff to communicate with nursing staff when something is repaired. He expected maintenance staff to do rounds of the building.

Based on observation and interview, the facility failed to post the Missouri Department of Health and Senior Services (DHSS) Elder Abuse and Neglect Hotline phone number and failed to provide contact information for the State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities by helping ensure their rights were preserved and respected) in a visible location. The sample was 47. The census was 166.Observation on 1/6/26 through 1/9/26, 1/12/26, and 1/13/26, showed: -No DHSS Abuse and Neglect hotline numbers or Ombudsman contact information on the facility's elevators;-The Corporate compliance contact information posted on the wall of Terrace 2. No DHSS Abuse and Neglect hotline number or Ombudsman contact information;-The Corporate compliance contact information posted on the double doors in the middle hall of Terrace 3. No DHSS Abuse and Neglect hotline number or Ombudsman contact information;-No DHSS Abuse and Neglect hotline number or Ombudsman contact information on 3 Short;-No DHSS Abuse and Neglect hotline number or Ombudsman contact information on 3 Long;-No DHSS Abuse and Neglect hotline number or Ombudsman contact information on the Loop. During an interview on 1/8/26 at 1:30 P.M., all eight residents present during the resident council meeting said they were not aware of the Ombudsman program and confirmed the information was not posted. One resident asked for the correct spelling of the advocacy agency. Observation on 1/8/26 at 2:52 P.M., showed a bulletin board on the wall in the front lobby, with typed up sign that showed, if you suspect any form of abuse and neglect, please contact the Administrator and provided the administrator's contact number. Observation on 1/8/26 at 2:55 P.M., showed a 12-inch x 18-inch Resident Rights poster outside of the Social Worker's office. At the bottom of the poster, a letter label, approximately 1 inch x 2 5/8 inches in size with the Ombudsman's contact number. There was a second sign on the door that showed Corporate's confidential reporting hotline for facility company. No observation of the hotline number for DHSS. During an interview on 1/13/26 at 1:30 P.M., the Administrator said there should be signs for the hotline number by the business office, by the stairwell near Terrace 2, and bird cages. He was only aware of those areas. He would have to see the print for the Ombudsman contact number, but he would expect the print to be large enough for residents to see. 1698646

Based on interview and record review, the facility failed to ensure residents received mail on Saturdays, a regular mail delivery day as identified by the United States Postal Service. The facility also failed to ensure mail was delivered timely. The sample was 47. The facility census was 166.During the resident council interview conducted with eight residents who represent the resident council, on 1/8/26 at 1:30 P.M., residents said mail is not delivered timely. It will sit in the activities room before they give it out. They have not had mail delivered this week. Some mail is time sensitive, that may have a due date or expiration date on it. One resident received his/her birthday card nearly one month late. He/She checked the postmark. He/She waited for the birthday card because there was $25 in there. He/She was upset it was delivered late. During an interview on 1/8/26 at 3:00 P.M., the Director of Activities said mail is delivered at the end of the day. After the facility receives the mail, the reception staff sort it out. He/She just got into the position, so he/she was not sure if there were issues with mail being delivered, but there are residents that keep track. Observation at this time of the Director of Activities desk showed a stack of envelopes with room numbers written on them. There were two letters with a visible post mark of 12/30/25 and 1/2/26. There was another large stack of mail on the second desk in the office. Observation on 1/13/26 at 7:54 A.M., showed the Director of Activities had a stack of envelopes on his/her desk. The post mark dated 1/9/26. The Director of Activities said mail came yesterday. He/She will write room numbers on the envelope and give them to the activity aides to deliver. During an interview on 1/13/26 at 10:39 A.M., Receptionist D said on the weekends, receptionist does not sort the mail. They do not know how to sort it properly, so they wait until Monday, so they go through it at that time. During an interview on 1/13/26 at 1:30 P.M., the Administrator said he would expect mail to be delivered timely and on Saturdays. He was not aware of staff waiting until Monday to sort mail delivered on Saturday.

Based on observation, interview and record review, the facility failed to ensure the facility was clean and homelike. The facility failed to ensure two of 47 sampled residents had a clean room and clean medical equipment (Residents #135 and #72), failed to ensure the 3rd floor terrace had a clean shower room and fire extinguisher cabinet, failed to ensure the 3rd floor windows were free from cracks, failed to ensure the floors in room [ROOM NUMBER] were clean and failed to ensure the loop main hallway was clean and free from odors. The sample is 47. The census was 166. Review of the facility's cleaning policy, undated, showed: -Policy: The facility has employed team members of environmental service at the facility to ensure that all areas of the facility, including resident rooms, offices, and public areas, are clean and homelike; -Procedure: Walk through the assigned area checking for spills, debris, and unsafe items / situations to clean or remove immediately. The areas should be ready for residents, guests, and employees use ensuring professional first impression; -Trash and soiled linen removal: Safely load all hamper bags into soiled linen carts and safely transport to the nearest soiled linen utility. Replace linen where required. Environmental services are required to replace linen only on discharged resident beds; clinical staff replace linen on occupied beds. Review of the facility's cleaning and disinfection of resident care equipment policy, dated 8/1/25, showed: - Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection; -For durable medical equipment, such as feeding pumps, staff shall store used/dirty equipment in soiled utility room. The central supply clerk shall be responsible for terminal cleaning/disinfection in designated locations, covering the equipment to prevent dust and other contamination, and storing in clean utility or other designated storage rooms. Verify the disinfectant is compatible with the equipment. 1. Review of Resident #135's medical record, showed; -admission date,12/16/25; -Diagnoses included osteomyelitis (infection of the bone) of left ankle and foot, muscle weakness, unsteady gait, and need for assistance with personal care. Observation of the resident's room on 1/6/26 at 10:15 A.M., 1/7/26 at 1:22 P.M., and 1/8/26 at 1:17 P.M., showed an intravenous (IV) pole had thick crusted yellow dried liquid on the bottom of the pole and wheel coverings. The resident's fitted sheets on his/her bed showed drops of maroon and dark brown stains and smears. There were crumbs along the baseboards and behind the resident's dresser. The resident's clothing was stored in a clear trash bag. During an interview on 1/8/26 at 1:17 P.M., the resident said his/her sheets have never been changed since he/she had been there and thinks it's gross. The crusted liquid on the IV pole has been on the pole since they brought it into his/her room. The resident said his/her room is filthy. 2. Review of Resident #72's medical record, showed: -admission date, 12/15/25; -Diagnoses included cellulitis (skin infection) of left lower limb and lymphedema (swelling of extremities). Observation on 1/6/26 at 10:15 A.M., 1/7/26 at 1:22 P.M., and 1/8/26 at 1:17 P.M., showed used towels with stains, in the corner of the resident's room. In the bathroom, there were used washcloths and towels on the floor. The resident had a grocery bag full of trash tied to his/her nightstand. The resident's fitted bed sheet had brown smears and yellow stains. During an interview on 1/8/26 at 1:17 P.M., the resident said his/her sheets have never been change since he/she had been there. The resident said staff will say they will come in and change the sheets, but they never do. The washcloths in the bathroom are from when he/she took a shower. The towels in the corner of the resident's room were left from the Wound Nurse last week. The resident said he/she would clean the room him/herself because it is so dirty, but he/she is unable to do so. 3. During an interview on 1/13/26 at 9:40 A.M., Certified Nursing Assistant (CNA) U said resident sheets are changed on shower days. Towels and washcloths can be picked up housekeeping or nursing. Clothing should be placed in the closet, not in trash bags. 4. During an interview on 1/13/26 at approximately 11:30 A.M., Housekeeper BB said sheets are changed by nursing. Towels and trash should be removed by housekeeping when they clean the room. Housekeeper BB will usually ask the resident what they would like removed out of their room. Resident rooms are cleaned daily and furniture is moved to sweep or mop behind it. If there is something that housekeeping cannot clean, such as medical equipment, Housekeeper BB would notify his/her supervisor. 5. During an interview on 1/13/26 at 2:40 P.M., the Administrator and the Director of Nursing (DON) said residents' sheets should be changed twice a week. In resident rooms, linens should be picked up off the floor and their clothes stored in the closets. Any staff can clean a soiled IV pole. 6. Observations on 1/6/26 at 12:31 P.M., on 1/8/26 at 6:01 A.M. and on 1/12/26 at 7:58 A.M, of the fire extinguisher cabinet near room [ROOM NUMBER], showed a large, unidentifiable white stain covering the cabinet. Observations on 1/7/26 at 9:01 A.M. and on1/8/26 at 6:11 A.M., of the resident hall shower rooms on the 3rd Floor Terrace, showed: -Three wet towels on the floor and two stained washcloths left in the sink of the men's shower room; -Two stained wash cloths in the second shower stall of the women's shower room. Observation of the [NAME] wing elevator, showed: -On 1/7/26 at 9:19 A.M., a scattering of dark, sticky stains on the floor of the elevator; -On 1/9/26 at 9:15 A.M., a scattering of dark, sticky stains on the floor of the elevator. Residents' and staff's shoes could be heard sticking to the elevator floor while entering and exiting the elevator; -On 1/12/26 at 8:24 A.M., a scattering of dark, sticky stains on the floor of the elevator. Residents' and staff's shoes could be heard sticking to the elevator floor while entering and exiting the elevator. Observation on 1/9/26 at 9:17 A.M. and on 1/12/25 at 8:17 A.M., of the wall opposite the elevator on the 3rd Floor Terrace level, showed an unidentified red splatter on the green wallpaper. Observation on 1/9/26 at 12:42 P.M. and on 1/12/26 at 8:22 A.M., of the artwork near the 3rd Floor Terrace elevator, showed a large, unidentifiable white stain covering the paintings on the wall. During an interview on 1/13/26 at 9:51 A.M. CNA L and Certified Medication Technician (CMT) M said housekeeping staff were responsible for cleaning the shower rooms on the hall, but all care staff should clean up after themselves when taking a resident to complete a shower in the shower room. Towels and wash cloths should be cleared and if a biologic spill needs to be cleaned up, housekeeping can be contacted for assistance. Shower rooms should be cleaned daily by housekeeping staff, but some housekeeping staff were more diligent about cleaning shower rooms than others. During an interview on 1/13/26 at 10:01 A.M., Registered Nurse (RN) G said housekeeping staff were responsible for cleaning the shower rooms on the hall, but all care staff should clean up after themselves when taking a resident to complete a shower in the shower room. If a biologic spill needs to be cleaned up, housekeeping can be contacted for assistance. During an interview on 1/13/26 at 1:41 P.M., the facility Director of Nurses (DON) and Administrator said any staff were able to clean up shower rooms on the resident halls, but housekeeping staff were primarily responsible for keeping these areas clean. Resident hall shower rooms should be cleaned daily and maintained in a clean and orderly fashion to promote a homelike environment. The facility elevators should be cleaned daily or as needed if spills or accidents occur. 7. Observation of the 3rd floor dining room on 1/6/26 through 1/9/26 and 1/12/26 through 1/13/26, showed double windows on both sides of the room, with 11 double windows on both sides. Several double windows were cracked, broken, or unable to close fully. There was a large piece of cardboard, 36 x 18 inches, that covered one half of a window. Observation on 1/9/26 at 12:05 P.M., showed a loose, small handrail outside of room [ROOM NUMBER] that moved down when touched. 8. Observation of room112, showed: -On 1/6/26 at 9:49 A.M., the floor was dirty with trash and a large dust like material splatter in the bathroom; -On 1/7/26 at 7:04 A.M., the floor was dirty with various trash wrappers and a large dust like material splatter in the bathroom; -On 1/12/26 at 7:29 A.M., the floor was dirty with trash wrappers in various areas of the room. 9. Observation of the loop main hallway, showed: -On 1/8/26 at 1:32 P.M., a strong odor of urine and sweat wafting in the hallway. The floor in the main hallway was sticky; -On 1/9/26 at 6:54 A.M., a strong odor of urine and sweat was wafting in the hallway. The floor in the main hallway was sticky. Various trash items were on the floor; -On 1/9/26 at 8:21 A.M., a strong odor of urine and bowel movement was wafting from the dirty linen cart positioned in the hallway. The lid was open; -On 1/13/26 at 6:55 A.M., a strong odor of bowel movement and urine was in the hallway. Bags of visibly dirty linens and depends were sitting on the ground in the main hallway. 10. During an interview on 1/13/26 at 12:49 P.M., the Director of Housekeeping said housekeepers were responsible for cleaning resident rooms. The floor technicians were responsible for cleaning the hallways and resident room floors. He expected floors to be clean and free from debris and trash. The machine used for cleaning the hallways was currently broken. 11. During an interview on 1/13/26 at 2:30 P.M., the Administrator and DON said they expected the floors on the loop hallway to be clean and free from trash. They expected dirty linen and depends to be stored properly in bins. They expected resident rooms to be clean. 260738 2566352 1698661 1698646 1698637 2712327

Based on observation, interview and record review, the facility failed to ensure residents received appropriate activity of daily living (ADL, daily care) care to meet the needs of residents, including showers, personal hygiene, and nail care (Residents #15, #26, #143, #133, #153, #11, #21, #137, and #177). The sample was 47. The census was 166.Review of the facility's Activity of Daily Living policy, revised 4/23/25, showed:-Policy: The facility will, based on the comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-Care and services will be provided for the following ADLs:--Bathing, dressing, grooming and oral care;--Transfer and ambulation;--Toileting;-Explanation and compliance guidelines: -Conditions which may demonstrate unavoidable decline in ADLs include:--Natural progression of the resident's disease state with known functional decline;--Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities;--Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment, counsel and/or offer alternatives to the resident or representative;-A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene; -The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for the decline, potential decline of lack of improvement;-Terminology for ADL evaluation and documentation will follow definitions from the State's Resident Assessment Instrument (RAI) manual:--Independent: If the resident completes the activity by themselves with no assistance from a helper;--Setup or clean up assistance: If the helper sets up or cleans up, resident completes activity. Helper assists only prior to or following the activity, but not during the activity;--Supervision/touching assistance: If the helper provides verbal cues or touching/steadying/contact guard assistance;--Partial/moderate assistance: If helper does less than half the effort;--Substantial/maximal assistance: If the helper does more than half the effort;--Dependent: If the helper does all the effort and resident does none of the effort to complete the activity. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/25, showed:-Cognitively intact;-Required supervision or touch assistance with bathing, personal hygiene, and toileting hygiene. Review of the resident's medical record, showed:-admission date 12/16/25;-Diagnosis included osteomyelitis (infection of the bone) of left ankle and foot, diabetes, abnormalities with gait, and muscle weakness. Review of the resident's shower and skin condition report for December 2025, showed on 12/19/25, 12/23/25, 12/30/25, and 1/2/26/25, staff documented the resident received a shower. Observation on 1/6/26 at 10:15 A.M., showed the resident sat on the side of the bed with a foot and ankle dressing on his/her left foot and a tall surgical boot on his/her left foot. He/She had a peripherally inserted central catheter (PICC, a long thin tube inserted into the vein used for medications and blood draws) line in his/her right upper arm. The resident had long facial hair, approximately one inch long. During an interview, the resident said he/she liked to be clean shaven. He/She had an odor and was embarrassed how he/she looked. He/She had never received a shower because no staff member would assist him/her with removing his/her dressing to his/her left foot and staff would not cover his/her PICC line with plastic to protect it from getting wet. 2. Review of Resident #26's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Functional limitation in range of motion to upper and lower extremities, both sides;-Required full staff care for bed mobility, transfers, oral care, bathing, personal hygiene and dressing;-Diagnoses included amyotrophic lateral sclerosis (ALS, a terminal progressive neurodegenerative disease attacking motor neurons, causing gradual muscle weakness, twitching and loss of control, leading to difficulty walking, speaking, swallowing and breathing), bipolar disorder (emotions ranging from high to low), muscle wasting and atrophy (muscle loss), need for assistance with personal care, dysphagia (difficulty swallowing), and bladder dysfunction. Review of the resident's care plan, in use during the survey, showed:-Focus: The resident has ADL self-care performance deficit related to diagnoses of disease process;-Goal: The resident will maintain current level of ADL function;-Interventions: Dependent on staff for ADL care and mobility. Review of the Certified Nurse Aide (CNA) assignment and shower book on the resident's hall, showed the resident scheduled to have a shower every Wednesday and Saturday. Observations and interviews, showed:-On 1/9/16 at 9:08 A.M., the resident awake in bed. Using a visual communication tablet, he/she said he/she had not had a shower the month of January. He/She felt dirty. He/She wanted his/her hair washed;-On 1/12/26 at 9:24 A.M., the resident asleep in bed. His/Her hair appeared oily;-On 1/13/26 at 9:45 A.M., the resident awake in bed. Using a visual communication tablet, he/she said he/she wanted a shower. He/She wanted his/her hair washed, and he/she stank. He/She had not had a shower in weeks, and he/she would like a shower before his/her wound care appointment. He/She appeared tearful and requested surveyor to inform management of the shower request. During an interview on 1/13/26 at 9:59 A.M., CNA U said the resident's hallway required heavy care and sometimes showers did not get completed. 3. Review of Resident #143's quarterly MDS, dated [DATE], showed:-admitted : 7/15/25;-Cognitively intact;-Diagnoses included gastrostomy placement (a surgical opening into the stomach used to administer nutrition and/or medications), history of sepsis (a potentially fatal infection in the bloodstream), heart failure, and dysphagia (difficulty swallowing). Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident had an ADL care deficit requiring staff assistance with bathing and showering;-Interventions included providing total assistance with bathing and showering activities, checking nail length on bath days, and providing a bed bath when a shower is not possible. Review of the resident's December 2025 shower sheets, showed:-A shower sheet, dated 12/3/25 on day shift, showed staff documented a bed bath completed;-No completed shower sheets between 12/3/25 and 12/21/25, a period of 18 days;-A shower sheet, dated 12/22/25 on evening shift, showed staff documented a bed bath completed;-No completed shower sheets between 12/22/25 and 12/28/25, a period of six days;-A shower sheet, dated 12/29/25 on evening shift, showed staff documented a shower completed;-No completed shower sheets between 12/29/25 and 1/7/26, a period of nine days. Observation on 1/6/25 at 9:42 A.M., showed the resident in bed with a hospital gown on. He/She had oily skin and disheveled hair. During an interview, the resident said he/she had not received a shower in weeks and staff routinely told him/her a shower could not be provided due to equipment not working or shower rooms unavailable. Review of the resident's shower sheet, dated 1/7/26, showed staff documented a shower completed. Observation on 1/8/25 at 6:01 A.M, showed the resident in bed with a hospital gown on. He/She had oily skin and disheveled hair. During an interview, the resident said he/she asked for a shower yesterday afternoon and staff told him/her they could not transfer him/her because the Hoyer lift was not charged. Review of the resident's shower sheet, dated 1/9/26, showed staff documented a shower completed. Observation on 1/9/25 at 12:43 P.M., showed the resident in bed with a hospital gown on. During an interview, the resident stated he/she had not received a shower in the month of January 2026. He/She had a visitor on 1/8/26, and the visitor told him/her that he/she smelled. The resident felt the staff do not care about him/her, and he/she is forgotten about. Review of the resident's progress notes, showed no documentation of any care or shower refusals for the month of January. During an interview on 1/13/25 at 9:51 A.M. CNA L and Certified Medication Technician (CMT) N said residents should receive showers or bed baths at least twice per week or if a resident requests one. CNA L and CMT N were unaware of any non-functioning Hoyer lifts on the floor and were unable to say when the resident had last received a shower. During an interview on 1/13/25 at 10:01 A.M. Registered Nurse (RN) G said a period of 18 days without a shower was unacceptable. 4. Review of Resident #133's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Required maximum assistance with bathing, personal hygiene, and toilet hygiene. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an ADL self-care deficit;-Plan: Use short simple instructions to promote independence and avoid scrubbing and pat dry sensitive skin. Review of the resident's medical record, showed:-admission date, 11/25/25;-discharge date , 12/2/25;-readmission date,12/4/25.-Diagnosis included cirrhosis of the liver (hardening of the liver resulting in dysfunction) and encephalopathy (brain disease or damage). Review of the resident's shower sheets and skin condition report, showed:-The resident received a shower on 12/3/25, 12/17/25, 12/20/25, 12/24/25, and 12/27/25;-No shower sheets provided for January 2026. Observation on 1/6/26 at approximately 10:30 A.M., showed the resident in bed. His/Her arms and upper chest were very dry. His/Her hair was oily and stringy. During an interview, the resident said he/she had never received a shower or hair wash since he/she had been at the facility. His/Her skin was itchy and dry. Staff wipe him/her down but he/she wouldn't consider it a bath. A staff member promised the resident that they were going to get him/her into the shower using the Hoyer lift and a shower chair. Observation on 1/12/26 at 8:50 A.M., showed the resident in bed. His/Her arms and upper chest were very dry, and his/her hair was oily and stringy. During an interview, the resident said he/she had not received a shower. He/She was told by staff that there was no shower chair available. During an interview on 1/12/26 at approximately 9:00 A.M., CNA U said there was a shower chair on the third floor that could be used for the resident's shower. 5. Review of Resident #153's quarterly MDS, dated [DATE], showed:-Diagnoses included Alzheimer's disease, chronic kidney disease, major depressive disorder, and Parkinson's disease;-Moderately impaired cognition;-Required moderate staff assistance for personal hygiene. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has an ADL self-care performance deficit;-Goal: The resident will maintain current level of ADL function through the review date;-Interventions: Personal hygiene requires partial or moderate assistance from staff. Observation on 1/6/26 at 9:56 A.M., showed the resident in the doorway to his/her room. His/Her nails were long and uneven. During an interview, the resident said his/her nails are too long and he/she wanted a nail file. Observation on 1/8/26 at 8:24 A.M., showed the resident in the dining room for breakfast. His/Her fingernails were long and jagged. During an interview, the resident said he/she wanted his/her nails trimmed. During an interview on 1/13/26 at 7:46 A.M., CNA I said the nurse is responsible for trimming the resident's fingernails. He/She was unsure where to find nail files for the resident. 6. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included stroke, dementia and anxiety;-Dependent on staff for personal hygiene, toilet hygiene and bathing;-Received hospice care. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has an ADL self-care performance deficit due to immobility;-Plan: The resident is dependent on staff for bathing, personal hygiene, toilet hygiene. Review the resident's hospice communication form, showed:-Visit date: 12/31/25, bed bath given and assisted with personal care and ADLs;-Visit date: 1/5/26, bed bath given and assisted with personal care and ADLs;-Visit date: 1/7/26, bed bath given and assisted with personal care and ADLs;-Visit date: 1/12/26, bed bath given and assisted with personal care and ADLs. Observation on 1/6/26 at 9:50 A.M., 1/8/26 at 8:22 A.M., and 1/9/26 at 8:14 A.M., showed the resident with an unshaven face with approximately one-inch-long facial hair. The resident's fingernails on both hands were approximately one half an inch long with dark matter underneath. The resident's face was oily with large white flakes in the resident's neck skin folds. Observation on 1/13/25 at approximately 10:00 A.M., showed the resident's face with a partial shave. His/Her cheeks were shaved and had he/she had approximately one inch of hair on his/her neck and mouth. The resident's fingernails on both hands were approximately one half an inch long with dark matter underneath. 7. Review of Resident #21's quarterly MDS, dated [DATE], showed:-Diagnoses included Alzheimer's disease, major depressive disorder, and muscle weakness;-Moderately impaired cognition;-Required maximum staff assistance for personal hygiene. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has an ADL self-care performance deficit;-Goal: The resident will maintain current level of ADL function through the review date;-Interventions: The resident is dependent on staff for showering and hygiene. Observation on 1/6/26 at 11:47 A.M., showed the resident had long jagged nails with matter underneath. Observation on 1/8/26 at 9:10 A.M., showed the resident in the dining room eating breakfast. The resident's nails were long and jagged with matter underneath. Observation on 1/9/26 at 9:57 A.M., showed the resident seated in the dining room after breakfast. The resident's nails were long and jagged. During an interview on 1/13/26 at 7:46 A.M., Certified Nurse Aide (CNA) I said the nurse is responsible for trimming the resident's fingernails. He/She said the resident's hospice nurse can also trim the resident's nails. 8. Review of Resident #137's quarterly MDS, dated [DATE], showed:-Diagnoses included Parkinson's disease (a neurological disease causing weakness), dementia, and muscle weakness;-Severe cognitive impairment;-Required full staff assistance for care needs. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident has an ADL self-care performance deficit;-Goal: The resident will maintain/improve level of functioning;-Interventions: Bathing required substantial/maximum assistance from staff, personal hygiene required substantial/maximum assistance from staff. Observations on 1/6/26 at 9:51 A.M., 1/8/26 at 7:28 A.M., and 1/9/26 at 9:02 A.M., showed the resident with long, oily hair and an unkempt beard. His/Her nails were uneven and dirty with matter underneath. 9. Review of Resident #177's admission MDS, dated [DATE], showed:-admission date 12/16/25;-Severe cognitive impairment;-Dependent on staff for bathing, personal hygiene, oral hygiene, and toileting hygiene. Review of the resident's medical record, showed diagnoses included dementia, muscle weakness, intellectual disabilities, schizoaffective disorder (mood disorder), Parkinsonism (movement disorder) and difficulty walking. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has ADL self-performance deficient related to Parkinson's disease;-Plan: Provide sponge bath when a full bath cannot be tolerated. Review of the resident's shower sheets and skin condition report, showed:-On 12/2/26, 12/5/26, 12/9/26, and 12/12/25, staff documented bathing as completed;-No shower sheets were provided dated January 2026. Observations on 1/6/26 at 9:57 A.M. and 1/7/26 at 8:30 A.M., showed the resident in bed with a hospital gown on. His/Her teeth were caked with yellow matter. His/Her fingernails on both hands had brown matter underneath. 10. During an interview on 1/12/26 at approximately 9:00 A.M., CNA U said that residents receive baths twice a week and the showers and baths are assigned daily by the nurse. Bathing includes shaving and nail trimming and cleaning and oral care. Shower sheets are filled out by the person providing the shower and the charge nurse signs off on them. During an interview on 1/13/26 at 9:59 A.M., CNA U said at times, residents received a bed bath instead of a shower. CNAs should document the care provided on the shower sheets and in the resident's electronic medical record. The charge nurse reviews the shower sheet and turns it in. 11. During an interview on 1/13/26 at 7:46 A.M., CNA H said the nurse is responsible for setting up hair appointments for the residents. The nurse is responsible for trimming resident's fingernails. 12. During an interview on 1/13/26 at 10:05 A.M., Licensed Practical Nurse (LPN) I said the Social Worker is responsible for setting up hair appointments for the residents. He/She expected residents' hair and beards to be kempt. CNAs are responsible for trimming the resident's nails unless the resident is diabetic; then the responsibility is on the nurse. 13. During an interview on 1/13/25 at 10:01 A.M., RN G said residents should receive showers or bed baths twice a week or when requested by a resident. Nurses on the hall were responsible for ensuring shower sheets are signed and checked off. Nursing staff could and should assist residents in bathing and hygiene activities. 14. During an interview on 1/13/26 at 9:56 A.M., Regional Nurse DD said CNAs were assigned daily showers and shower sheets should be completed for each resident. If a resident refused a shower, staff should document on the shower sheet, the resident should sign the shower sheet, and staff should also document in the progress notes of missed or refused showers. 15. During an interview on 1/13/26 at 2:31 P.M., the Director of Nursing (DON) said she expected resident nails to be trimmed and clean. She expected residents' hair and beards to be kempt and cut according to the resident's wants/needs. 16. During an interview on 1/13/25 at 1:41 P.M. the DON and Administrator said residents should receive bed baths or showers twice per week or when requested. Nursing staff were responsible for ensuring showers or bed baths are completed. The charge nurse assigned daily showers to the CNAs. The aides were responsible to complete the shower and document on the shower sheet. If a resident refused a shower, the aide should notify the nurse, and the nurse should document the refusal in the progress note. 2607380169863716986342712327

Based on observation, interview and record review, the facility failed to implement a resident centered activities program that incorporated the resident's interests, hobbies and cultural preferences for two residents (Resident #153 and Resident #166) who resided on The Loop. In addition, the facility failed to provide one-to-one activities for one resident (Resident #177) who was unable to participate in group activities. The sample was 47. The census was 166. Review of the facility's Activities policy, date last revised, 8/1/25, showed:-Policy: it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preference of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community;-Each resident's interest and needs will be assessed on a routine basis;-Activities may be conducted in different ways: Programs of activities to include a combination of large and small groups, one to one, and self-directed as the resident desires to attend;-A schedule of activities is posted in a prominent place in the facility;-Resident's are encouraged, but not mandated, to participate in scheduled activities;-Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs; These may include but are not limited to considerations for: Residents who engage in behaviors not conducive to a therapeutic home-like environment. Residents who exhibit behaviors that require a less stimulating environment. Residents who excessively seek attention from staff or peers. Residents that lack awareness of personal safety. Resident who has delusional and hallucinatory behavior that is stressful to themselves;-Staff will assist the residents to and from activities when necessary;-Activities can occur at any time and are not limited to formal activities provided by the activities staff and can include other facility staff members, volunteers, visitors, residents, and family members. 1. Review of Resident #153's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 10/7/25, showed:-Diagnoses included Alzheimer's disease, chronic kidney disease, major depressive disorder, and Parkinson's disease;-Moderately impaired cognition. During an interview on 1/9/26 at 9:43 A.M., the resident said there are not enough activities and he/she would like more to do. Observation at this time, showed the resident resided on The Loop. 2. Review of Resident #166's quarterly MDS, dated [DATE], showed:-Diagnoses included dementia, major depressive disorder, anxiety, and chronic kidney disease;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: The resident is very involved in activities. The resident enjoys trivia, bingo, church and helping out;-Goal: The resident will participate in activities of choice, including bingo, trivia, church, and helping out;-Interventions: Explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation. Invite/encourage the resident's family members to attend activities with resident, to support participation. During an interview on 1/7/26 at 7:08 A.M., the resident said there are not enough activities and he/she is bored most of the time. Observation at this time showed the resident resided on The Loop. 3. Review of the facility's January 2025, activities calendar, showed:-On 1/8/26: 9am country hits, 10am Bible study, 11am boardgames, 2pm trivia, 4:30pm movie;-On 1/9/26: 9am morning worship, 10am chair Zumba, 11am trivia, 2pm happy hour, 4:30pm movies;-On 1/12/26: 9am jazz inspiration, 10am chair Zumba, 11am LRC/Uno, 2pm poker, 4:30pm movie;-The activity calendar did not indicate the location of the activities. Observations on The Loop, showed no activities in progress:-On 1/8/26 at 11:05 A.M., at 1:33 P.M., and at 1:41 P.M.;-On 1/9/26 at 8:00 A.M., at 9:01 A.M., at 9:30 A.M., at 10:00 A.M., and at 10:30 A.M.;-On 1/12/26 at 9:04 A.M., at 9:30 A.M., and at 9:40 A.M. During an interview on 1/13/26 at 7:51 A.M., Certified Nursing Assistant (CNA) H said there are not enough activities on The Loop. Activity staff do not even take the residents off the hallway to do activities. The residents just sit around in the dining room all day. During an interview on 1/13/26 at 10:08 A.M., Licensed Practical Nurse (LPN) I said it depends on which activity aide comes to provide activities to The Loop on whether or not activities occur. He/She feels like more activities could be done and would be beneficial to the residents. During an interview on 1/13/26 at 2:40 P.M., the Administrator and the Director of Nursing (DON) said they would expect activities on The Loop to be meaningful and stimulate the residents. The activities in the hall need some work. 3. Review of Resident #177's, admission MDS, dated [DATE], showed:-Severe cognitive impairment;-It is very important for the resident to pick out his/her own clothing, listen to music he/she likes, to be around animal and pets, to do things with group of people, to do his/her favorite activities, to go outside and get fresh air when the weather is good, to participate in religious service or practices;-The primary respondent for the daily and activity preference: The resident. Review of the resident's medical record, showed diagnosis that included intellectual disabilities, dementia, Parkinsons disease, schizoaffective disorder (a mental disorder that causes disorganized thinking), muscle weakness, needs assistance with personal care, and cognitive communicative deficit, and bipolar disease (a mental disorder that causes extreme shifts in mood). Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has little to no interest in activities;-Interventions: Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary; Invite and encourage the resident's family members to attend activities with resident in order to support participation; Monitor and document impact of medical problems on activity level. Observation on 1/6/26 at 9:57 A.M., on 1/7/26 at 8:30 A.M., 9:04 A.M., 9:55 A.M., 10:24 A.M., and on 1/8/26 at approximately 9:00 A.M., showed the resident lay in bed with a green hospital gown on. The resident yelled very loudly and could be heard in the hallway. The resident's foot of his/her bed faced the door, and a privacy curtain was pulled to where the resident could not see out in the hall. The room was dark and the blinds on the window were closed. An activities calendar posted on the wall in the resident's room was dated December 2025. Review of the facility's one to one activities list, dated January 2026, did not list the resident. During an interview on 1/7/25 at 9:04 A.M. Speech Therapist (ST) F said the resident seems scared and anxious a lot of the time. The resident can answer some yes and no questions. During an interview on 1/8/26 at 8:45 A.M., Nurse Practitioner (NP) J said the resident would benefit from one-to-one activities due to his/her behaviors and anxiety. The resident should be placed in clothing other than a hospital gown and assisted out of bed and placed in the common area where the TV is. During an interview on 1/12/26 at 9:35 A.M., the Activities Director (AD) said she had never met the resident or assessed him/her for activities. Th AD is expected to do an assessment within 10 days of admission. For residents to meet the one-to-one criteria, the resident must be bed bound or if the resident requests it. One to one is good for residents exhibiting behaviors or anxiety that cannot participate in group. During an interview on 1/13/26 at 2:40 P.M., the Administrator and the DON said the resident is someone that should have been on one-to-one activities due to him/her yelling out and anxiety. 4. During the resident council interview on 1/8/26 at 1:30 P.M., residents said they stopped doing a lot of activities. They do chair yoga, but no one goes. One resident said he/she has therapy five times a week, so he/she did not want to do chair yoga. They used to play bingo four days a week, but it is now down to once a week. They used to give prizes, but now residents must draw a ticket for their prize. Other activities are watching The Price is Right and The Young and the Restless. The activities are not there anymore. The residents used to have happy hour, but the staff quit doing it every Friday. They changed it to every other Friday. Residents said activities like Country Hits were playing country music in the lobby and nothing else. Review of the activity calendar, dated 1/4/26 through 1/10/26, showed: -Chair Zumba was scheduled on 1/5/26, 1/7/26, and 1/9/26 at 10:00 A.M. -On 1/5/26 at 9:00 A.M., Jazz Inspiration was scheduled; -On 1/6/26 at 9:00 A.M., Classical music was scheduled;-On 1/7/26 at 9:00 A.M., R&B hits was scheduled;-On 1/8/26 at 9:00 A.M., Country hits was scheduled;-On 1/9/26 at 9:00 A.M., morning worship was scheduled;-On 1/20/26 at 9:00 A.M., Classical music was scheduled. 5. Observation of the activity calendar dated 1/9/26 at 9:00 A.M., showed morning worship. The Director of Activities said the residents are not in the chapel. For morning worship, he/she will play gospel music on his/her phone on the patio. 6. During an interview on 1/13/26 at 7:54 A.M., the Director of Activities said there are three activities aides. One aide goes downstairs on the Loop for activities and the other two are conducting activities in the main hall. He/She believed there are enough supplies for activities to do what is needed.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining dressing change orders for one resident that had a recent toe amputation (Resident #135) and by not changing one resident's leg wound dressing as scheduled and when it was saturated with fluid and dislodged (Resident #72). In addition, the facility failed to obtain a urinalysis (UA, a urine test to check for infection and obtain the results) as ordered for one resident (Resident # 3). The sample was 47. The census was 166.Review of the facility's Wound Treatment Management policy, revised, 9/1/25, showed:-Policy: To promote wound healing of various types of wounds. It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Policy explanation and compliance guidelines:-Wound treatments will be provide in accordance with physician order, including the cleansing method, type of dressing, and frequency of dressing change;-In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absences of the treatment nurse;-Dressing changes may be provided outside the frequency parameters in certain situations, including when the dressing has dislodged or the dressing is soiled or is wet;-Treatments will be documented on the treatment administration record (TAR). Review of the facility's Laboratory Services and Reporting policy, revised 8/1/25, showed:-Policy: The facility must provide or obtain services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law;-Policy explanation and compliance guidelines:-The facility must provide or obtain laboratory service sit meet the needs of its residents;-The facility is responsible of the timeliness of the services;-All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record;-Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that call outside the clinical reference range. 1. Review of Resident #135's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/25, showed:-admission date: 12/16/25;-Cognitively intact;-Diagnoses included peripheral vascular disease (PVD, a decreased blood flow in the legs cause by narrowed blood vessels) and diabetes. Review of the resident's care plan, in use at the time of survey, showed;-Focus: The resident has an infection to his/her left foot and ankle;-Intervention: Administer antibiotics as ordered. Review of the resident's electronic physician order sheet (ePOS), showed no orders for wound dressing changes to the resident's left foot from 12/16/25 to 1/5/26. Observation on 1/6/26 at 10:15 A.M., showed the resident sat on the side of the bed with a dressing on his/her left foot and ankle, and a tall surgical boot on his/her left foot. During an interview, the resident said he/she had all of his/her toes removed on his/her left foot due to osteomyelitis (bone infection). He/She always has to ask staff to change his/her dressing. During an interview on 1/6/26 at 11:30 A.M., Licensed Practical Nurse (LPN) C said there were no physician orders for the resident's foot dressing and that he/she changes it when the resident asks him/her to. LPN C said he/she will reach out to the physician to obtain orders. Review of the resident's medical record, showed an order, dated 1/6/26, start date, 1/7/26, for left foot, cleanse toes with wound cleaner, apply abdominal pad (a type of dressing), and wrap with Kerlix (a specialized wrap dressing) every two days. Observation on 1/8/26 at 1:17 P.M., showed the resident sat on the side of the bed with a leg and foot brace on. The resident removed his/her leg and foot brace. His/Her left foot was wrapped with Kerlix and Coban dressing (a specialized wrap) and dated 1/3/26. During an interview on 1/13/26 at 2:40 P.M., the Director of Nurses (DON) said she expected the staff to have reached out to the surgeon to get orders for dressing changes for the resident's foot and not to just ask the resident. 2. Review of Resident #72's medical record, showed:-admission date: 12/15/25;-Diagnoses included cellulitis (skin infection) of left lower limb and lymphedema (swelling of the extremities);-A physician order, dated 12/24/25, to cleanse left calf with normal saline or wound cleanser, apply methylene blue (a specialized dressing) foam and cover with abdominal pads, wrap with gauze roll and secure with tape, Change three times a week and as needed (PRN) if saturated, soiled or dislodged. Review of the resident's admission MDS, dated [DATE], showed the resident cognitively intact. Review of the resident's care plan, in use at the time of survey, showed;-Focus: The resident has potential for impairment to skin integrity related to lymphedema;-Intervention: Weekly treatment documentation to include measurement of skin breakdown. Review of the resident's medical record, showed:-On 1/12/26, the resident's calf dressing change not documented as completed as scheduled;-No PRN dressing changes documented as completed from 1/10/26 through 1/12/26. Observation on 1/12/26 at approximately 8:30 A.M., showed the resident in a recliner chair with his/her left leg exposed. An undated dressing on the resident's leg, saturated with serous (yellow fluid), with the dressing wrap falling off the resident's leg. A bed pad was located on the floor underneath the resident's left foot. During an interview, the resident said his/her dressing was leaking so bad that he/she placed a bed pad underneath his/her foot to contain the moisture. His/Her dressing had been wet for the last two days. Observation on 1/13/26 at 9:32 A.M., showed the resident in a recliner chair with his/her left leg exposed. An undated dressing on the resident's leg, saturated with serous drainage, with the dressing wrap falling off the resident. A pillowcase underneath the resident's left foot with rings of yellow serous drainage on it. During an interview, the resident said he/she replaced the bed pad underneath his/her foot with a pillowcase because the bed pad was wet with drainage. During an interview on 1/13/26 at 11:39 A.M., Registered Nurse (RN) G said staff should complete all treatments and wound care before leaving their shift. If a resident's dressing is soiled or loose, the nurse should change the dressing. Dressing change orders need to be obtained on admission and staff should not wait for the resident to request their dressing to be changed. During an interview on 1/13/26 at 9:45 A.M., Regional Resource Nurse B said it is expected that staff change the dressing when it is scheduled and as needed, including when it is wet or dislodged. During an interview on 1/13/26 at 11:16 A.M., Wound Physician II said he/she expected staff to change the dressings when ordered and as needed. 3. Review of the Resident #3's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included anemia, heart failure, hypertension (high blood pressure), orthostatic hypotension (low blood pressure), renal failure, diabetes, hyponatremia (electrolyte imbalance), non-Alzheimer's dementia, anxiety, depression, post-traumatic stress disorder, and asthma;-Required partial/moderate assistance with toileting hygiene;-Occasionally incontinent with bladder. Review of the resident's care plan, in use during survey, showed:-Focus: Resident has an Activities of Daily Living (ADL) self-care performance deficit related to small bowel obstruction (SBO) and hypotension;-Intervention: Staff intervention to the extent needed to accomplish task;-Focus: Resident has an ADL self-care performance deficit limited mobility;-Interventions: Personal hygiene: Supervision/touch assist for personal hygiene. Partial/moderate assistance for toilet hygiene. Review of the resident's ePOS, showed:-An order, dated 1/6/26, for please obtain STAT (immediately) UA with reflex (automatically performing a second test on the same patient sample when the initial test yields a specific result) to culture;-An order, dated 1/7/26, for please obtain STAT UA with reflex to culture. Observation on 1/8/26 at 4:20 P.M., showed the resident in bed. During an interview, the resident said he/she had not completed a urine test yet. He/She was verbally unable to explain the reason. When asked if there was pain and if there is pain during urinating, the resident said yes. He/She denied blood in the urine. He/She had been in pain for weeks. He/She had not urinated today. During an interview on 1/8/26 at 4:23 P.M., LPN AA said they had not obtained urine from the resident. The resident is not refusing: it was just not obtained. The resident had only been to the bathroom once since he/she had been here. Further review of the resident's ePOS, showed:-An order, dated 1/9/26, for comprehensive metabolic panel (CMP, routine blood test), complete blood count (CBC, blood test that analyzes white and red blood cells and platelets) culture, urine one time only. A note showed, Send to lab on 1/9/26 2:02 P.M. Central time);-An order, dated 1/9/26, for CMP, CBC culture, urine one time only. A note showed, Waiting to be sent. During an interview on 1/9/26 at 8:22 A.M., the resident said he/she did not give a urine sample. He/She did not have pain when urinating; however, he/she had lower abdomen pain that made it feel like he/she had to urinate, but he/she did not. During an interview on 1/9/26 at 9:42 A.M., LPN S said he/she was in the process of putting in the resident's labs right now. The resident was supposed to get lab work today. LPN S was in the process of collecting it now. They notified the doctor that they did not collect the resident's urine. Normally a STAT UA should come with orders to straight catheterize (insert a catheter into the bladder to drain urine), if necessary. That is what LPN S would have done. Observation on 1/9/26 at 12:06 P.M., showed a lab tech from a lab company entered the resident's room. The resident was overheard saying, I just went, as the lab tech entered and closed the door. At 12:15 P.M., the lab tech exited the resident's room and left the unit. During an interview on 1/12/26 at 11:54 A.M., the resident said he/she had pain during urination, but it is at night when trying to sleep. He/She continued to have pain to the lower left abdomen.Review of the resident's acute care note, dated 1/12/26, showed:-History: Following up on the patient, ordered UA on Monday;--Was advised patient still pending UA 2/2 needing a hat;---Advised on straight catheterization if it takes more time;-Assessment/plan: Frequency of micturition (frequency of urination). Will check urine for infection and empiric (initial antibiotics to treat a suspected bacterial infection before the specific germ is identified) antibiotic if symptoms worse/continue. Review of the resident's UA results, dated 1/12/26, showed:-Please indicate urine source: Urine - clean catch;-Report date/time: 1/12/26 at 4:09 P.M.;-Culture Observation: Urogenital flora (normal bacteria from the genital area that contaminated the sample) isolated. No further testing performed. Further review of the resident's ePOS, showed:-An order, dated 1/11/26, for sodium chloride solution (saline) 0.9%, use 50 milliliters (ml.) per (/) hour (hr.) intravenously (IV, into the vein) one time a day for hyponatremia for one day;-An order, dated 1/11/26, for place an IV for IVF (intravenous fluids);-An order, dated 1/12/26, for IV peripheral - type 22 gauge (diameter of catheter), location in right antecubital fossa (AC, crease of inner elbow) one time only for two days;-An order, dated 1/12/26, for IV peripheral flush with 10 ml. saline before and after medication infusion (use 10 ml. syringe) every shift for two days until finished. During an interview on 1/13/26 at 10:44 P.M., LPN S said the resident's UA was completed, but he/she was unable to see results. The blood work came back and the resident's sodium level was low. The physician was here and ordered sodium chloride. Staff went into the emergency kit and pulled all of what was needed for the order. The resident received the sodium chloride yesterday. During an interview on 1/13/26 at 12:37 P.M., the DON said there was a UA completed on the resident, but she was unable to log into the system to check the results. If staff could obtain urine from a resident as ordered by the physician, she expected staff to notify the physician within 24 hours. If staff were unable to obtain a urine sample, she expected staff to relay the information to the next shift, so they can obtain the sample. She was not aware of the resident's hydration issues. At 1:50 P.M., the DON said staff should notify the Nurse Practitioner if labs were missed. 2702576

Based on observation, interview, and record review, the facility failed to ensure four of 47 sampled residents received foot care and were on the podiatry list as needed (Residents #133, #72, #69 and #177). The census was 166. Review of the facility's activities of daily living (ADL) policy, dated 9/1/25, showed:-Policy: the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #133's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/25, showed:-Cognitively intact;-The resident requires maximum assistance with bathing, lower body dressing, personal hygiene, and putting on and taking off footwear. Review of the resident's medical record, showed diagnoses that included cirrhosis of the liver (hardening of the liver resulting in dysfunction), left humerus (upper arm bone) fracture and difficulty walking. Observation and interview on 1/12/26 at 8:50 A.M., showed the resident lay in bed. The resident exposed his/her feet by pulling the bed sheet up. Both of the resident's feet appeared extremely dry, both of his/her big toes had nail polish chipped off. The resident's toenails on both feet were approximately half an inch long and appeared thick and jagged. The resident said he/she is a diabetic and normally goes to the salon to get a pedicure (nail care). The resident was tearful and said his/her toenails look like eagle talons. No staff member has provided any foot care and the resident was not aware that a podiatrist (foot doctor) visited the building. Review of the facility's podiatrist list dated 1/7/26, showed the resident not listed. 2. Review of Resident #72's admission MDS, dated [DATE], showed:-Cognitively intact;-The resident required supervision or touching assistance with bathing, lower body dressing, personal hygiene and putting on and taking off footwear. Review of the resident's medical record, showed diagnoses included cellulitis (skin infection) of the left lower limb and lymphedema (swelling of extremities). Observation and interview on 1/6/26 at approximately 10:00 A.M. and 1/7/26 at 1:28 P.M., showed the resident sat in his/her recliner in his/her room. The resident's feet were exposed. Both of the resident's feet had gray thick toenails that curled under approximately half an inch. The resident said he/she was so embarrassed and wished he/she could receive some foot care. Observation and interview on 1/13/26 at 10:05 A.M., showed the resident sat in his/her recliner in his/her room. The resident's feet were exposed. Both of the resident's feet had gray thick toenails that curled under approximately half an inch. Regional Resource Nurse B examined the resident's feet and said that the resident needed his/her toenails trimmed and that since the resident was not diabetic the nurse could trim and file the resident's toenails. Review of the facility's podiatrist list dated 1/7/26, showed the resident not listed. 3. Review of Resident #69's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition;-Dependent on staff for dressing his/her lower body. Observation on 1/8/26 at 11:06 A.M., showed the resident sat in his/her wheelchair in his/her room. His/Her left foot had thick yellow toenails. The heel and ball of the resident's left foot had peeled dry skin. The resident's right foot had thick yellow toenails at various lengths. The heel and ball of the resident's right foot had peeled dry skin. Review of the facility's podiatrist list dated 1/7/26, showed the resident not listed. 4. Review of Resident #177's admission MDS, dated [DATE], showed:-Severe cognitive impairment;-Dependent on staff for bathing, lower body dressing, personal hygiene and putting on and taking off footwear. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has actual skin impairment due to immobility;-Plan: Use lotion on dry skin. Review of the resident's medical record, showed diagnoses included dementia, muscle weakness, intellectual disabilities, and difficulty walking. Observation on 1/7/26 at 9:04 A.M., showed the resident lay in bed. Physical Therapy Assistant (PTA) E and Speech Therapist (ST) F removed the resident's socks. The resident's right heel appeared dry and peeled. Both of the resident's feet were extremely dry and flakes of skin fell off when the resident's socks were removed. Review of the facility's podiatrist list dated 1/7/26, showed the resident not listed. 5. During an interview on 1/13/26 at 11:39 A.M., Registered Nurse (RN) G said if the resident needs to be seen by the podiatrist, social services is informed and will place the resident on the podiatry list. Nurses normally do not trim toenails and will refer the resident to the podiatrist. Lotion can be applied to the resident's feet on their shower days and as needed. 6. During an interview on 1/13/26 at 2:32 P.M., the Director of Nursing (DON) and Administrator said they would expect residents to be on the list to see the podiatrist if they have skin/nail concerns or are diabetic. They would expect non-diabetic patients to have their nails trimmed by the nurse. They would expect dry skin to be treated.

Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (tube that drains the urine from the bladder) had physician orders to include catheter care instructions, for two of three residents sampled with indwelling urinary catheters (Residents #182 and #10). The facility identified 12 residents with indwelling urinary catheters. The sample was 47. The census was 166.Review of the facility's Catheter Care policy, revised 8/1/25, showed:-It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;-Catheter care will be performed every shift and as needed by nursing personnel;-Empty drainage bags when bag is half-full or every three to six hours;-Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Review of Resident #10's electronic Physician's Orders Sheet (ePOS), dated November 2025, showed:-An order dated 11/22/25, to discontinue order for change foley catheter and drainage bag monthly and as needed (PRN);-An order dated 11/22/25, to discontinue order for catheter care;-An order dated 11/22/25, to discontinue order for catheter to remain covered for privacy every shift. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/25, showed:-Mild cognitive impairment;-Diagnoses included high blood pressure, kidney failure, and neurogenic bladder (lack of bladder control);-Used a wheelchair;-Limitation in range of motion: Impairment on both sides of the lower extremity;-Required substantial/maximal assistance with toileting hygiene;-Indwelling urinary catheter. Review of the resident's care plan, in use during survey, showed:-Focus: Resident has a Foley catheter (brand of indwelling urinary catheter) related to bilateral (both sides) lower extremity amputation and skin impairment;-Goal: Resident will remain free from catheter-related trauma;-Interventions: Provide catheter care every shift. Observation on 1/6/26 at 12:21 P.M., 1/7/26 at 12:42 P.M., 1/8/26 at 1:30 P.M., and 1/9/26 at 8:30 A.M., showed the resident in his/her electric wheelchair. The catheter positioned on the right side of his/her wheelchair. The catheter drainage bag hung on the right arm rest of the wheelchair. Review of the resident's ePOS, dated January 2026, showed:-An order, dated 11/25/25, Foley catheter to gravity drain. Catheter size 16 Fr. (size) Balloon size 30 milliliter.-An order, dated 1/6/26, catheter care every shift; -An order, dated 1/6/26, change catheter anchor weekly and as needed if soiled;-An order, dated 1/6/26, Foley catheter to leg bag when out of bed if ambulatory. During an interview on 1/13/26 at 12:37 P.M. and 1:50 P.M., the Director of Nursing (DON) said they recently went through an auditing process so she was not sure if the orders for catheter care was changed or if it was caught during the auditing process. Catheter orders and care orders are expected to be in the POS at the time of re-admission. 2. Review of Resident #182's medical record, showed diagnoses included benign prostatic hyperplasia (an enlarged prostate gland that causes difficulty in urination) with lower urinary tract symptoms. Review of the resident's care plan, in use while the resident was admitted to the facility, showed:-Focus: The resident has a urinary catheter;-Plan: Provide catheter care every shift. Review of the resident's physician order sheets dated, 12/31/25 through 1/3/26, showed no order related to urinary catheter care. During an on 1/13/26 at 11:39 A.M., Registered Nurse (RN) G said all residents that have urinary catheters are expected to have orders for catheter care. During an interview on 1/13/26 at 2:40 P.M., the DON said she would expect staff to place catheter care orders on all the residents that have catheters. She would expect the orders to be placed on admission. 2713484

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 47. The facility census was 166.Review of the facility's 2025 QAPI Plan, showed:-Establish a facility-wide process to identify opportunities of improvement through continuous attention to quality of care, quality of life and resident safety;-Address gaps in systems or processes;-Ensure adequate provision of staffing, time, equipment and technical training resources;-Establish clear expectations around safety, quality, rights, choice and respect;-Continually improve the quality of care and services provided to our residents;-The facility conducts performance improvement plans (PIPs) to examine and improve care and/or services in specifically identified areas. PIPs are chosen based upon their importance and meaningfulness, in relation to the scope of services provided by the facility. The focus is on preventing problems and improving current systems and services. The facility seeks to prioritize projects in high risk, high frequency and/or problem prone areas that impact quality of care and quality of life for our residents and conducts one improvement project annually based on these areas;-Clinical data elements to monitor may include, but are not limited to falls, medication errors, polypharmacy, pressure injuries, infections, vaccination compliance, nutrition, physical/chemical restraints, unplanned hospitalizations, unexpected deaths, dementia care, abuse/neglect, and decline in functional status. Organizational data elements to monitor may include, but are not limited to, safety-related events, employee illnesses, functional status of alarms (such as door, fire, bed/chair, etc.), staff retention, regulatory survey outcomes, laundry services, dietary services, environmental services, recreational programming, staff education/training, employee immunization, and criminal background checks. During an interview on 1/12/26 at 12:37 P.M., the Administrator and Director of Nursing (DON) said they pull data in metrics to determine areas of concern. If there is a need for interventions for residents returning to the hospital, meal timeliness, and wounds, the facility will come up with interventions to increase a better outcome. They have not completed their QAPI for the month of December 2025, so until November 2025, they had not identified issues with obtaining labs timely. It had been a while since obtaining weights were discussed. A PIP was implemented to obtain weights upon admission and re-admission. They do not discuss showers in QAPI; it comes up in resident council or grievance process. Residents administered antibiotics are discussed during the clinical meeting or weekly risk meetings. The clinical team reviews the orders in the morning to ensure residents with orders from the hospital are followed. They did not identify pharmacy issues such as ordering medications timely. The DON said medications should be ordered before the medication runs out. During an interview on 1/13/26 at 1:50 P.M., the DON said she attended one QAPI meeting, at the end of December 2025. To her knowledge, re-ordering medication timely and pharmacy issues had not been identified as a concern. During her own audit, the DON identified there were concerns and did an in-service on 12/22/25 regarding documentation of medication on orders, steps needed to notify the pharmacy, and documenting in the medication administration record (MAR). Issues with ordering medication for residents re-admitted from the hospital was not identified. There were no issues regarding obtaining resident weights during the QAPI meeting. Showers and antibiotic issues were not identified as a concern.

Based on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain weights as ordered for two residents (Residents #175 and #177). The facility also failed to ensure physician's orders for hemodialysis (a life sustaining treatment for kidney failure that removes waste and extra fluids from the blood) assessments were obtained for one resident out of three residents sampled for hemodialysis (Resident #5). The sample was 47. The census was 166. Review of the facility's Weight Monitoring policy, revised 9/1/25, showed:-Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Compliance guidelines: Weights should be recorded at the time obtained. Newly admitted residents are to be monitored weekly for four weeks. If clinically indicated, monitor weekly or daily as recommended by the dietician or physician. Review of the facility's Dialysis policy, revised 3/15/24, showed:-Guideline: Care required when a resident's disease trajectory requires hemodialysis may exceed the usual interventions provided to residents in long-term care setting. The following information will provide addition direction in assessment, planning, and provision of care to our residents requiring hemodialysis;-Post-dialysis protocol: Review transfer forms or user defined assessment documents for any pertinent information;-Remove fistula/graft-dressing evening of dialysis treatment or as instructed by dialysis center or physician order;-Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula). This must be done daily, best after dressing is removed. If you do not feel a pulse or hear a bruit, check again by placing your fingers gently over fistula and check for a thrill. Call thedialysis unit immediately. If the unit is closed, call the physician;-Daily fistula/graft check: Check for any signs of infection daily, these may appear as: redness, hardness, swelling pain, drainage, and elevated temperature and body chills. Call physician promptly;-Documentation on treatment sheets includes fistula checks daily and monitoring for presence of bruit and thrill;-Checks for signs/symptoms of infection daily. 1. Review of Resident #175's medical record, showed:-admission date 12/23/25;-Diagnosis included moderate protein calorie malnutrition (poor nutrition), dementia, seizures, and muscle weakness;-An order, dated 12/23/25, for weekly weights from admission for four weeks, then monthly. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a nutritional problem or potential nutritional problem, moderate protein malnutrition and dysphagia (difficulty swallowing);-Interventions: Monitor weight as indicated. Review of the resident's weights, dated 12/23/25 through 1/12/26, showed:-On 12/26/25: 92.6 pounds (lbs.);-On 1/6/26: 89.2 lbs.;-No admission weight noted. 2. Review of Resident #177's medical record, showed:-Initial admission date 12/16/25;-discharge date [DATE];-readmission date 12/25/25;-Diagnosis included, dementia, muscle weakness, intellectual disabilities, schizoaffective disorder (mood disorder), moderate protein calorie malnutrition, dysphagia (difficulty swallowing), and difficulty walking;-An order, dated 12/16/25, for weekly weights from admission for four weeks, then monthly. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a nutritional problem or potential nutrition problem;-Goal: The resident will maintain adequate nutrition status as evidence of maintaining weight;-Plan: Provide and serve diet as ordered. Review of the resident's weights, dated 12/16/25 through 1/8/25, showed:-On 12/16/25: 141.0 lbs.;-On 1/6/26: 109.4 lbs.;-On 1/8/26: 119.4 lbs.;-No readmission weight from 12/25/25 noted. 3. During an interview on 1/8/26 at 8:35 A.M., Nurse Practitioner (NP) J said he/she expected residents to be weighed on admission and when re-admitted from the hospital, especially when they have a malnutrition diagnosis. He/She expected the resident to be weighed weekly from the admission date. During an interview on 1/13/26 at 9:42 A.M., Licensed Practical Nurse (LPN) K said it is a nursing team effort to get the weights on residents. Everyone is responsible for getting weights. Weights are to be completed on admission and then weekly for four weeks. The resident should be weighed when they return from the hospital to get a new baseline. During an interview on 1/13/26 at 2:40 P.M., the Director of Nursing (DON) said she expected staff to follow physician orders and obtain resident weights on admission and weekly for four weeks. She expected the residents to be weighed when readmitted from the hospital. 4. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/25, showed:-Cognitively intact;-Diagnoses include anemia, heart failure, high blood pressure, kidney failure, diabetes, hyperlipidemia, anxiety, depression, bipolar, and asthma;-Dialysis received. Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident receives dialysis related to chronic kidney failure;-Goal: Resident will have minimized risk of complications related to dialysis;-Interventions included:--Check and change dressing daily at access site as ordered;--Monitor vital signs before and after dialysis. Notify physician of abnormalities;--Monitor/document/report new/worsening edema, weight gain;--Monitor/document/report as needed (PRN) any signs and symptoms of infection to access site: redness, swelling, warmth or drainage;--Monitor/document/report signs and symptoms of renal insufficiency. Review of the resident's Physician Order Sheet (POS), dated January 2026, showed:-An order, dated 9/6/25, for renal (kidney) care on Mondays, Wednesdays, and Fridays (chair time 8:25 A.M.);-An order, dated 10/16/25, to ensure dialysis dressing remains clean, dry, intact every shift, notify dialysis if not;-An order, dated 1/6/26, to monitor access site for bruising, bleeding and signs and symptoms of infection. If bleeding noted, apply direct pressure until bleeding is controlled and notify physician for further directions every shift for monitoring. Document progress note for any observed signs and symptoms of bruising, bleeding, and/or infections and notification of physician;-An order, dated 1/6/26, to assess dialysis site for thrill and bruit every shift for monitoring;-Review of the resident's order history showed no physician's orders to monitor assess site and assess dialysis site for thrill and bruit prior to 1/6/26. During an interview on 1/6/26 at 11:19 A.M. the resident said he/she goes to dialysis on Monday, Wednesday, and Friday at 5:00 A.M. He/She returns at 11:00 A.M. During an interview on 1/12/26 at 11:57 A.M., the resident said he/she returned from dialysis. Staff do not complete assessments on him/her after dialysis. They have never checked his/her bruit and thill. During an interview on 1/13/26 at 12:37 P.M., the DON said she expected the resident to have physician's orders to assess the resident's dialysis site and bruit and thill and for nursing staff to complete it. She was not sure why it was not ordered until 1/6/26, if it was previously discontinued or if something was caught during the auditing process. 2698569

Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when facility staff left medication in one resident's room (Resident #135), who did not have a physician order for self-administration or medications to be left at the bedside. The sample was 47. The census was 166.Review of the facility's Resident Self Administration of Medications policy, last revised, 8/1/25, showed;-Policy: It is the policy of this facility to support each resident's right to self-administer medication; a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely;-Policy explanation and Compliance Guidelines: -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: -The medications appropriate and safe for self-administration; -The resident's physical capacity to swallow without difficulty, open medication bottles, administer injections; -The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; -The resident's capability to follow directions and tell time to know when medications need to be taken; -The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff; -The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs; -The resident's ability to ensure that medication is stored safely and securely; -The results of the interdisciplinary team assessment are recorded for the medication self-administration assessment form, which is placed in the resident's medical record; -Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the medication administration record (MAR); -All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Review of the Resident #135's physician order sheets dated, 1/7/26, showed:-An order dated, 12/16/25, Ofloxacin Ophthalmic solution 0.3% (eye medication to treat eye infections); one drop to both eyes four times a day for cataracts (cloudy film over eyes that is surgically removed);-An order dated, 12/17/25, Ketorolac Tromethamine solution 0.5 % (eye medication to treat inflammation and pain); one drop to both eyes four times a day for cataract;-An order dated, 12/17/25, Prednisolone acetate ophthalmic suspension 1 % (eye medication to treat inflammation); one drop to both eyes four times a day for cataract.-No order for self-administration of eye drops or that the eye medications can be left a bedside. Review of the resident medical record showed a no self-administration assessment completed. Observations on 1/6/26 at 10:15 A.M., 1/8/26 at 1:17 P.M. and 1/12/26 at 8:30 A.M., showed the resident had three eye drop bottles on his/her bedside table. The eye drops were Ofloxacin, Ketorolac, and Prednisolone. During an interview on 1/6/26 at 10:15 A.M., the resident said he/she administers the eye medications him/herself. During an interview on 1/13/26 at 11:39 A.M., Registered Nurse (RN) G said residents who want to administer their own medication need to be assessed by management to determine if they are safe and competent enough to do so. The assessment would be located in the medical record, and a physician order needs to be obtained stating that resident may self-administer medications and medications may be left at bedside. During an interview on 1/13/26 at 2:40 P.M., the Director of Nursing (DON) said she would expect staff to complete a self-administration assessment and obtain an order that the resident could self-administer the eye medication, and that the medication could be left at the bedside.

Based on interview and record review, the facility failed to ensure bed hold notices were provided for two of four residents investigated for discharge (Residents #166 and #177). The sample was 47. The census was 166. Review of the facility's Bed Hold Notice Upon Transfer policy, dated 8/1/25, showed:-Policy: at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed;-The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1. Review of Resident #166's medical record, showed: -Discharge to the hospital on [DATE];-No filled out and signed bed hold notice provided by the facility for the date of 10/16/25. 2. Review of Resident #177's, medical record, showed:-Discharge to the hospital on [DATE];-No filled out and signed bed hold notice provided by the facility for the date of 12/22/25. 3. During an interview on 1/13/26 at approximately 10:30 A.M., Licensed Practical Nurse (LPN) K, said the nurse discharging the resident should specifically document on the form whom they spoke with regarding the resident's discharge and the bed hold policy. The reason for the discharge should also be filled in on the bed hold form. The bed hold form should be completed in its entirety. 4. During an interview on 1/13/26 at 2:46 P.M., the Administrator said he would expect bed holds to be given to the resident or resident's representative before the resident leaves the facility. He would expect the form to be filled out and signed.

Based on observation, interview and record review, the facility failed to ensure resident care plans included revisions to address individual care needs for two of 47 sampled residents, when the facility included incorrect information about diet orders and code status on resident care plans (Residents #12 and #143). The facility census was 166.Review of the facility's Care Planning - Resident Participation Policy, revised 8/1/25, showed:-The care planning process should include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care;-The facility will encourage and assist the resident and/or representative to participate in choosing care and treatment options including: initial decisions about treatment, decisions about changes in treatment, and the right to refuse treatment;-If participation of the resident or resident's representative is determined not practicable for the development of a resident's care plan, an explanation will be documented in the resident's medical record. 1. Review of Resident #12's most recent quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/18/25, showed:-An admission date of 3/10/23;-The resident has some cognitive impairment;-Medical diagnoses included: Diabetes, Chronic Kidney Disease (CKD, a condition that involves impairment of the kidneys' ability to filter toxins from the blood), atherosclerotic heart disease (impairment of the myocardium caused by a blockage of the arteries), and heart failure. Observation of the 3rd Floor Terrace Code Status book on 1/7/26 at 10:18 A.M. showed a three-ring binder with copies of code statuses for residents on the hall. A Do Not Resuscitate (DNR, an advanced directive indicating life saving measures should be withheld in the event of a change in condition) code status signed by the resident's representative on 11/4/25 and signed by the hospice physician on 11/5/25, located in the code status book. Review of the resident's medical record, showed:-An active physician order for full code placed in the medical record on 11/3/25;-A scanned copy of the resident's DNR order;-A running ribbon at the top of the electronic medical record, included the resident's date of birth , physician, allergies and code status, which showed the resident was a full code. Review of the resident's care plan, in use at the time of survey, showed a focus that the resident was a full code. Interventions included ensuring the resident's advanced directives wishes were honored, and the resident had completed a full code directive. 2. Review of Resident #143's most recent quarterly MDS, dated [DATE], showed:-An admission date of 7/15/25;-The resident has no cognitive impairment;-Medical diagnoses including gastrostomy placement (a surgical opening into the stomach used to administer nutrition and/or medications), history of sepsis (a potentially fatal infection in the bloodstream), congestive heart failure (CHF, a condition in which the lower chambers of the heart do not pump blood adequately to the rest of the body), and dysphagia (difficulty swallowing). Observation and interview on 1/6/26 at 9:42 A.M., showed the resident resting in bed with a hospital gown on. The resident stated he/she received a pureed order for breakfast. During an interview on 1/9/26 at 12:43 P.M., the resident said he/she was received a pureed texture lunch meal. Observation on 1/12/26 at 9:05 A.M., showed the resident had a pureed texture breakfast meal on his/her meal tray. Review of the resident's care plan, in use at the time of survey, showed:-A focus that the resident is at risk of aspiration due to noncompliance with NPO (nothing by mouth) status. Interventions included the resident had signed a risk acknowledgment form and was educated regarding the risks and benefits of an NPO diet status;-A focus that the resident requires tube feeding for nutrition. Interventions included checking for feeding tube placement, keeping the head of the bed elevated, and a quarterly consult from the Registered Dietician;-No further mention of the resident's diet orders or nutritional needs. Review of the resident's active physician orders, showed:-An active order for regular diet, pureed texture, placed on 12/17/2025;-An order for the resident to be NPO after midnight on 2/9/26;-No active order for tube feeding. 3. During an interview on 1/13/26 at 9:51 A.M. Certified Nursing Assistant (CNA) L and Certified Medication Technician (CMT) N said care plans designed for residents should be individualized to each resident's needs. Diet orders should be included and accurate so front line care staff know which residents will require additional supervision or assistance with meals. Care plans should include active and accurate code status orders, as all code status orders in the medical record should be accurate in all areas of the record. 4. During an interview on 1/13/26 at 10:01 A.M. Registered Nurse (RN) G said care plans were designed on an individual basis to treat each resident's specific needs. Diet orders should be accurate so that the aides know which residents require assistance. Code status orders should be accurate and match in each part of the resident's medical record. 5. During an interview on 1/13/26 at 1:41 P.M. the facility Director of Nursing (DON) and Administrator said care plans should be individualized to each resident's needs so that staff are able to appropriately care for a resident. The facility DON did not know the answer as to whether or not diet orders should be included in a resident's care plan. The DON and Administrator said they would expect code status orders to be reflected accurately in each resident's care plan.

Based on observation, interview and record review, the facility failed to ensure staff attempted to communicate with a resident, who was non-English dominate speaking resident, in in a form and manner that the resident can understand. The facility did not provide an activity calendar in his/her dominate language, a communication board, or use a translation application to communicate with the resident (Resident #176). The sample was 47. The census was 166.Review of the facility's Culturally Competent Care policy, revised 4/23/25, showed:-Policy: to provide culturally competent care in accordance with professional standards of practice. The facility has established a culture that treats each resident with respect and dignity as an individual, as well as addresses, supports and/or enhances his/her feelings of self-worth including personal control over choices and cultural preference;-Effective communication: describes a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand;-Language assistance services is defined as language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. This may include oral interpretation, written language translation, or both;-The facility will use the facility assessment to identify resident populations having unique cultural characteristics, such as language (including American Sign Language), religious or cultural practices, values, and preferences;-If the resident is non-English speaking, the facility will identify how communication will occur with the resident. If indicated, language assistance services will be arranged for the resident. The care plan will identify the language spoken and tools used to communicate;-If communication systems are used, all staff interacting with the resident will know where those materials are kept, will understand how to use them, and consistently implement use of those methods. Staff will demonstrate proficiency in communicating with the resident to assure that critical information can be conveyed, such as a change in condition, the presence of pain, explanation of routine care, and the ability to refuse care and services;-Resident-specific approaches will be developed and included in the resident's care plan. These interventions will be provided consistently, and supervising staff will monitor the delivery of care and staff interactions with the resident to assure they are implemented as written;-Residents will be informed in a language they can understand of their total health status, and will be provided notice of rights and services both orally and in writing in a language that they understand. This may involve facility staff evaluating how forms, including informed consent forms, are provided in the language used by the resident. Review of the Facility Assessment, dated 7/10/25, showed:-Ethnic, cultural or religious factors: the facility respects ethnic, cultural or religious factors and/or personal resident preferences that may potentially affect the care provided to residents. Examples include activities, food and nutrition services, languages, clothing preferences, access to religious services or religious-based advanced directives. The facility evaluates residents upon admission and periodically throughout the stay to determine any changes needed to maintain and/or improve socialization and overall physical, emotional, and spiritual well-being. Cultural, ethnic and spiritual preferences are heavily considered when integrating and/or developing facility programming and services;-Languages: use communication boards and Google translator to meet the needs of the resident;-Provide person centered directed care including psychosocial, spiritual support: the staff strive to develop a rapport with residents and families to understand the preferences. This allows the facility staff to determine preferences and routines, triggers, and recovery methods. This information will be incorporated into the care plan to ensure staff caring the resident understand and are aware of necessary treatment and care preferences. Staff will provide culturally competent care, learn about the residents' preferences and practices, including about their culture and religion. Staff will remain open to requests and preferences and work to support those as appropriate. Staff will provide or support access to religious and spiritual preferences, as well as provide opportunities for social activities/life enrichment. Review of Resident #176's medical record, showed diagnoses included irregular heartbeat, altered mental status, protein calorie malnutrition, diabetes and muscle weakness; Review of the resident's hospital Discharge summary, dated [DATE], showed:-admitted following a change in condition. Patient received fluids for dehydration, and nutritional support;-Patient is Cantonese speaking, video translator used and able to obtain some response to questions;-Patient non-English speaking, long term care staff stated this is patient's baseline. Hospital staff left a message for patient daughter. Review of the resident's care plan, revised 1/6/26, showed:-Focus: The resident is sometimes understood and sometimes understands;-Goal: Needs will be met on a daily basis;-Interventions: Communication: allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face the resident when speaking and make eye contact, turn off the TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple brief words/cues, and use alternative communication tools as needed;-The care plan did not direct staff on how to communicate with the resident in a form and manner that the resident can access and understand. Observation on 1/6/25 at 10:15 A.M. and on 1/7/26 at 7:15 A.M. and 1:44 P.M., showed the resident's room noted to have a green Budda figurine and bamboo greenery on the bedside table. A facility February activity calendar in English text was present. Observation and interview on 1/8/26 at 10:15 A.M., showed the resident asleep in his/her bed. Certified Medication Technician (CMT) Z approached the resident's doorway with the medication cart. CMT Z entered the resident's room and said to the resident time to get up, sit on the side of the bed to take your medications. CMT Z obtained the resident's medication from the medication cart as the resident stood in the doorway. CMT Z administered the resident the medication and handed the resident his/her liquid nutritional supplement and told the resident drink. The resident entered his/her room and placed the supplement on the desk. CMT Z said the resident can understand some English. The resident does not have a communication board available. CMT Z had not attempted to use Google translate to explain medications or care to the resident. During an interview on 1/8/26 at 10:38 A.M., the resident sat at a table in the third-floor main dining room. The surveyor used a translation application to converse with the resident. The resident said the staff do not use a communication board to explain things to him/her. Staff point to items, or he/she would use hand gestures to understand. He/She enjoyed talking with the surveyor using the translation application because he/she could hear and read the Cantonese language. He/She cannot read the activity calendar in his/her room. Staff have called his/her family to explain care. During an interview on 1/8/26 at 1:13 P.M., Licensed Practical Nurse (LPN) AA said staff used hand gestures to communicate with the resident. He/She had not received training on the resident's dominate language, communication boards or the need for Google translate. During an interview on 1/13/26 at 1:50 P.M., the Administrator and Director of Nursing (DON) said a resident's language preferences should be assessed by nursing and social services at admission. Staff should use a communication board and/or translation application to communicate with non-English dominate speaking residents. Communication means should be in the care plan. Staff should notify nursing, management and social services if no communication board is located. The activity calendar should be printed in a manner the resident can read and understand.

Based on observation, interview and record review, the facility failed to ensure safety and adequate monitoring were provided during meals for two residents who had recommendations from Speech Therapy regarding proper positioning, type of required assistance during meals and/or monitoring during meals (Resident #109 and #11). The resident sample was 47. The census was 166.Review of the facility's Activities of Daily Living (ADLs) policy, revised 4/23/25, showed:-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.-Care and services will be provided for the following activities of daily living: Eating to include meals and snacks;-Terminology for ADL evaluation and documentation will follow definitions from the State's Resident Assessment Instrument Manual: Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort;-Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Review of the facility's Assisted Nutrition and Hydration policy, revised 8/1/25, showed:-The facility will: Provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment;-Recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration;-Provide a therapeutic diet taking into account the resident's clinical condition and preferences;-Based on the resident's comprehensive assessment, the facility will ensure each resident: Maintains acceptable parameters of nutritional and status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Is offered sufficient fluid intake to maintain proper hydration and health;-Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet;-Documentation for nutrition and hydration services to include consent and risks vs benefits will be found in the resident's chart. 1. Review of Resident #109's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/25, showed:-Mild Cognitive impairment;-Diagnoses included neurogenic bladder (lacks bladder control due to brain, spinal cord, or nerve damage), malnutrition, other hereditary ataxias (genetic disorders causing progressive loss of balance and coordination), cerebellar ataxia (a movement disorder caused by damage to the cerebellum (motor control and cognitive function), muscle weakness, muscle wasting and atrophy, abnormal posture, dysphagia (difficulty swallowing), and cognitive communication deficit;-Dependent with eating;-Therapy services administered at least 15 minutes a day on one or more days in the last seven days: Speech language pathology and audiology services. Review of the resident's care plan, in use during survey, showed:-Focus: Resident likes to roll on his/her stomach and lay on the floor;--Goal: Resident will remain safe;--Interventions: Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes;-Focus: Resident has nutritional problem or potential nutritional problem. He/She is on a regular diet and has thin liquids. Resident likes finger foods;--Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs and symptoms of malnutrition;--Interventions: Monitor/document/report as needed (PRN) any signs and symptoms of dysphagia. Monitor/record/report to physician PRN signs and symptoms of malnutrition. Provide, serve diet as ordered. Monitor intake and record every meal. Registered Dietician (RD) to evaluate and make diet change recommendations PRN. Review of the resident's Speech Therapy (ST) evaluation, dated 12/30/25, showed:-Diagnoses: Cerebellar ataxia, cognitive communication deficit, and dysphagia;-Reason for referral/current illness: Referred to speech therapy for evaluation of cognitive communicative abilities and swallowing abilities;-How often does patient require supervision/assistance at mealtime due to swallow safety: 91-100% of the time;-Patient was observed with regular texture and thin liquids this date. Patient was unable to feed him/herself this date, requiring 1:1 feeding assistance. Recommending regular textures with thin liquids. Patient requires skilled ST to ensure consistent oral care, as well as, to implement compensatory swallowing strategies and educate nursing. Patient warranted for ST three times a week/45 days. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated January 2026, showed:-An order dated 12/1/25, frozen/thickened nutritional supplement, two times a day magic cup meals (nutrition supplement);-An order dated 12/1/25, health shake (dietary) with meals;-An order dated 12/22/25, regular diet, regular texture, regular/thin liquids consistency for small/bite size soft;-An order dated 12/30/25, ST clarification order: SLP completed eval this date. Patient requires skilled ST 3x a week/45 days to target communicative deficits and swallowing abilities. Observation on 1/6/26 at 12:50 P.M., showed the resident lay in bed on his/her stomach. The resident had a meal tray underneath him/her. The resident ate his/her meal while he/she lay on his/her stomach. The resident had chicken tetrazzini and green beans, juice and a health shake. The resident used a spoon to feed him/herself without assistance. No staff were in the room monitoring the resident. At 1:05 P.M., staff entered room and asked the resident if he/she was finished with his/her meal. The resident said done and the staff member removed the tray from underneath the resident, leaving pieces of pasta and green beans on the bed under the resident. Observation on 1/7/26 at 8:50 A.M., showed the resident lay in bed on his/her stomach. He/she fed him/herself breakfast and consumed most of the meal. The resident continued to feed him/herself without assistance or staff monitoring. Observation on 1/9/26 at 8:27 A.M., showed the resident lay in bed on his/her stomach. He/She had bacon, French toast, cream of wheat, oatmeal cream pie, a health shake and orange juice. The resident fed him/herself without assistance. He/She coughed a couple of times during the meal. The cough was loud and harsh. The resident spit out food. During an interview on 1/12/26 at 1:13 P.M., the Director of Therapy confirmed that the resident eats meals on his/her stomach. He/She would expect the resident to have oversight while eating. During an interview on 1/12/26 at 1:20 P.M., Speech Therapist F said the instructions were for staff to have the resident up in his/her chair at meals. Sometimes the resident refuses, and he/she rolls on his/her stomach. He/She cannot tolerate being on his/her back. If the resident refuses and eats in his/her room, staff are expected to provide oversight if he/she is eating on his/her stomach. During an interview on 1/12/26 at 1:50 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to provide protective oversight during meals if the physician ordered it. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Requires partial to moderate assistance with eating;-Diagnoses included stroke, dementia and anxiety. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has a potential nutritional problem related to dementia;-Plan: Provide assistance with dining, such as set up tray, cutting up food, identifying items on tray, and feeding residents as needed. Observation on 1/8/26 at 8:22 A.M., showed in the resident's room, a sign posted on the wall near the resident's bed that read: Swallowing Strategies: Assist the resident in cutting up food and tray set up, supervision at mealtimes, upright position at mealtimes, small bites and sips, slow rate, alternate food and liquids every couple of bites. Observation showed the resident lay in bed with his/her meal tray positioned in front of him/her on a bedside table. The resident slumped down in bed and ate ground sausage with his/her fingers. No staff member supervised the resident while eating. Observation on 1/9/26 at 8:14 A.M., showed Assistant Director of Nursing (ADON) X and Certified Nursing Assistant (CNA) T positioned the resident up in the bed, placed the resident's food in front of him/her on a bedside table, and assisted the resident with opening containers. The ADON and CNA then left the room, and the resident began to eat his/her breakfast with his/her fingers. The resident's swallowing strategies sign was posted on the wall near the resident's bed. No Staff member supervised the resident eating. During an interview on 1/12/26 at 9:05 A.M., CNA U said he/she was aware of the resident's swallowing strategies sign. The resident should be up out of bed for meals and supervised in the dining room so that the resident does not choke on food. During an interview on 1/13/26 at 1:20 P.M., ST F said staff is expected to follow the swallowing strategies sign posted in the resident's room and the resident is to be supervised during meals and in an upright position. During an interview on 1/13/26 at 2:40 P.M., the DON said she would expect staff to follow speech therapy recommendations and have the resident sit upright and supervise the resident during meals. 2702576

Based on observation, interview and record review, the facility staff failed to ensure one of five sampled residents was free from physical abuse (Resident #1). Resident #1 had diagnoses including dementia, restlessness, agitation, cognitive communication deficit, and other abnormalities of gait and mobility. On 6/6/25 at approximately 5:00 P.M., certified medication technician (CMT) C told the resident he/she was nasty when the resident coughed or pretended to cough on CMT D's neck. CMT C began arguing with the resident, used profanity, and they threatened each other. CMT C pushed the resident and the resident pushed back. CMT C swung at the resident, hitting the resident around the face and neck, and the resident was pushed back against the wall. Staff intervened and pulled the resident away, causing him/her to fall to the ground. The CMT continued to try and strike the resident before staff pulled him/her away. The resident sustained visible injuries to his/her neck and hand. The facility census was 158. The Administrator was notified on 6/11/25 at 2:00 P.M., of an immediate jeopardy (IJ) which began on 6/6/25. The IJ was removed on 6/10/25 as confirmed by surveyor on-site verification. Review of the facility's Abuse, Neglect and Exploitation policy revised 8/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: --Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology; --Willful: Means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; --Verbal abuse: Means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability; --Physical abuse: Includes but is not limited to, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment; --Mistreatment: Means inappropriate treatment or exploitation of a resident; -Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspect abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law; 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written; -Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: --Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms; --The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect; --Providing residents, representatives and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and providing feedback regarding the concerns that have been expressed; --Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors; -Identification of Abuse, Neglect and Exploitation; --The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations; --Possible indicators of abuse include, but are not limited to: --Resident, staff or family report of abuse; --Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body; --Verbal abuse of a resident overheard; --Physical abuse of a resident observed; --Psychological abuse of a resident observed; -Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: --Responding immediately to protect the alleged victim and integrity of the investigation; --Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; --Increased supervision of the alleged victim and residents; --Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; --Protection from retaliation; --Providing emotional support and counseling to the resident during and after the investigation, as needed; --Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse; --Assuring the reporters are free from retaliation or reprisal; --Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the state survey agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint; Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/9/25, showed: -Adequate hearing and vision; -Sometimes understands others and is sometimes understood; -Moderately cognitively impaired; -No behaviors or rejection of care noted; -Diagnoses included dementia, bladder cancer, generalized anxiety disorder, degenerative disease of the nervous system, restlessness and agitation, lack of coordination, other abnormalities of gait and mobility, elevated blood pressure and muscle weakness. Review of the resident's care plan dated 6/6/25, showed: -Focus: Resident rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination; -Interventions: The resident has the right to be treated with consideration, respect, and dignity, to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and to be free from restraint (physical or chemical); -Focus: Resident is verbally aggressive related to dementia, ineffective coping skills and mental /emotional illness; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Give the resident as many choices as possible about care and activities; -Focus: Resident is resistive to care. Resident will sometimes refuse to get blood sugar checked: -Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. If resident resists with activities of daily living (ADLs), reassure resident, leave and return five to ten minutes later and try again. Praise the resident when behavior is appropriate; -Focus: Resident will have behaviors when he/she gets agitated; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Provide a program of activities that is of interest and accommodates residents status; -Focus: Resident has dementia; -Interventions: Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Cue, reorient and supervise as needed; -Focus: The resident has a communication problem related to dementia; -Interventions: Anticipate and meet needs. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, bed in lowest position and wheels locked. Avoid isolation. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Review of the resident's progress notes, showed: -On 6/6/25 at 5:25 P.M., per staff on duty (CMT C, CMT D, certified nurse aide (CNA) E, CNA F and CNA G), CMT C asked the resident to cover his/her mouth when coughing by CMT D. The resident became irate yelling profanity, increased agitation, and upset. The resident charged CMT C, striking him/her in the face and grabbing him/her. Staff had to get in between the resident and CMT C so the CMT could be allowed to get to safety. The nurse assessed the resident with findings as follows: No visible bruising or open areas. Resident stated he/she hates the sight of the CMT C. At 6:33 P.M., the nurse called the resident's physician and informed him/her of resident aggression towards staff. The physician sent an as needed (PRN) order for Trazodone (used to treat anxiety) 50 milligrams twice a day as needed. At 6:45 P.M., the nurse informed the resident's daughter about new order obtained PRN for agitation/anxiety. The resident's family member returned phone call, and this nurse informed him/her of the resident's aggression towards staff. Review of the resident's skin assessment dated [DATE], showed no new skin issues. Review of the resident's care task record dated 5/13/25 through 6/9/25, showed: -Task: Behavior monitoring and interventions: -On 6/6/25 at 2:00 P.M., no behaviors observed; -No other documentation of behaviors for 6/6/25. Review of the resident's June 2025 physician's order sheet, showed: -Pain monitoring every shift; -Aspirin, 81 milligrams (mg) tablet, give one tablet by mouth one time a day for high blood pressure; -Citalopram Hydrobromide, 20 mg tablet, give one tablet by mouth, one time a day for depression; -Quetiapine furmate, 25 mg, give one tablet one time a day for generalized anxiety disorder, restlessness and agitation; -Memantine hydrochloride (HCl), 500 mg, give one tablet by mouth two times a day for depression; -Trazodone HCl, 50 mg, give 50 mg by mouth two times a day related to anxiety disorder. Review of the resident's June 2025 electronic Medication Administration Record, showed: -On 6/6/25: -Aspirin, 81 mg, at 8:00 A.M., drug refused; -Citalopram Hydrobromide 20 mg, at 8:00 A.M., drug refused; -Quetiapine Furmate, 25 mg, at 8:00 A.M., drug refused; -Memantine HCI, 5 mg, at 8:00 A.M. and at 5:00 P.M., drug refused; -Trazodone HCI, 50 mg, at 8:00 A.M. and at 5:00 P.M., drug refused; -On 6/7/25, a 10 recorded for pain monitored on the day shift. During an interview on 6/9/25 at 11:30 A.M., the resident said he/she got beat a few days ago by the second in command behind the nurse (CMT C). This was the third time the resident had been assaulted by him/her. The staff member was throwing punches at him/her. The staff member continually insulted him/her and told him/her he/she would never get out of the facility. Other staff were there and saw it happen. The staff member beat him/her good. The resident was injured in the incident when the staff member hit him/her in the face and scratched his/her neck. The nurse told the resident he/she would take care of it, but he/she did not do anything. The nurse was never around when things happened. The resident no longer felt safe in the facility and did not trust the staff to help him/her. Observations of the resident on 6/9/25 between 11:30 A.M. and 5:00 P.M., showed a scratch on the right side of his/her neck, a scratch on the left side of his/her neck and a scratch on his/her right hand. During an interview on 6/11/25 at 4:30 P.M., the wound nurse said he/she measured the resident's wounds on this date and found the wound on the left side of the neck measured 3 centimeters (cm), the wound on the right side of the neck measured 0.3 cm width on the top and 0.5 cm length at the bottom. The wound on the resident's left wrist measured 0.3 cm in width by 0.5 cm in length. Review of the resident's trauma informed care form, dated 6/10/25, showed: Physical assault: Happened to me. During an interview on 6/9/24 at 12:25 P.M., Registered Nurse (RN) J said on 6/6/24, he/she was on his/her way home from working at the facility and CNA G called and told him/her Resident #1 had assaulted CMT C. He/She called the DON and reported the allegation and the DON told RN J he/she needed to return to the facility to get statements from all of the staff who were working. The resident was still agitated when he/she got back to the facility and said he/she wanted a fair fight. He/She never said he/she was assaulted. RN J did not ask him/her if he/she was assaulted, only if he/she was in pain and if he/she felt safe. He/She assessed the resident and did not see any injuries at the time. The staff interviewed who were working (CMT C, CMT D, CNA E, CNA F and CNA G) reported the resident attacked CMT C, and the other staff (CMT D, CNA E, CNA F and CNA G) had to get him/her off him/her. The resident allegedly coughed on CMT D and when CMT C told him/her to cover his/her mouth, the resident ran towards him/her and the staff (CMT D, CNA E, CNA F and CNA G) had to pull the resident off him/her. All of the staff (CMT C, CMT D, CNA E, CNA F and CNA G) who were present wrote statements indicating this is what happened. He/She did not interview the staff individually about what happened, just asked them to write out statements. The resident had never physically assaulted anyone before, but there were certain staff he/she did not like. He/She did not like CMT C, because he/she often had to redirect him/her, and the resident did not like that. The resident told the nurse he/she did not want to be there with CMT C anymore. The RN did not know if the resident received his/her medication on 6/6/25 because CMT C did not tell him/her the resident refused his/her medications and he/she did not administer it that day. Review of a written statement by CMT C dated 6/6/25, provided by the DON on 6/9/24, showed the resident walked behind him/her and CMT D, and the resident coughed. CMT C told the resident to cover his/her mouth, and the resident turned around and charged him/her, attacking him/her. During an interview on 6/9/25 at 1:55 P.M., CMT C said he/she and CMT D were at the nurse's station and the resident walked by and coughed on CMT D's neck. CMT C told the resident to cover his/her mouth. The resident does not like CMT C and always has an attitude. CMT C asked the resident why he/she coughed on CMT D, and the resident became enraged, rushed towards CMT C and grabbed his/her arms. The CMT started struggling trying to get free and grabbed at the resident trying to get loose. The other staff (CMT D, CNA E, CNA F and CNA G) pulled the resident back away from him/her, but the resident kept trying to attack him/her. He/She never struck the resident, and he/she did not fall to the ground. CMT C did not know why the resident did not like him/her. The resident would get angry with him/her when he/she found the resident in the wrong. CMT C usually just ignored the resident's behavior when he/she got angry. CMT C did not know who administered the resident's medication on 6/6/25 because he/she often would refuse to take medication from him/her, and he/she would have to get the nurse to administer it. Review of a written statement by CMT D dated 6/6/25 and provided by the DON on 6/9/25, showed the resident walked behind him/her and coughed on his/her neck. CMT C told him to cover his/her mouth, and then the resident charged at him/her while the staff tried to get him/her off CMT C. During an interview on 6/6/25 at 1:45 P.M., CMT D said the incident started because the resident walked by and coughed on him/her. CMT C let the resident know not to do that, and the resident got really aggressive, and they had to restrain him/her. The resident got angry so fast. It was out of nowhere. He/She charged at CMT C and the staff had to restrain him/her. CMT C grabbed the resident's arms to try and prevent him/her from hitting him/her. CMT D did not usually work on the memory care floor, so did not know if the resident and CMT C had prior problems with each other. Review of a written statement by CNA G dated 6/6/25 and provided by the DON on 6/9/25, showed CMT C was talking to CMT D and the resident walked by and coughed on CMT D's neck. CMT C asked the resident why he/she coughed on CMT D's neck. That is when he/she saw the resident walk towards CMT C. CMT C told the resident not to get up in his/her face, and then the resident pushed CMT C and called him/her a bitch. During interviews on 6/9/25 at 2:20 P.M. and at 3:30 P.M., CNA G said he/she was in the dining room on the day of the incident and heard Resident #1 and CMT C yelling at each other. The resident had coughed on CMT D's neck and CMT C asked the resident why he/she coughed on his/her neck. CMT C told the resident he/she could not believe he/she coughed on his/her neck. CNA G thought they were joking at first, but then the resident got angry and walked towards CMT C. CMT C told the resident not to walk up on him/her, and then the resident charged at CMT C. The resident fell, and CNA E got him/her in a headlock. The resident was on the ground and CNA E had his/her arm around the resident's neck. CNA F grabbed CMT C and attempted to pull him/her away from the resident. CNA G yelled at CNA D to let the resident go and helped him/her up from the ground. The resident was bleeding from his/her neck and hand. CNA G took the resident into the dining room and tried to get him/her to eat dinner. The resident was very upset and asked if CNA G saw what happened. CNA G wrote the statement about the staff member being attacked because he/she was afraid he/she would lose his/her job. Review of a written statement by CNA E dated 6/6/25 and provided by the DON on 6/9/25, showed he/she heard CMT C ask Resident #1 to cover his/her mouth, and then the resident charged at the CMT. CMT D grabbed CMT C's neck until they could pry the resident's hands from his/her neck. During interviews on 6/9/25 at 2:10 P.M. and on 6/11/25 at 8:50 A.M., CNA E said he/she was in the dining room on the night of the incident, at the back of the room and did not see what started the problem. He/She heard Resident #1 and CMT C yelling at each other about the resident covering his/her mouth. CNA E had to finish passing out the tray he/she was holding and got there at the end of it. No one was on the floor. CMT D, CNA E, CNA F, and CNA G were standing between the resident and CMT C. The resident was up against the wall. It was chaos and everybody was everywhere. The resident had been upset and agitated all day. He/She did not know if the resident got his/her medication that day. Residents can get agitated if they do not get their medication. The resident did not like to be redirected by CMT C. The resident told CNA E all the staff jumped on him/her except for him/her. He/She did not report it, because he/she believed the resident was restrained to prevent him/her from assaulting CMT C. Review of a written statement by CNA F dated 6/6/25 and provided by the DON on 6/9/25, showed the resident walked by CMT C and CMT D, and the resident coughed on CMT D's neck. CMT C asked the resident why he/she would do that and to cover his/her mouth. The resident then got mad and charged at CMT C. CNA F, CMT D, CNA E and CNA G had to get the resident off CMT C. During interviews on 6/9/25 at 2:05 P.M., and on 6/11/25 at 8:15 A.M., CNA F said he/she was in the dining room serving trays on the night of the incident. Resident #1 walked by the nurse's station and he/she playfully coughed on CMT D, and CMT C turned around and started yelling at him/her. CMT C told the resident he/she was nasty. They started arguing back and forth, and then the resident threatened to hit him/her. CMT C said he/she wished the resident would hit him/her. The resident then walked closer to CMT C, and he/she pointed his/her finger in the resident's face and said, You better get the f**k out of my face. The resident stepped closer, and then the CMT pushed him/her back. The resident pushed the CMT and then the CMT started swinging at the resident. CMT C was hitting the resident around the face and neck, and the resident was pushed back against the wall. CNA E got behind the resident and attempted to pull him/her away from the CMT and he/she fell on him/her. CNA F was trying to pull CMT C away from the resident and was telling him/her it was not worth losing his/her job. CMT C continued to yell, I told your ass and tried to swing on the resident again while he/she was on the ground. They were finally able to get CMT C away from the resident and behind the nurse's station. The resident was bleeding from wounds on his/her face and neck. CNA F wrote two statements. The first one was the night of the incident. RN J came in and told all of the staff to write statements about what they witnessed. This was done in front of all of the staff, and CNA F did not feel comfortable writing one. The nurse told him/her the resident attacked the staff, and the staff restrained him/her to protect the CMT and asked if that is what he/she witnessed. The nurse read everyone's statement out loud to ensure they all matched up and then left. CNA F thought about it overnight and then called the DON the next day to tell him/her what really happened, and he/she wanted to change his/her statement. The DON came to the facility on 6/7/25, and CNA F gave him/her a new statement and told him/her CMT C had assaulted the resident. The DON told him/her since they were past the time to report the incident it would look bad if the CNA changed his/her story and he/she would be perceived as a liar. The DON told him/her they were going to go with the original statements and he/she would be back in on 6/11/25 to further investigate the incident. The CNA had a copy of the second statement and had recorded the conversation between him/her and the DON. Review of the second written statement by CNA F dated 6/7/25, sent to DHSS on 6/11/25 at 8:32 A.M., showed he/she and CNA E were in the dining room the night of the incident, passing trays for dinner. Resident #1 walked by CMT C and CMT D and playfully coughed on CMT D. CMT C told the resident he/she was nasty and why would he/she do that. The resident started getting agitated and they began arguing back and forth. The resident told CMT C he/she would hit him/her, and the CMT told the resident he/she wished he/she would hit him/her. The resident walked up to CMT C, and CMT C said, You better get the f**k out of my face and pushed the resident. The resident pushed the CMT back, and CMT C started swinging on the resident and grabbed him/her down to the floor. CMT D, CNA E and CNA F tried to break up the fight. CNA E got the resident away from the CMT, and CNA F pulled CMT C away. CMT C kept yelling I told your ass! They got the resident to calm down, but he/she would get agitated again every time he/she saw CMT C. RN J called and said he/she was on his/her way back to the building and wanted statements. CNA F felt coerced to write the statement the RN told him/her to write. The resident had visible scratches on both sides of his/her neck. Review of a recorded interview between the DON and CNA F, provided by CNA F on 6/11/25 at 8:35 A.M., showed: -The resident was in front of the nurse's station on the night of the incident. He/She was in a playful mood and acted like he/she was going to cough on CMT D; -CMT C started to yell at the resident, saying he/she saw what he/she did, and it was nasty; -The resident argued he/she had not done this, but CMT C kept saying he/she did, and the resident started to get agitated; -The resident and the CMT had words earlier in the day when the resident thought he/she had taken his/her cereal; -The resident told CMT C he/she would hit him/her, and he/she told the resident he/she wished he/she would hit him/her; -The resident was on his/her way to the dining room and turned around and came back when the CMT said this to him/her; -CMT C pointed his/her finger in the resident's face and said, You better get the f**k out of my face; -The resident took another step closer to the CMT, and CMT C pushed the resident back; -The resident then pushed the CMT back; -CMT C then started swinging at the resident and pushed him/her into the wall; -CMT C was grabbing at the resident's clothes with one hand and swinging with the other; -CMT C hit the resident on the side of his/her head. The resident was not swinging back; -The resident fell to the ground; -CNA F grabbed CMT C by the arms and tried to pull him/her back away from the resident while another staff member was trying to get the resident away. CNA E attempted to pull the resident away and the resident fell on him/her; -CMT C continued to try and swing on the resident while he/she was on the floor and yelled, I told you not to get in my face; -The resident was on the ground screaming, This is going to be a lawsuit; -The staff were finally able to get the CMT to go behind the nurse's station and the resident to the dining room. During an interview on 6/9/25 at 2:50 P.M., CNA I said he/she was not working the night of the incident but came in the next morning and heard CNA F and CNA H talking about the resident getting jumped on by staff the night before. The resident had visible scratches on both sides of his/her neck, and the resident said they hurt. CNA I did not report this to anyone, because he/she thought they already knew about it. During an interview on 6/9/25 at 4:30 P.M., CNA H said when he/she came to work on 6/7/25, CNA F told him/her the resident had been jumped on by staff the night before. CNA H told CNA F he/she should do the right thing and report it. Resident #5 told CNA H, he/she saw a staff member put Resident #1 in a choke hold. He/She did not report it, because he/she did not witness it and thought CNA F reported it. Review of Resident #5's quarterly MDS dated [DATE], showed: -Moderately cognitively impaired; -Adequate hearing and vision; -Usually understands others and makes self understood. During an interview on 6/9/25 at 4:05 P.M., Resident #5 said he/she was in the dining room the night of the incident and heard Resident #1 and CMT C yelling at each other. Then the yelling stopped, and the staff started running out of the dining room, so he/she went out to see what was happening. Resident #1 was on the floor, and a staff member had a reverse choke hold (a choke hold applied from behind the person, typically with one arm wrapped around the neck) on him/her. The resident had stopped yelling at this time. During interviews on 6/9/25 at 1:00 P.M. and on 6/11/25 at 11:35 A.M., the DON said she received a call on 6/6/25 around 5:00 P.M. from RN J stating Resident #1 had assaulted CMT C. She directed the RN to return to the facility to take statements from the staff. The staff told the DON the resident became agitated at CMT C after he/she asked the resident not to cough on CMT D and the resident charged at him/her. Staff had to restrain the resident so CMT C could get to safety. The DON removed CMT C as he/she was a trigger for the resident and asked him/her not to return until 6/9/25 so she could investigate the incident further. The DON planned to come back in to the facility on 6/7 and start an investigation. The DON told the staff to keep an eye on the resident. The DON returned to the facility on 6/7/25 after receiving a call from from CNA F regarding the incident. The DON assessed the resident and did not see any injuries. The resident did not allege he/she was abused. The DON did not specifically ask the resident if he/she was assaulted. The first night the resident told CNA E he/she was jumped by six staff members. The DON thought he/she was just confused from being restrained by the staff members. The DON would have expected the staff to document these allegations so they could have been investigated. The DON ensured a referral for a psychiatric evaluation was made for the resident and his/her physician was contacted to get an order for an as needed medication in case he/she got agitated again. The DON knew the resident did not like the CMT but believed it was because the CMT brought in food for the residents who behaved well, and he/she often did not get the food, and it made him/her angry. The DON did not remove the staff member from the unit prior to the incident, because he/she believed the resident just did not like being redirected. No one told the DON, CMT C had expressed he/she did not like the resident. RN J told her the witness statements verified the resident attacked the staff member. The DON suspended CMT C because he/she admitted calling the resident nasty and this was not an appropriate reply, until she could meet with CMT C on 6/9/25 to discuss appropriate behavioral responses. No one told the DON the resident was alleging he/she was abused or they witnessed the resident being abused. If staff had notified her about this, she would have immediately started an investigation and reported the allegations. During interviews on 6/9/25 at 5:30 P.M. and on 6/11/25 at 3:00 P.M., the Administrator said he is the abuse/neglect coordinator and staff, residents or family can report allegations to him at anytime. He expects staff to report all al[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide supervision to ensure the safety of one of three sampled residents (Resident #1) diagnosed with vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) and encephalopathy (alteration in consciousness caused by diffuse/global brain dysfunction due to a chemical imbalance). On the morning of 1/9/24, the resident became agitated and physically aggressive towards staff. He/She forced his/her way off the locked unit on which he/she resided, was redirected back onto the unit by staff and then shattered a first-floor window in the secured unit and climbed through it. He/She was assessed and treated at the hospital. The resident returned to the facility and became agitated, tearing pictures from the walls in his/her room, sweeping belongings into the hallway and attempting to leave the secured unit. In response, the facility moved the resident to an third-floor unit. Staff, who were unaware of his/her attempt to climb out of a first floor window, failed to provide an appropriate level of supervision when he/she began wandering around the third floor. The resident jumped from a 3rd floor window and incurred fatal injuries. The census was 131. The administrator was notified on 2/2/24, of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 1/9/24. The facility provided training and in-servicing for all staff regarding the facility's elopement policy as well as monitoring new onset of behaviors and the administration of as needed (PRN) psychotropic medications for behavioral management. The facility also completed elopement assessments on all residents, audited the elopement binder to ensure it was up to date, interviewed all residents for trauma informed care, completed elopement and wandering prevention audits and an environmental audit. The IJ was corrected on 1/12/24. Review of the facility's policy titled Elopements and Wandering Residents, reviewed/revised, 9/1/22, showed the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Wandering was defined as random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed/aimless. Elopement was defined as occurring when a resident left the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility was to establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents were to be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team (IDT) was to evaluate the unique factors contributing to risk, in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to the appropriate staff. Adequate supervision was to be provided to help prevent accidents or elopements. Charge Nurses and Unit Managers were to monitor the implementation of interventions, response to interventions, and document accordingly. The effectiveness of interventions was to be evaluated and changes made PRN. Any changes or new interventions were to be communicated to relevant staff. Review of the facility policy titled, Incidents and Accidents, reviewed/revised 9/1/22, showed it was the policy of the facility for staff to report, investigate, and review any accidents or incidents that occurred or allegedly occurred on facility property and might involve or allegedly involved a resident. An accident referred to any unexpected or unintentional incident, which resulted or may result in injury or illness to a resident. An incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization. That could involve a visitor, vendor or staff member. The purpose of incident reporting could include assuring that appropriate and immediate interventions were implemented and corrective actions were taken to prevent recurrences and improve the management of resident care. In the event of an incident or accident, immediate assistance was to be provided or securement of the area was to be initiated, unless it placed one at risk for harm. Any injuries would be assessed by a licensed nurse or practitioner and the affected individual would not be moved, until safe to do so. First aid would be provided for minor injuries such as cuts or abrasions. Review of Resident #1's undated face sheet, showed an admitted [DATE]. Review of the resident's undated physician's orders, showed the following: -1/4/24, Levetiracetam tablet 500 mg (milligrams), give 1 tablet two times daily for encephalopathy; -1/4/24, Quetiapine Fumarate tablet 25 mg, give 1 tablet in the morning for agitation; -1/4/24, Quetiapine Fumarate tablet 25 mg, give 75 mg at bedtime for agitation; -1/4/24, Hydroxyzine HCL (hydrochloride) tablet 10 mg, give 10 mg every 8 hours PRN for agitation; -1/4/24, Divalproex Sodium delayed release tablet 125 mg, give 1 tablet three times daily for vascular dementia. Review of the resident's all-inclusive admission and readmission assessment, dated 1/5/24, showed the following: -Orientation: oriented to person (knows his/her name and can recognize significant others); -Cognition: confused, short-term memory problem; -Psychotropic medication intervention: administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift; -Reason for admission according to resident/power of attorney (POA): dementia; -Wandering risk score: 4, wandering risk: at risk for wandering; -Elopement risk/wanderer intervention: avoid events that lead to wandering behaviors/triggers whenever possible. Identify and avoid the trigger; -Fall risk score: 28.0, fall risk category: high risk; Review of the resident's brief interview for mental status evaluation (BIMS), dated 1/5/24, showed a score of 0.0 (indicating severe cognitive impairment). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/8/24, showed the following: -Short-term memory OK; -Other behavioral symptoms not directed towards others (e.g. pacing, screaming, disruptive sounds, etc.) occurred four to six days but less than daily; -Rejection of care occurred one to three days; -Wandering occurred daily; -Diagnoses including essential (primary) high blood pressure, cerebral infarction (stroke) due to embolism of right anterior cerebral artery (occurs when a blood clot forms in one part of the body and then travels through the blood to the brain, where it blocks adequate oxygen and blood flow in one of the three major arteries that supply blood to the largest part of the brain), aphasia (language disorder caused by damage in the area of the brain that controls language expression and comprehension) following cerebral infarction, muscle weakness (generalized), other abnormalities of gait and mobility, diabetes mellitus; -Required supervision or touching assistance with eating, oral hygiene, sit to lying/lying to sitting, sit to stand, chair/bed-to-chair transfers, ambulating 10 feet, ambulating 50 feet with two turns; -Required partial/moderate assistance with lower body dressing, putting on/removing footwear and toilet transfers; -Required substantial/maximal assistance with toileting hygiene, shower/bathing, upper body dressing. Review of the resident's undated care plan, showed the following: -The resident is an elopement risk related to poor safety awareness, diminished cognition related to vascular dementia, acute on chronic (when a chronic condition develops an acute condition) metabolic encephalopathy; -Distract him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book; -Monitor for exit-seeking behaviors and document; -The resident has potential to be physically aggressive and refuse care related to diminished orientation and communication deficits related to vascular dementia, history of cerebral infarction due to embolism of left middle cerebral artery, acute on chronic metabolic encephalopathy and aphasia following cerebral infarction; -Administer medications as ordered. Monitor/document for side effects and effectiveness; -Communication: provide physical and verbal cues to alleviate anxiety: give positive feedback, assist in verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated; -Monitor/document/report PRN any signs or symptoms of resident posing a danger to self and others; -Psychiatric/psychogeriatric consult PRN; -When the resident becomes agitated, intervene before agitation escalates: guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later; -He/She has a communication problem related to vascular dementia, acute on chronic metabolic encephalopathy, mood disorder, history of cerebral infarction, history of hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) post cerebral infarction affecting right dominant side and aphasia; -Speak on an adult level, speaking clearly and slower than normal; -Administer psychotropic medications as ordered by his/her physician. Monitor for side effects and effectiveness every shift. Review of the resident's progress note, showed on 1/9/24 at 7:35 A.M., LATE ENTRY: at approximately 6:30 A.M. on 1/9/24 the resident started becoming agitated and was becoming violent with staff. Central supply staff (Central Supply Coordinator Q) entered the locked unit and was able to redirect the resident. Central supply staff walked the resident to the nurse's station and the resident appeared calm at that time. Central supply staff exited the locked unit, and the resident then went to the window in the hallway, started hitting it and broke the window sustaining small lacerations to both hands. The Physician and Director of Nursing (DON) were notified, and RN received new orders to send the resident out 911 for an evaluation. Review of the resident's Medication Administration Record (MAR), dated 1/1/24 through 1/31/24, showed no doses of Hydroxyzine HCL 10 mg, prescribed to be given every 8 hours for agitation were administered. Review of the resident's incident report, dated 1/9/24 at 6:50 A.M., showed the resident was having aggressive behaviors, pushed through the door, trying to get away from staff while staff attempted to redirect the resident. The resident punched out a window and climbed out the window. Central Supply Coordinator Q was with the resident at all times and redirected the resident back into the facility. He/She exhibited aggressive behaviors of charging at staff, swinging at them and breaking items in his/her room. They got the resident into the bathroom, where he/she calmed down. Nurse Supervisor J called 911. His/Her injuries included abrasions to the backs of his/her hands. Predisposing physiological factors were confusion and impaired memory. Nurse Supervisor J notified his/her physician and family member. Review of the resident's undated police report, showed the following: -Call received on 1/9/24 at 6:48 A.M.; -Time of arrival: 6:57 A.M.; -Police were dispatched to the facility for a resident who had busted out a window, was currently outside and reportedly being violent with staff. Upon arrival of the police, it was determined the window was on the ground floor. The window was in the memory care unit of the facility (Loop Unit). Staff members notified the officer the resident had been awake all night and started to pound his/her fists against the window and when it broke, he/she climbed out. The resident had a minor laceration to his/her left hand from the window and kept repeating his/her last name as the police officers escorted him/her to the exit and out to EMS (Emergency Medical Services). As paramedics secured the resident in the ambulance, the resident kept saying his/her family member's name. Review of the resident's ambulance record, dated 1/9/24, showed the following: -Call received: 6:51 A.M.; -On scene: 7:04 A.M.; -Primary impression: behavioral/psychiatric episode; -Secondary impression: laceration/abrasion/hematoma (minor surface trauma); -Injury: sharp glass contact; -Thumb laceration; -Chief complaint: behavioral episode; -EMS arrived on the scene at the nursing home and was greeted by police officers walking out with the patient. The patient stated that he/she did not want to hurt him/herself, but that he/she wanted to get out of there. Review of the resident's hospital Emergency Department notes, dated 1/9/24, showed the following: -The hospital graduate nurse (GN) received a call from the facility and a staff member (DON) said they needed an intervention for the resident's behavior, in order to be able to take him/her back. The caller explained the resident had become agitated that morning, broke a window, and tried to leave the facility. The GN said the resident had been calm, cooperative and verbally redirectable since his/her arrival at the hospital. The GN was told the facility still needed to know what actions to take, if the resident was to have that behavior again, in order to take him/her back. Otherwise, the resident was going to wind up back at the emergency room (ER) and she did not want the resident to hurt him/herself. The GN explained the interventions which were provided during the resident's stay at the hospital along with the appropriate referrals per the resident's discharge paperwork. The GN notified the resident's hospital Case Manager A of the situation; -The resident's nurse requested that Case Manager A contact facility staff. The resident was assessed by a Behavioral Health Intake Specialist (BHIS) and did not meet inpatient behavior health criteria. He/She was cleared to return to the facility. Case Manager A phoned the facility DON and discussed the resident's discharge orders to return to the facility. Case Manager A explained the resident had been seen by the ER physician and BHIS, was medically cleared and determined not to qualify for inpatient behavioral health treatment. The DON inquired about discharge plans. Case Manager A encouraged the DON to contact their facility physician. The DON verbalized understanding and agreed the resident could return to the facility; -The DON received a Registered Nurse (RN) to RN report via telephone. The DON verbally agreed to the resident's transfer back to the facility. All questions were answered by the hospital RN, including the care that was provided to the resident during his/her visit and resources provided in the discharge paperwork. The DON verbalized no further questions at that time. Review of the resident's hospital after visit summary, dated 1/9/24, showed: -Reason for visit: laceration; -Diagnoses: open wound, dementia caused by blood vessel disease, Type II diabetes mellitus with diabetic neuropathy (a common complication of diabetes; damage to the nerves that enable one to feel sensations such as pain), unspecified whether long term insulin use; -The patient was seen in the ED (emergency department) by an intake clinician. Per the consulting provider, it has been determined the patient is safe for discharge to the facility at this time. He/She lacks evidence of intent, plan and means to do harm and appears to be at baseline functioning; -The patient has received the following recommendations: psychiatrist: see referrals below, therapist: see referrals below, other: see referrals below (community resources specifically to help with dementia related concerns, suicide prevention and crisis hotlines); -You should follow up with your primary care and specialty physicians as directed for ongoing medication management; -The treatment you received today was not a substitute for, nor an effort to provide, complete and ongoing medical care. Review of the written statement of the DON, signed 1/10/24, showed on 1/9/24 at 12:53 P.M., she received a call from the hospital GN and hospital RN (Nurse B). The DON requested information on the resident's current status and aggressive behaviors. They told her the resident was stable and had not displayed any behaviors at all. The nurse (Nurse B) reported the resident had been pleasant and cooperative and took all medications as prescribed. The DON requested that a new intervention be put in place for behaviors, before the resident returned to the facility. The hospital nurse said that no psychiatrist had been assigned to the resident, because he/she displayed no behaviors and no new interventions had been put in place at that time. The nurse stated the resident was not a threat to him/herself or others at that time and had no wandering behaviors. At 2:13 P.M., the DON received a call from the hospital. She spoke with a Charge Nurse (Nurse B) related to her concerns about the resident's aggressive behaviors and treatment in behavioral health and the lack of interventions provided to keep the resident safe. The Charge Nurse said they had evaluated the resident and determined that he/she was safe for return and required no further intervention. The Charge Nurse also stated the psychiatrist recommended sending the resident back to the facility. Review of the written statements of the Administrator, dated 1/9/24, showed he spoke with a staff person from the hospital's behavioral health floor who asked if they could send the resident back to the facility. The Administrator questioned this, as the resident had just had a behavioral episode earlier in the morning. He asked if the resident could undergo a psychiatric consult, was told the hospital was not admitting the resident and they deemed it was safe for the resident to return to the facility. Again, the Administrator questioned this, then asked if there would be a nurse to provide report on the resident and was told the ER nurse would call to make report. When the Administrator last saw the resident (after the resident returned from the hospital), the resident was sitting in the DON's office at around 3:15 P.M. The resident was very pleasant, showed no signs of behaviors or exit seeking. Review of the resident's progress notes, dated 1/9/24 at 2:40 P.M., showed staff documented opening the door to the Loop unit for Emergency Medical Technicians (EMTs) escorting the resident in, standing on both sides of him/her holding him/her by the arms, leading him/her through the door. An EMT stated the resident did not want to stay on the stretcher, was saying he/she had to leave and had to go. The resident retrieved a broom and began making sweeping motions with it, knocking pictures, books, and clothing into the hallway. The RN (Nurse M) immediately called the DON, informing her the resident had returned to the facility and was showing signs of agitation. The DON came to the unit and informed the RN (Nurse M) that she was removing the resident from the unit for safety reasons. Review of the resident's care plan, showed no interventions added to increase staff awareness of the high risk behaviors which led to the resident's hospitalization on [DATE], modify his/her agitated, aggressive and violent behaviors, or to minimize risks associated with the hazards which occurred with him/her breaking a first floor window and jumping through it in an attempt to leave were added to the resident's care plan. Review of the facility investigation, dated 1/12/24, showed on 1/9/24 at approximately 2:41 P.M., RN (Nurse M) called the DON and notified her the resident had returned and was becoming aggressive again. At approximately 2:43 P.M., the DON arrived on the locked unit and observed the resident striking the door with an object, kicking the walls, and tearing up pictures. Other residents were ambulating on the locked unit, while the resident was having the observed behaviors. The DON removed the resident from the locked unit, in an attempt to de-escalate his/her current behaviors as this was identified as a potential trigger, and to maintain the safety of the other residents on the memory care unit. At approximately 2:46 P.M., the DON escorted the resident to his/her office and attempted to notify his/her Responsible Representative (RR) of the behaviors and have the RR assist with calming the resident. The DON was unsuccessful in contacting the RR. The DON offered verbal de-escalation which was noted to be successful. Review of the written statement of the Assistant Director of Nursing (ADON), dated 1/9/24, showed the Infection Control Nurse called, stating that paramedics were having a difficult time bringing the resident into the building. Once the ADON got down to the Loop unit with the DON, the resident was sweeping items up with a broom. The ADON and DON escorted the resident up to the DON's office. The resident was calm and pleasant. Several times they phoned the resident's family members, who were listed in his/her chart with no answer. The resident sat in a chair humming and answering simple questions. The ADON then left the DON's office. Review of the facility investigation, dated 1/12/24, showed the resident remained in the DON's office with the Administrator, the DON and ADON from approximately 3:08 P.M. until 3:35 P.M. They were attempting to contact the RR, to provide an update on the resident's behaviors and notification that he/she was being assigned to a new room on the third floor. The resident remained calm and cooperative with no displays of aggressive, exit seeking or self-harm behaviors while sitting in the DON's office. The IDT (interdisciplinary team) determined that he/she was de-escalated from his/her previous behaviors and the intervention of bringing him/her off the locked unit was effective. At approximately 3:35 P.M., staff notified the DON the resident's room was prepared, and his/her belongings had been transferred to the room. The DON then escorted the resident to his/her room and introduced the resident to his/her roommate. The DON escorted the resident around the unit, to orient him/her to the floor. At approximately 3:35 P.M., the DON took the resident to the nurses' station to introduce him/her to Nurse C, Certified Medication Technician (CMT) D and CNA E. Afterwards, she sat the resident in a chair across from the nurses' station and went into another office next to the nurses' station to speak with a staff member. According to staff who were present, the resident showed no signs of physical or verbal aggression, exit seeking or self-harm behaviors. At approximately 3:45 P.M. CNA E witnessed the resident ambulating on the hall. There were no signs of exit seeking, aggressive or self-harm behaviors noted. Review of the written statement of CMT D, dated 1/9/24, showed the period of time documented on was from 4:15 P.M.- 4:39 P.M. CMT D first saw the resident, when the DON was showing the resident the room in which the resident would be sleeping. Then she walked the resident back up to the front, where the resident sat in a chair by the desk (nurses' station). CMT D moved away from the desk while working. The resident got up and walked to the T3 Hall and sat in the sitting area. CMT D tried to get the resident to come with him/her, but the resident just sat there. Another worker came and helped CMT D get the resident back onto 3 Long Hall. The resident sat back down in the chair by the nurses' station. CMT D returned to his/her medication cart and was looking at his/her computer. He/She and did not see the resident get up and walk down 3 Long Hall. When CMT D noticed the resident was no longer sitting by the nurses' station, CMT D looked down the hall, saw the resident and called out for the resident to return to his/her seat. As the resident turned around and started walking back up the hall escorted by CNA F, Nurse M gave CMT D the resident's medications to put into the medication cart. Another co-worker then came up to the third floor, with the resident's TV and asked CMT D to hook it up. CMT D proceeded to go and do that. As CMT D walked towards the resident's room, he/she passed the DON who said the resident was in her office. CMT D went to the resident's room and hooked up the TV. While CMT D was doing that, he/she got a call from Nurse C at 4:39 P.M. asking where CMT D was and saying that something happened. Review of the facility investigation, dated 1/12/24, showed at approximately 4:15 P.M., CNA F observed the resident ambulating along the rear of 3 Long Hall and redirected him/her. The resident turned around and started walking towards his/her room. The resident was not showing any signs of exit seeking, aggressive or self-harm behaviors. Sometime between 4:20 P.M. and 4:25 P.M., CMT D observed the resident walking down 3 Long Hall and called the resident back toward his/her room. The resident was not exhibiting aggressive, exit seeking or self-harm behaviors. At 4:25 P.M., the DON entered her office and observed the resident sitting in her office again. She spoke with the resident, who responded appropriately showing no signs of physical or verbal aggression, exit seeking or self-harm behavior. CMT D was standing in the hallway at the DON's office door. The DON let CMT D know it was ok for the resident to sit in her office. The DON returned to her meeting in the office next door. At approximately 4:30 P.M., Nurse C observed the resident sitting in a chair in the DON's office appearing calm with no signs of aggression, exit seeking or self-harm behavior noted. At around 4:31 P.M., Housekeeper G was taking trash out to the dumpster, when he/she heard a noise and saw a window screen fall to the ground. Housekeeper G looked up and saw the resident hanging headfirst from a (third floor) window out to his/her waist. Housekeeper G yelled for the resident to go back inside. After a few times instructing the resident to go back inside the building, the resident complied and backed into the facility. At that moment, Housekeeper G ran inside and up the stairs to the 3 Hall nurses' station and yelled asking where was the resident. Housekeeper G, along with other staff members, began looking for the resident. Review of the undated written statement of Nurse C, showed on 1/9/24, he/she saw the resident standing in the DON's office between 4:28 P.M. and 4:30 P.M. At approximately 4:31 P.M., Nurse C was going down 3 Long Hall and noticed Housekeeper G running towards the hall asking where was the resident. At approximately 4:33 P.M., while Nurse C was helping staff look for the resident, Nurse C heard a scream from CNA H in the therapy room on 3 Short Hall. When Nurse C went into the room, he/she saw that the window was open. When Nurse C looked out the window, he/she saw the resident lying face down on the ground. Observation of the facility grounds, on 1/23/24, showed the therapy/recreation window located on the East side of the building, three floors up with slightly sloped asphalt below. Review of the facility investigation, dated 1/12/24, showed at approximately 4:31 P.M., the DON was still in a meeting in the office next door (to her office), when she saw staff running and heard a male voice yell, asking where is he/she? Staff immediately searched the third floor for the resident from approximately 4:31 P.M. to 4:33 P.M. At around 4:35 P.M., staff heard a yell from CNA H in the therapy/recreation room. The DON entered the room, observed an open window, looked out the window and saw the resident lying on the ground under the window. The DON instructed staff to call 911 and bring a crash cart downstairs. The DON with assistance from Physician I, who was at the facility at the time of the incident, immediately went to assess the resident. Physician I instructed staff not to move the resident. The resident's vital signs at the time were: blood pressure 169/119, (BP normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg), heart rate 107, (normal range: 60 - 100 beats per minute), temperature, 97.8 degrees Fahrenheit (normal range: 97.8 - 99.1 degrees Fahrenheit), respirations 12, (rate of breathing, normal range: 12-18 breaths per minute), and oxygen saturation, 98% (normal range: 94% to 99%). Staff applied oxygen but did not move the resident who was lying on his/her left side. At 4:40 P.M., the DON placed another call to 911 to report the resident's condition and obtain an estimated time of arrival for EMS. At 4:41 P.M., the police arrived followed by EMS who assumed care of the resident and transported him/her to the hospital. Review of the resident's incident report, dated 1/9/24 at 4:38 P.M., showed the resident's mental status was disoriented (distracted, unable to think clearly and being confused about time, location, and identity). Predisposing factors were a self-inflicted injury and impaired memory. The predisposing situational factor was the resident's recent room change. Review of Physician I's written statement, dated 1/11/24, showed on 1/9/24, he/she happened to be on the third floor early in the afternoon hours for rounding and saw staff running and calling out to one another about a resident who just jumped off the third floor out from a window. The Administrator was at the scene and showed Physician I. Once Physician I saw the resident on the ground, they went down to assess the situation. Staff members were coming out with a crash cart. Physician I directed staff not to move the body, due to possible head and neck trauma. The resident was unconscious and not responding to voice. He/she was face down, on his/her side. Someone had already placed a beanie under his/her face. The resident had blood coming out of his/her right ear and possibly mouth. The DON placed a BP cuff on the forearm. The resident had a BP of 130/ and HR 100. Physician I listened to the resident's breathing with a stethoscope, and he/she had breath sounds on both sides. Staff had already called 911. The police arrived first, and Physician I spoke with them. The medics arrived shortly thereafter. The medics asked a few questions and then log rolled the resident onto his/her back and placed a neck collar on him/her. Physician I helped them move the resident onto the stretcher. The medics immediately transported the resident to the hospital. Review of the resident's undated police report, showed the following: -Date/time call received: 1/9/24 at 4:39 P.M.; -Arrival time: 4:41 P.M.; -Upon arrival, the officers located the resident who was being treated by Physician I. The resident was unconscious, breathing and appeared to have a major internal head injury as there was a lot of blood coming from the interior of his/her right ear canal. Physician I advised the facility did not have a neck brace onsite, and they did not move the resident from his/her current location and position. Physician I was administering oxygen to the resident. Staff members advised the resident had jumped from the third story window. The officer asked them if the resident had made any statements indicating suicidal ideations and they said the resident had not. EMS arrived on scene, treated, and transported the resident to the hospital. The DON advised t [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide acceptable nursing practice for one resident with bilateral (right and left) leg wounds (Resident #1). The resident routinely refused care and treatment from nursing staff, and he/she had physician orders for treatments to be performed daily by the resident with staff monitoring the treatments. Staff documented the treatments were completed, however during interviews, staff said they falsely documented completion and had not observed the resident perform his/her wound treatments as ordered. On 9/19/23, the resident called Emergency Medical Services (EMS) for assistance after a fall. EMS arrived, noted an overwhelming odor and had concerns of severe infection and necrosis (dead tissue) in the open wounds. The resident was transferred to the hospital, where it was determined he/she had sepsis (presence of bacteria and infectious organisms in the blood stream), Methicillin-resistant Staphylococcus aureus bacteremia (MRSA, a bacteria that is responsible for many hard-to-treat infections) likely secondary to left extremity (left leg) infection, likely osteomyelitis (infection of the bone), and chronic lymphedema (swelling caused by fluid buildup) of the bilateral lower legs and feet with chronic skin change and wounds. Bilateral amputation was recommended. Additionally, the facility failed to document administration of an opioid medication administered to Resident #2. The facility failed to notify Resident #2's primary care physician when the resident transferred to the hospital after becoming unconscious and unresponsive, requiring Naloxone (Narcan, used to reverse the effects of an opioid overdose) administration by Emergency Medical Services (EMS). The facility failed to investigate the incident, and implement necessary nursing services related to potential medication contraindications when Resident #2 was prescribed medications with potential for drug interactions and was found to have used cannabis purchased off-market. The facility failed to follow-up with the hospital upon discharge of the resident after the overdose, requiring emergency intervention, to determine any changes in treatment or recommendations made to the resident. Nursing staff failed to take immediate action to protect the resident from further health risks, by ensuring the physician, administration, and police were aware and intervene when staff became aware of the resident having possession of the potentially opioid-contaminated product. The facility failed to follow physicians orders and obtain a urine sample for a drug screen in a timely manner. Additionally, the facility failed to notify Resident #4's physician of the resident using marijuana and failed to include the use in the resident's care plan. The sample size was three. The census was 131. 1. The administrator was informed on 9/22/23 of an Immediate Jeopardy (IJ), which began on 9/19/23. The IJ was removed on 9/26/23 as confirmed by surveyor on-site verification. Review of Resident #1's care plan, undated, showed the following: -Focus: the resident's desired personal care routine to complete his/her own wound care; Interventions included the resident was educated on wound care, nursing to monitor for changes in the wound, nurses to observe when the resident performed wound care to his/her right lower extremity (RLE, right lower leg); -Focus: the resident was non-adherent to treatment plan, does not allow nursing staff to clean, treat or evaluate bilateral lower extremities (BLE, right and left lower legs), the resident often stated he/she had performed his/her own wound treatments; -Goal: the resident will not experience a negative outcome related to non-adherence; Interventions included documentation of the resident's response to education, notify the provider of non-adherence, provide the resident education related to non-adherence to facility or provider treatment plan, and refer to Social Services for potential interventions; -Focus: The resident has actual impairment to skin integrity of the BLE and will not allow the staff to measure, assess, or treat the area; -Interventions included: Document refusals, the wound doctor may consult or oversee the resident's wound care with interventions to manage and treat the wounds, frequently monitor and inquire with the resident about self-performed wound care with any potential complications and/or recommendations. Review of the resident's physician order sheets (POS), showed the following: -An order, dated 5/9/23, perform weekly skin assessments every night shift on Tuesdays; -An order, dated 5/17/23, the resident may have wound care products at bedside for dressing changes; -An order, dated 5/17/23, wound cleanser or normal saline, collagen pad (absorbs wound drainage), calcium alginate (absorbs wound drainage), kerlix (gauze bandage roll) and tape. The resident to change dressing daily and as needed (PRN); -An order, dated 5/18/23, the resident may perform self-care for wound on left lower leg. Nursing must observe application by the resident, monitor for wound changes and call the doctor with any changes. Review of the resident's Treatment Administration Record (TAR), dated July 2023, showed the following: -The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered on every day except 7/17, 7/20, 7/28 and 7/29, when the resident refused; -The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered, except for 7/28 and 7/29, when the resident refused; -The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered, except for 7/28 and 7/29, when the resident refused; -The nurses documented they completed weekly skin assessments every Tuesday, as ordered, except on 7/4 and 7/25, when the resident refused; -The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered, except for night shift on 7/1, day shift on 7/6, day shift on 7/20 and day shift on 7/30, when the resident refused. Review of the resident's TAR, dated August 2023, showed the following: -The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered; -The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered; -The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered; -The nurses documented they completed weekly skin assessments every Tuesday, as ordered; -The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered. Review of the resident's medical record, showed the following: -The facility log, dated 9/5/23, showed the resident had the following: left leg lateral, lymphedema, arterial wound, measuring 9.0 cm by 6.0 cm by 0.2 cm; left leg medial, lymphatic wound, measuring 12.0 cm by 11.0 cm by 0.2 cm; right left medial, lymphatic wound, measuring 3.0 cm by 3.0 cm by 0.2 cm. The resident declined assessment; -On 9/6/23 at 5:37 A.M., a weekly skin assessment, showed the resident's right lower leg (front), left lower leg (front), right lower leg (rear), left lower leg (rear), left ankle (inner), right ankle (outer), right heel and left heel were all identified; none of the sites had any descriptions or assessments noted. Existing skin issues to BLE with no new skin issues were noted. Nurse Supervisor F signed the document; -The facility log, dated 9/12/23, showed the resident had the following: left leg lateral, lymphedema, arterial wound, measuring 9.0 cm by 6.0 cm by 0.2 cm; left leg medial, lymphatic wound, measuring 12.0 cm by 11.0 cm by 0.2 cm; right left medial, lymphatic wound, measuring 3.0 cm by 3.0 cm by 0.2 cm. The resident declined assessment; -On 9/13/23 at 4:25 A.M., a weekly skin assessment, showed no areas were identified. Existing skin issues on BLE with treatments were in place and no new skin issues were noted. Nurse Supervisor F signed the document; -On 9/15/23 at 3:30 A.M., a weekly skin assessment, showed no areas were identified. Existing skin issues to BLE with no new wounds identified. Nurse Supervisor D signed the document; -On 9/19/23 at 9:26 P.M., a weekly skin assessment, showed no areas were identified. Areas noted to the BLE and treated with no new open areas. Nurse E started the assessment on 9/19/23 and Nurse Supervisor F signed the document on 9/20/23; -On 9/19/23 at 9:51 P.M., EMS came to the floor, stating someone had called to say they were on the floor. The nurse and EMS entered the resident's room and found him/her on the floor, at bedside, with urine soaked linen. The resident denied pain and did not want to go to the hospital. EMS told the resident he/she would lose his/her legs if he/she did not let a doctor see his/her legs. The resident agreed to go to the hospital; -On 9/19/23 at 10:03 P.M., EMS took the resident to the hospital. Review of the resident's TAR, dated 9/1/23 through 9/19/23, showed the following: -The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered; -The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered; -The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered; -The nurses documented they completed weekly skin assessments every Tuesday, as ordered; -The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered. During an interview on 9/21/22 at 2:43 P.M., Certified Nursing Assistant (CNA) C said the following: -On 9/19/23, he/she did smell the resident's wound. It was so strong and foul the EMS staff, who were standing outside of the resident's room and wearing surgical masks, tucked their noses into their shirts; -He/She had smelled the same foul odor emitting from the resident's room since as early as July; -He/She had alerted Nurse B the resident's wounds smelled like they were infected for months; -He/She expected the nurse to address the situation and when nothing changed, he/she continued to report to Nurse B. He/She did not report up the chain of command. During an interview on 9/22/23 at 10:49 A.M., Nurse E said the following: -He/She was working on the resident's floor on 9/19/23; -He/She was at the nurses' station when the EMS staff came onto the floor; -He/She last saw the resident's BLE months ago, and can only remember they looked red; -He/She did not start or complete a weekly skin check on the resident on 9/19/23, and said if his/her name was on the assessment it must have been in error. Review of the EMS patient care report, dated 9/19/23, showed the following: -The resident called 911 on 9/19/23 at 9:32 P.M., to report he/she had slid out of bed a few hours ago and staff would not help him/her back into bed. The resident complained of bilateral leg pain and requested help back into his/her bed. The resident said he/she saw someone about his/her legs one week ago and was told there was an infection. He/She was not currently taking antibiotics; -The staff on the scene at the facility knew nothing about the resident; -The resident was found in his/her room seated on the floor. The resident was alert and oriented times four (to self, place, time and situation). The resident's BLE were swollen, reddened, edematous (swollen) and necrotic with white, flakey skin and foul odor. The resident's right leg had an open wound that appeared severely infected. Both legs smelled of necrosis; -Assessment of the resident's BLE described necrosis in both lower legs with pain and swelling. There was an open wound and what appeared to be severe, limb threatening infection in the right lower leg; -EMS left the facility at 10:02 P.M. and arrived at the hospital with the resident at 10:11 P.M. Review of the resident's hospital record, showed the following: -On 9/19/23 at 10:15 P.M., emergency room physician notes, the resident presented with a wound infection. History was difficult to obtain from the resident due to the acuity of his/her condition. Per EMS, the resident was found with chronic wound to the distal aspect (lower part) of his/her BLE. The resident stated his/her legs were like that for a long time. -On 9/20/23 at 12:54 A.M., the medical decision making note, the resident presented with fever, sepsis, extensive lower extremity wounds worse to the left side. Extensive skin changes over the feet bilaterally, unclear when the resident's wound dressings were last changed but findings suggesting significant ulcerations with sepsis, no clear evidence of necrotizing infection at this time but plan of broad-spectrum antibiotics and admission to the hospital for podiatry and wound debridement. Significant osteomyelitis on x-ray is most likely; -On 9/20/23 at 12:37 P.M., the physician progress note, Diagnoses included severe sepsis, suspected osteomyelitis vs. cellulitis, venous stasis dermatitis (condition of the skin which becomes swollen or inflamed caused by poor blood circulation in the veins), charcot's joint BLE, acute metabolic encephalopathy (brain dysfunction caused by a deficiency of vitamins, oxygen or glucose (sugar)) in setting of sepsis. The resident was alert and oriented to place only; -On 9/21/23 at 12:55 P.M., a physician progress note, the assessment and plan included MRSA bacteremia likely related to left lower extremity infection, related to endocarditis (infection of the heart's inner lining) and osteomyelitis; left lower leg and foot wound infection highly suspect underlining osteomyelitis; chronic bilateral lower leg and feet lymphedema with chronic skin change and wounds; The resident's family member was present with the resident and physician. They discussed the resident's diagnosis and recommendation for leg amputation. -On 9/21/23 at 1:19 P.M., a physician progress note, the resident was followed by the vascular team who recommended bilateral above the knee amputation for source control and due to unsalvageable nature of bilateral lower limbs. The resident was not agreeable to amputation. During an interview on 9/20/23 at 11:15 A.M., the resident's nurse at the hospital said the following: -The resident was admitted with wound infection, the wound was from his/her shin down, not really deep, not really describable, both legs are swollen and weeping; -The resident's white blood cell count was low at 20.6, showing possible infection; -The resident seemed fearful or in pain, whenever you touched him/her, he/she said Ow; - The resident was cleaned up and while getting a bath, he/she was crying in pain. During an interview on 9/20/23 at 11:21 A.M., the resident's doctor at the hospital said the following: -The resident has cellulitis (bacterial skin infection); -The resident had a wound on his/her calf and one on his/her shin; -The wounds are very difficult to determine condition due to the build up on his/her legs. He/She had a lot of fungus growth on his/her legs. The fungal infection appeared to have traveled up his/her legs from a toenail fungus that went untreated; -There was a yellow and black film on the wound and testing had to be done to see if there was bone involvement but it appeared necrosis was present in the wound. During an interview on 9/21/23 at 12:32 P.M., Wound Nurse A said the following: -She became the facility's wound nurse on 9/4/23; -She was responsible for collecting shower sheets, auditing weekly skin assessments, completing wound rounds with the Wound Medical Doctor (WMD), collecting the WMD progress notes after his visit and updating the resident's medical record and facility wound logs with the information; -She was also responsible for all wound treatments in the facility, Monday through Friday; -Nurses were responsible for wound care when she was not at the facility, on the weekends and when she alerted nurses she was not able to complete treatments; -She had not seen the resident since she was hired for the position; -On 9/19/23, the resident had denied a visit from the WMD during wound rounds; -She expected nurses to administer treatments as ordered; -She was told by the previous wound nurse, the resident completed his/her own wound treatments and the nurse had to watch the dressing changes to monitor the wound and for infection control; -She expected the nurses to document in progress notes any changes to a wound, if and when a resident refused orders or the plan of care; -She was not aware the resident refused to let nurses watch him/her complete his/her wound treatments, refused skin assessments and showers; -She would have alerted the WMD if she had known the resident had refused the plan of care; -She expected nurses to completely fill out weekly skin assessments identifying the location, appearance, if there was exudate, if it look infected of any skin condition found on the resident's skin; -It was important for nurses to give details on the weekly skin assessment or in their corresponding progress note so she knew what action to take when she audited residents' medical records. During an interview on 9/21/23 at 1:33 P.M., Nurse B said the following: -He/She worked on the resident's hall on a regular basis on the 7:00 A.M. through 7:00 P.M. shifts; -He/She was responsible for completing all and any orders on the TAR that were assigned to his/her shift; -Nurses were responsible for weekly skin assessments; -Nurses were expected to complete an assessment if there was a new skin condition, document in a progress note the location, appearance of the skin condition, how it was treated, who was notified and when, and put new orders in place if needed; -He/She would alert the Wound Nurse, Director of Nursing, (DON), nursing supervisors, the Administrator and the Primary Care Physician (PCP) if there was a new skin condition or if an existing wound had changed; -The resident refused all care and completed his/her own wound care; -He/She did not document the resident refused wound care since the resident did his/her own wound care; -He/She did not watch the resident complete his/her own wound care; -He/She had never seen the resident's BLE or feet; -He/She knew the resident had an order for the nurse to watch him/her complete wound care; -He/She documented he/she watched the resident complete wound care even though it was not true; -He/She documented he/she checked the resident's right leg for redness daily even though it was not true; -He/She trusted the resident to complete his/her wound care without a nurse supervising; -The resident did not have the cognitive abilities or knowledge to accurately assess his/her own wounds and report any deterioration to nursing staff; -He/She said the resident's room always had a strong odor. It was not an odor of urine or bowel movement. The odor was from the resident's wounds; -If a wound had a foul or strong odor, it meant the wounds were infected or needed medical attention; -He/She did not document that the resident's wounds were malodorous, did not notify the PCP or wound nurse; -He/She should have documented and notified the PCP, wound nurse, and nursing supervisors of the resident's continued refusal to allow nurses to watch wound changes and of the foul odor in the resident's room; -He/She should have documented every time he/she was not able to complete the order as written as it could have alerted physicians and nursing supervisors that the condition of the resident's wounds were unknown and it could have changed the plan of care; -The resident's medical record was not accurate as he/she documented orders were completed when they were not. During an interview on 9/21/23 at 3:12 P.M., Nurse Supervisor D said the following: -He/She was the Nurse Supervisor for the resident's floor; -He/She was not aware the resident was out to the hospital until the morning of 9/20/23; -He/She had not seen the resident's BLE since at least a month ago. He/She could not provide a description; -The resident was noncompliant to care, refusing showers, housekeeping services and wouldn't allow nurses to oversee wound treatments; -The nurses were responsible to oversee the resident's wound treatments; -The resident's room had a strong odor due to not letting anyone in to clean the room; -The resident's room also had a foul odor from his/her wounds; -He/She believed due to the odor of the wounds, they needed attention as it was likely the wounds had a change in condition; -Staff had reported for months the resident's room had a foul odor; -He/She did not know why he/she did not alert PCP or administrative staff to the foul odor; -He/She expected nurses to chart truthfully and accurately, only documenting what they did during their shift; -If the nurses were not able to supervise the resident's wound care, they needed to document in the TAR and write a progress note; -He/She was not aware Nurse B was not able to supervise the resident's wound care; -He/She was not aware the Wound Nurse had not seen the resident since she was hired on 9/4/23; -He/She was aware the resident refused treatment and evaluation from the WMD; -If wounds did not receive the appropriate treatment they could deteriorate, get infected, possible gangrene, cause sepsis and result in the loss of a body part or death; -He/She expected nurses to document when the resident refused care or did not follow physicians orders, especially if the refusal of care was ongoing as it could affect the plan of care; -He/She expected nurses to document when they educated the resident on risks of refusal of plan of care, notification of the physicians, wound nurse and administrative staff; -He/She was responsible for making sure staff followed orders and provided care to the residents as within their professional scope of practice; -He/She expected nurses to chart truthfully as it was important to know when a task or order was not followed as it could cause a resident to decline. During an interview on 9/22/23, at 12:01 P.M., Nurse Supervisor F said the following: -He/She did not see the resident's BLE. The resident always covered them up and refused to let him/her watch when the resident completed wound care; -He/She falsely documented supervision of the resident's wound care. He/She did not witness the resident treat his/her wounds; -He/She falsely documented monitoring the resident's RLE for redness. He/She did not assess the resident's RLE; -He/She falsely documented completed weekly skin assessments. He/She did not assess the resident's skin; -The purpose of the weekly skin assessments was to assess all areas of the resident's body to see if there were any new conditions or changes to existing skin conditions. They were used to determine plan of care; -The purpose of supervising the resident's wound care was to ensure the resident was following the treatment orders correctly and to assess the wounds condition, to determine if there was a change of condition; -It was important to document the resident's refusal of care as it could affect the plan of care by the physicians; -There was an odor emitting from the resident's room, but he/she could not determine the source. In retrospect, he/she should have found the source or documented the foul odor so that others would be aware. During an interview on 9/22/23 at 10:48 A.M., the Social Worker (SW) said the following: -He/She had not seen or heard from the resident since August; -The resident called him/her when he/she needed something or had any questions; -The resident called the SW in August to inquire about billing; -He/She was aware there was an odor emitting from the resident's room and assumed it was from old food; -He/She was not aware the resident was refusing the plan of care; -He/She would have tried to intervene if he/she was aware of the resident's non-compliance. During an interview on 9/22/23 at 1:17 P.M., the DON said the following: -She expected staff to follow physician orders as written; -She expected staff to document accurately and truthfully; -She expected staff to alert the PCP and Nursing Supervisors when the resident continued to reject care; -She expected staff to follow care plans and apply interventions as written; -She expected staff to document the resident's refusals each time it occurred; -She expected staff to document when and what education they gave the resident; -She expected staff to complete weekly skin assessments and to alert the PCP and Nursing Supervisors when the resident refused; -Weekly skin checks are performed to assess whether or not a resident had new skin conditions and/or if existing skin conditions had a change; -Wounds can change overnight, that is why it was so important for a nurse to witness the resident tending to his/her wounds. The nurses needed to see the wounds on a daily basis to ensure there was not a change of condition. Their observations were important as the resident would not have the knowledge to assess the wounds him/herself; -If the PCP, WMD or Nursing Supervisors knew the resident was not letting staff complete weekly skin assessments, showers, and not letting nurses watch dressing changes, it would have changed the plan of care. They may have insisted the resident go out to the hospital for a higher level of care as the resident was in danger of further skin breakdown or infection; -She was not aware the resident's room had a strong odor; -She saw the resident about a week ago while doing rounds. There was no odor in his/her room and the resident was wearing a long dress that covered his/her legs and feet; -She had no knowledge of the resident refusing evaluation from the WMD, refused to let nurses watch him/her change his/her dressings, and refused skin assessments. During an interview on 9/22/23 at 3:25 P.M., the Administrator said the following: -She expected staff to follow the facility policies; -She expected staff to follow the resident's plan of care; -She expected staff to follow physician orders as written and to alert their supervisors if a resident continued non-compliance to the plan of care or physician orders; -She expected staff to complete weekly skin assessments by looking at the resident's entire body, preferably when they were laying down, and document their finding with details; -She expected staff to alert supervisors to strong odors and to try to locate the source as well as document all details in the resident's medical record; -She expected staff to document the care they gave or didn't give to residents accurately and truthfully; -Failure to document accurately could negatively impact the resident's plan of care. During an interview on 10/2/23 at 10:19 A.M., the facility WMD said the following: -He discovered the resident had a skin condition on his/her right lower leg on 8/22/23. Before then, the resident kept his/her right leg bandaged with a kerlix but would not allow the WMD to assess the leg; -The last time he saw the resident's bilateral lower legs was on 8/29/23. The resident only allowed him to measure his/her right leg anterior (front); -The resident had a history of refusing care from staff, including watching him/her apply wound treatments, showers and assessments; -He expected nursing staff to educate the resident each time the resident refused care; -There was not a smell from the resident's room or wounds on 8/22/23 or on 8/29/23. A strong odor would have alerted him to a possible infection in the resident's lower legs; -The resident was a higher risk of infection at his/her lower legs due to his/her lymphedema, poor blood circulation and denial of care; -Staff did not report a strong odor was emitting from the resident's room; -He expected staff to report strong odors associated with the resident. He would have changed the plan of care, attempted to get wound cultures or blood cultures or tried to send the resident out to the hospital for a higher level of care; -He sent the Wound Nurse his detailed progress notes after each visit so they could use the information to update the resident's medical record; -He expected nurses to document when the resident refused care from him. The progress notes from the nurse should accurately reflect his wound progress note; -He was not aware the nurses were not documenting truthfully in the resident's medical record, the TAR or the weekly skin assessments. He wasn't sure what was done for the resident if the medical record was not accurate or truthful; -He expected the nurse to document truthfully and accurately in the resident's medical record as it affected the plan of care; -He would have asked for a psychiatric consult to see if there was a change of condition or tried to send the resident out to the hospital for higher level of care if he had known the extent of the resident's refusal of care from staff; -The resident was responsible for self and could refuse to go to the hospital for higher level care. At that point, the facility and/or Administrator would have the responsibility to make a decision to send the resident out on an emergency or 30 day discharge due to non-compliance to plan of care, which put him/her at greater risk of complications related to his/her medical condition. 2. Review of the facility's Notification of Change policy, dated 9/1/21, showed: -The purpose of this policy was to ensure the facility promptly informed the resident, consulted the resident's physician and notified the resident's representative when there was a change requiring notification; -Circumstances requiring notification included significant change in the resident's physical, mental or psychosocial status, which may include life threatening conditions or clinical complications; a transfer or discharge of the resident from the facility. Review of the facility's Incident/Accident policy, undated, showed the following: -All accidents or incidents involving residents, employees, visitor, vendors, etc, occurring on our premises shall be investigated and reported to the Administrator; -The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident; -The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; n. T

Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when an employee, Nurse A, used profanity and derogatory language toward the resident and said he/she hoped the resident would lose his/her limbs and die. The resident stated it hurt his/her feelings as he/she already had one amputation. The sample was 29. The census was 141. Review of the facility's Abuse, Neglect and Exploitation policy, revised 9/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; -Definitions: --Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology; --Verbal abuse means the use of oral, written or gestured communication or sounds, that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability; -Policy Explanation and Compliance Guidelines: --The facility will develop and implement written policies and procedures that: --- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; ---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; --The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written; -Employee Training: --New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation; --Existing staff will receive annual education through planned in-services and as needed; --Training topics will include; ---Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; ---Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; ---Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; ---Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: ----Aggressive and/or catastrophic reactions of residents; ----Outbursts or yelling; -Prevention of Abuse, Neglect, and Exploitation: --The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves ---Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; ---Assigning responsibility for the supervision of staff on all shifts for identifying in appropriate staff behaviors; -Identification of Abuse, Neglect and Exploitation: -The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations; -Possible indicators of abuse include, but are not limited to: --Verbal abuse of a resident overheard; --Psychological abuse of a resident observed. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/22, showed: -Brief Interview for Mental Status (BIMS) of 15 out of a possible 15, showed the resident cognitively intact; -Mood interview showed resident feels down, depressed, or hopeless 12-14 days (nearly every day); -Behavioral symptoms and rejection of care not exhibited; -Lower extremity impairment on both sides; -Diagnoses included paraplegia (paralysis of lower portion of the body), anxiety, and depression; -One or more unhealed pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). Review of the resident's progress note, dated 3/8/2023 at 8:48 A.M., showed Nurse A documented while in the resident's room, the resident was asked by Certified Nurse Aide (CNA) if he/she wanted his/her breakfast tray, he/she refused to answer, then responded by mumbling something. When asked again, he/she began to cuss and yell at CNA, saying, I know damn well (he/she) heard me. Nurse informed the resident neither the CNA nor the Nurse heard what was said due to resident mumbling, he/she then began to yell and cuss at Nurse A. Nurse informed resident not to talk to him/her or staff in that manner. Resident continued to cuss and yell. Nurse then informed charge nurse that he/she would need to do wound treatments. Nurse also made the Administrator aware of behavior. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADL) self-care performance deficit; -Intervention: Staff assistance to the extent needed; -Focus: The resident has actual impairment to skin integrity, left hip, right hip, lower back, right outer ankle, left buttock, right heel; -Interventions/tasks included follow facility protocols for treatment; -The care plan did not identify the resident as having behaviors of refusing care or being aggressive toward staff. During an interview on 3/15/23 at 10:40 A.M., the resident said around breakfast on 3/8/23, Nurse A came into the resident's room to do his/her wound treatments. As Nurse A was getting ready to do the resident's treatment, the CNA came to the doorway and asked if the resident wanted his/her breakfast tray. The resident repeated him/herself twice and said, Damn, I guess motherfuckers can't hear me nowadays. Nurse A said, Ain't nobody owe you shit nigga. The resident and Nurse A started arguing, and the resident told Nurse A to shut up and get out of his/her room. Nurse A said, Fuck this, exited the room, and told Nurse C to do the resident's wound treatment. While Nurse A was in the hall outside of the resident's room, the resident heard Nurse A say, Fuck that nigga, I hope (his/her) limbs fall off. I hope (he/she) dies. This hurt the resident's feelings. He/She has already had one amputation. He/She had a love/hate relationship with Nurse A prior to that. They argued back and forth like siblings, but that day, Nurse A took it too far, to a level the resident never expected. During an interview on 3/15/23 at 11:10 A.M., Certified Medication Technician (CMT) D said right before or during breakfast on 3/8/23, he/she was in the hall when he/she heard CNA B ask the resident if he/she wanted his/her breakfast tray. CMT D heard the resident say yes, and the CNA asked again two more times, with the resident saying yes each time. The resident said he/she was not going to keep repeating him/herself. CMT D left the area for a few minutes and when he/she returned, he/she observed Nurse A in the hall saying, Don't nobody owe this nigga nothing. Nurse A was yelling this in the hall outside of the resident's room. As Nurse A walked down the hall to the nurse's station, he/she yelled things like, Fuck that nigga. I hope that nigga die. I hope the rest of (his/her) limbs fall off. CMT D saw the resident in his/her room with his/her mouth open. The resident heard what Nurse A said, and the resident said it hurt his/her feelings. The resident is completely alert. Nurse A sat at the nurse's station and continued to yell about the resident. CMT D has worked with the resident and Nurse A for quite some time. Nurse A's words were not shocking because this is how the nurse is; this is his/her attitude. Nurse A talks to people like that all the time and people get used to it. The resident can have a foul mouth with his/her language at times, but he/she wasn't being like that on that day. CMT D considers what Nurse A said to be verbal abuse. About 30-45 minutes after the incident, Medical Records (MR) staff came to the hall to meet with the resident on an unrelated issue and the resident told MR what happened. When an incident of abuse occurs, staff should immediately notify the Administrator or supervisor. CMT D reported the incident to MR when she came to the hall 30-45 minutes after the incident. During an interview on 3/15/23 at 11:24 A.M., CNA B said on 3/8/23 at around 8:00 A.M., he/she stopped at the resident's room and Nurse A was in the resident's room at that time. When the CNA asked if the resident wanted a breakfast tray, the resident did not respond and Nurse A told the resident the CNA could not hear him/her because he/she was mumbling. The resident used profanity and told Nurse A told leave him/her alone. Nurse A said, Fuck this, I'm not gonna deal with this, and exited the resident's room. In the hall, Nurse A told Nurse C that he/she had to do the resident's treatment because Nurse A was not going to do it, and he/she was not going to let the resident talk to him/her that way. Nurse A went up to the nurse's station and the CNA went the opposite way down the hall and did not see or hear anything else. CNA B knows the resident and has worked with Nurse A for the past year. The resident is alert and can be antagonistic, call staff names and go off on people. If a resident yells at or cusses at staff, staff should leave the room and report it to the charge nurse or Administrator. If an employee cusses at a resident or calls them a derogatory name, it is considered verbal abuse. If an employee witnesses their coworker being verbally abusive, or if they are made aware of an allegation of abuse, the employee should report it to the Administrator right away. During an interview on 3/16/23 at 7:56 A.M., Housekeeper E said he/she was cleaning on the resident's hall around breakfast time on 3/8/23. He/She heard an aide ask the resident if he/she wanted breakfast, then the aide kept walking. The resident said yes, he/she did want breakfast. Nurse A came flying out of the resident's room, arguing with the resident and yelling at him/her. Housekeeper E is not sure exactly what was said, but Nurse A was yelling at the resident. Housekeeper E entered a different resident's room and did not hear anything else. If a resident yells at an employee, the employee should give the resident space and time to cool down, then report to their supervisor and come back to the resident later. Staff cannot yell at residents. Staff yelling at a resident or telling them off is considered abuse. If an employee witnesses their coworker being abusive, they should tell their supervisor. Housekeeper E told MR about the incident when she came to the hall later that morning. During an interview on 3/16/23 at 9:03 A.M., MR said she attended the morning meeting on 3/8/23, around 9:00 A.M. During the meeting, it was discussed that the resident said something mean to staff that day, but not much more was described than that. After the meeting, around 9:45 A.M., she started her rounds. She went to the resident's hall and the resident was at the nurse's station with CMT D. MR was talking to the resident when the CMT stopped the resident and told him/her to tell MR what happened. CMT D said Nurse A told the resident, Don't nobody owe this nigga shit. I hope you die, and something about the resident losing the rest of his/her limbs. The resident went to the front office with MR and made a statement. The resident said a CNA came to his/her room and asked if he/she wanted breakfast. The CNA did not hear the resident's response and asked again several times. Nurse A came into the resident's room and hollered at the resident. The resident did not specify what Nurse A said, but said it upset him/her enough to tell Nurse A to shut the fuck up. The resident felt very disrespected and said he/she knew people had bad days, but Nurse A went too far. The resident said the CMT and Housekeeper were in the area and overheard it. MR believed the incident was verbal abuse and reported it to the Social Services Assistant (SSA) and the Director of Nurses (DON), around 10:00 A.M. The resident has no confusion and MR has never seen or known the resident to be mean. If staff witnessed Nurse A being verbally abusive to the resident, they should have immediately reported it up the chain of command. During an interview on 3/16/23 at 11:01 A.M., SSA said she became aware of the incident involving the resident and Nurse A after the morning meeting was over, around 9:30 A.M. or 10:00 A.M. on 3/8/23. The resident came to her office and said he/she needed to talk. SSA and MR met with the resident, who said he/she was very offended by what Nurse A said. According to the resident, Nurse A said, Nobody owes this nigga, and told the resident he/she hoped the resident dies and his/her limbs fall off. This was a terrible thing to say, especially because the resident was just told by the doctor they might have to take off the resident's other leg. The resident was hurt and disappointed because he/she had a rapport with Nurse A, but he/she took it too far. Nurse A has an aggressive personality and it was not surprising these statements came from him/her. Nurse A's statements would definitely be considered verbal abuse. The resident is very alert and had not had any other known incidents with other residents or staff. He/She might get an attitude if woken up early, but isn't known to cuss at staff. If a resident does cuss at an employee or yell at them, the employee should walk away from the situation, then report and document the incident. After the resident gave his/her statement, SSA and MR reported it to the DON and Administrator. During an interview on 3/17/23 at 2:36 P.M., Nurse C said on 3/8/23 at around 8:00 A.M., he/she was at the top of the resident's hall while Nurse A was doing wound treatment rounds. Nurse A came out of the resident's room into the hall, yelling and going back and forth with the resident. Nurse A came down the hall, mad, and said he/she was not going to do the resident's wound treatments. While passing by Nurse C in the hallway, Nurse A made a comment about hoping the resident's limbs fell off. Nurse C went to check on the resident. The resident was upset and said he/she couldn't deal with Nurse A and was tired of the nurse's mouth. The resident said CNA B asked if he/she wanted a breakfast tray. The resident said yes, but CNA B did not hear him/her from the hallway and asked multiple times. The resident was frustrated and said he/she was not going to keep repeating him/herself. Nurse A told the resident to stop mumbling, but the CMT and Housekeeper both heard him/her say he wanted a breakfast tray, so clearly, he/she was not mumbling. Nurse A told the resident he/she hoped the rest of his/her limbs fall off. The resident is alert and cognitively intact. This is not the first time there was a disagreement between the resident and Nurse A, but this was the first time it got to this extent. Previous disagreements were more centered around the resident not taking care of him/herself and his/her wounds. Nurse C completed the resident's wound treatments and then notified the DON about what happened. All signs of abuse need to be reported immediately. The department heads went to their morning meeting around 9:00 A.M. After the incident with the resident, Nurse A remained in the building for a while and continued to work with a different resident. Later, the DON came to the hall and started interviewing people and Nurse C wrote a statement about what happened. During an interview on 3/20/23 at 11:40 A.M., Nurse A said on 3/8/23, at around 8:00 A.M. or 8:30 A.M., he/she was in the resident's room, getting ready to do his/her wound treatments. CNA B stopped at the resident's doorway and asked if the resident wanted a tray. Nurse A was seated at the resident's bedside and heard the resident mumble, but couldn't understand him/her. CNA B asked again and the resident said he/she wasn't going to keep repeating him/herself. The resident used profanity toward the Nurse and told him/her to get out of the room and leave the resident alone. Nurse A said, No problem, I don't have to deal with this shit, and left the resident's room. In the hallway, Nurse A told Nurse C he/she was not going to do the resident's wound treatments. Prior to this incident, Nurse A had a decent rapport with the resident and they would sometimes bump heads, but not like what happened on 3/8/23. The resident is very alert and oriented, but is hard-headed and resistant to taking care of him/herself. Nurse A would talk to the resident on a personal level and was one of the few staff to whom the resident would listen. The resident was over the top that day. After the exchange, Nurse A told the Administrator what happened and that the resident was not going to talk to him/her like that. He/She finished doing what he/she needed to do for the day and clocked out around 10:00 A.M. Nurse A denied using other profanity toward the resident, using derogatory terms when speaking about the resident, or making comments about wishing the resident would die or lose his/her limbs. These actions and statements would be considered abuse. If an employee witnessed their co-worker being abusive toward a resident, the employee should tell their co-worker to stop and then immediately report it to Administration. Review of Nurse A's time punches, dated 3/8/23, showed the employee clocked in at 6:41 A.M. and clocked out at 10:50 A.M. During an interview on 3/16/23 at 1:11 P.M., the DON said on 3/8/23, MR notified her of the incident between the resident and Nurse A, sometime after morning meeting and before noon. Morning meeting usually ends around 10:00 A.M. When the DON found out about the incident, Nurse A was already gone for the day. The DON interviewed the resident, who said Nurse A came into his/her room to do his/her wound treatment that morning, around breakfast. The CNA came to the doorway and asked if the resident wanted breakfast several times and the resident said he/she was not going to keep repeating him/herself. Nurse A jumped in and said something about how the resident is not special and staff don't owe him/her a fucking thing. The resident told Nurse A to shut the fuck up, and Nurse A said he/she was not going to do his/her wound treatment. Nurse A walked out of the room and told Nurse C to do the wound treatment, then told the resident, I hope your other limbs fall off. This statement hurt the resident's feelings. The resident has already had one amputation and said he/she is fighting every day to keep his/her other limbs. Nurse A's statements are considered verbal abuse. If an employee witnesses their coworker being verbally abusive, the employee should leave immediately to go tell someone, a supervisor. The facility uses a lot of agency staff so maybe the staff who were in the area at the time of the incident did not know the facility's abuse policies. She would have expected staff who witnessed the incident to have reported it to the Administrator immediately. If the Administrator is not available, staff should report it to the DON. If the DON or Administrator had been notified of the abuse allegation sooner, they would have told Nurse A to leave the building and would have suspended him/her pending investigation. It is the policy of the facility to remove the alleged perpetrator in order to keep residents safe. During an interview on 3/20/23 at 10:35 A.M., the Administrator said during the morning meeting on 3/8/23, it might have been discussed that Nurse A was not getting along with the resident, but nothing that rose to the level of abuse. After the meeting, around 10:00 A.M., MR notified her of an incident involving the resident and Nurse A. The Administrator spoke to the resident, who reported between 8:00 A.M. and 8:30 A.M., Nurse A was in his/her room while breakfast was going out. According to the resident, an employee asked the resident if he/she wanted something and Nurse A told the resident they could not hear him/her. There was banter back and forth between the resident and Nurse A. As Nurse A was leaving the room, he/she made a comment that he/she hoped the resident's limbs fall off and he/she dies. The resident was just in the hospital and said usually, he/she has thick skin, but Nurse A's comments bothered him/her. The Administrator considers the statements made by Nurse A to be verbal abuse. When the Administrator was notified of the incident, Nurse A had already clocked out for the day. She spoke with Nurse A over the phone, who denied using any abusive language. Nurse A was nonchalant about the situation and said he/she jokes and plays around with the resident. Statements were obtained from staff and at least one employee overheard the exchange between the resident and Nurse A. The resident is cognitively intact and has a history of being verbally aggressive and refusing treatment. Other staff have reported this behavior, but there have not been any current issues. If these behaviors are ongoing, she would expect the behaviors to be documented in the resident's medical record, and care planned with interventions to address the behavior. If a resident becomes verbally aggressive toward an employee, she would expect the employee to step away, document the incident, and notify their supervisor. If staff overhear or witness abuse, they need to make sure the resident is safe, then immediately report the incident to the Administrator or supervisor so they can take action. Immediate action would include immediately suspending the employee who was allegedly being abusive, in order to prevent potential further abuse. If the incident occurred around 8:30 A.M., she would have expected to have been notified right away, more promptly than when it was reported. The Administrator concluded that the resident was treated inappropriately by Nurse A and he/she was terminated. MO00215173

Based on interview and record review, the facility failed to provide behavioral services for one of four sampled residents (Resident #1) who resided on the secured dementia unit. Resident #1 displayed aggressive behavior towards Resident #2 and Resident #4. Resident #1 displayed aggressive behavior towards a certified nurse aide (CNA) and on the same day in [DATE], towards Resident #3. Resident #3 sustained injuries and was transferred to the hospital. The facility failed to develop and implement interventions for Resident #1 and educate staff on the interventions to provide for the safety of the residents. The census was 127. The administrator was notified on [DATE] at 12:30 P.M. of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the senior administrator became aware of the violation. The former administrator was terminated. The facility inserviced staff on the resident-to-resident abuse policy and procedures, and implemented immediate 1:1 for residents involved in altercations. The IJ was removed and corrected on [DATE]. Record review of the facility's abuse prevention program policy, dated [DATE], showed no documentation discussing behavioral modifications/interventions that should be put in place for aggressive behaviors. Review of Resident #1's physician order [REDACTED]. -An order dated [DATE], to identify aggressive/combative behavior and reduce precipitating events as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admission date of [DATE]; -Resided on the locked memory care unit; -Short and long term memory problems; -Poor memory/recall ability; -Severely impaired cognitive skills for daily decision-making; -Behaviors of inattention and disorganized thinking; -Physical behavioral symptoms directed towards others occurred one to three days; -Required supervision of one staff for walking in room, in corridor and locomotion on unit; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, showed the following: -[DATE] at 10:17 P.M., the nurse turned to see the resident swing at another resident. Resident #1 stood up and struck the other resident in the face multiple times. There were no injuries to note from either party. Staff were aware and continued to monitor the situation. Further review of the resident's POS, dated [DATE] through [DATE], showed the following: -An order dated [DATE], to record aggressive/combative behavior on behavior monitoring, record every shift. Review of the resident's care plan, showed the following: -Focus: At risk for adverse consequences related to receiving antipsychotic medication; -Approach: On [DATE], the resident had episode towards another resident. Such behavior has not been recorded and has not been seen since incident. Staff to monitor for behaviors and record as appropriate; -No documentation showing the development and implementation of interventions with education of staff to keep the resident and others safe. Review of Resident #4's quarterly MDS, dated [DATE], showed the following: -Resided on the locked memory care unit; -Brief Interview for Mental Status (BIMS), a brief screener of cognition, score of 10 out of 15 (moderate cognitive impairment); -Able to make self-understood and understands others; -Physical behavioral symptoms directed toward others occurred one to three days; -Required supervision with locomotion on unit; -Used a wheelchair or walker for locomotion; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, showed the following: -On [DATE] at 10:19 P.M., the writer turned around just in time to see another resident swing at Resident #4. The other resident stood up and struck Resident #4 multiple times in the face. Messages were left for the family and doctor to call back. Staff was aware and continued to monitor. During an interview on [DATE] at 9:35 A.M., the senior administrator said the facility could not locate any other documentation in the resident's medical record showing they followed up on the [DATE] incident with an event investigation, completed contact with the resident's responsible party and physician and if they received new orders. Further review of Resident #1's progress notes, showed the following: -[DATE] at 5:00 P.M., the resident was seen walking down the hall, another resident yelled something at him/her. Resident #1 pushed the other resident down to the floor. Resident #1 then walked away. Staff continued to monitor. Further review of Resident #1's care plan, showed the following: -Focus: On [DATE], the resident was involved in a verbal altercation with another resident that culminated in him/her pushing the other resident; -Approach: Staff to ensure the resident and the other involved resident were not in the immediate vicinity of each other; Staff to monitor him/her for signs of aggressive behavior; -There was no documentation showing the development and implementation of interventions with education of staff to keep the resident and others safe. Review of Resident #2's progress notes, showed the following: -On [DATE] at 7:00 P.M., the resident was walking down the hall exercising, when he/she passed another resident. Resident #2 yelled at the other resident and the other resident turned around and pushed him/her to the floor. Resident #2 complained of pain to his/her right side rib area when the nurse performed a full body assessment. Resident #2 was moved to another unit for his/her safety; -On [DATE] at 11:34 A.M., Resident #2 was moved back into his/her old room, due to confusion on the different unit. The resident continued to walk up and down the hall. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Resided on the locked memory care unit; -BIMS score of 6 (severe cognitive impairment); -Usually able to make self understood and understands others; -Behaviors of inattention and disorganized thinking; -Delusions present; -Verbal behavioral symptoms directed towards others occurred one to three days; -Required supervision of staff when walking in room and in corridor; -Walker for locomotion; -[DIAGNOSES REDACTED]. Further review of Resident #1's progress notes, showed the following: -[DATE] at 4:01 A.M., the resident hit and swung at staff when approached to assist him/her; -[DATE] at 3:06 P.M., the resident hit a CNA while he/she was trying to redirect the resident to the table for lunch; -[DATE] at 9:53 P.M., the resident was up walking the hall independently without assistance. Safety precautions with visual monitoring and safe distancing to avoid being hit; -[DATE] at 4:23 P.M., the resident was running down the hall, running into walls. The resident fell while trying to walk between two other residents; -[DATE] at 3:47 P.M., the day nurse reported the resident was observed striking another resident. It was believed the resident pushed another resident down onto the floor and began striking him/her repeatedly before staff was able to intervene. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Resided on the locked memory care unit; -BIMS score of 5, (severe cognitive impairment); -Usually able to make self understood and understands others; -Other behavioral symptoms not directed towards others occurred one to three days; -Walked independently in room, in corridors and on the unit; -[DIAGNOSES REDACTED]. Review of the resident's progress notes, dated [DATE], showed the following: -At 1:43 P.M., a CNA reported Resident #3 was attacked and physically knocked to the ground by another resident. Resident #3 complained of pain to his/her left hip. A small raised area was noted on the resident's left side of his/her head and his/her left hand was discolored; -At 2:14 P.M., Resident #3 was pushed by another resident resulting in a fall. Resident #3 fell on his/her buttocks and hit his/her head on the handle of a door. The resident complained of pain in both hips, knees, lower legs and lower back upon touch. The resident could not bear weight on his/her extremities. The physician was notified. New order of x-rays to both legs; -At 6:29 P.M., the resident left the facility to go to the hospital. Review of the resident's hospital records, dated [DATE], showed the following: -At 4:51 P.M., a physician wrote the resident was admitted from the facility after a fall resulting in a pelvic fracture. The resident decompensated (inability of the heart to maintain adequate circulation) while in the intensive care unit (ICU) and was found to have small bowel (part of the intestine) and colon pneumatosis (buildup of gas) consistent with bowel perforation (a hole in the wall of the bowel); -Current [DIAGNOSES REDACTED].'t enough insulin in the body, triggered by infection or other illness), acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (fluid fills up in the air sacs in the lungs, preventing oxygen flowing to the heart, brain, or the rest of the body), acute pelvic fracture (fractures to pelvis are commonly caused by falls, [MEDICATION NAME] traumatic injury, or motor vehicle accidents) with subcutaneous hematoma (injury to blood vessels causing blood to collect and pool under the skin), acute blood loss [MEDICAL CONDITION] (sudden blood loss with an abrupt drop in red blood cells, most commonly caused by hemolysis (breakdown of red blood cells) or hemorrhage (escaped of blood from ruptured blood vessels)); -The resident was not a surgical candidate due to his/her advanced age and frailty, currently in shock (life threatening condition that occurs when the body is not getting enough blood flow) and would require aggressive resuscitation. Family consulted and decided to change resident's status to do not resuscitate with comfort directed care due to catastrophic bowel perforation and shock. Review of the resident's discharge summary from the hospital, dated [DATE], showed the following: -Resident expired overnight in the ICU; -[DIAGNOSES REDACTED]. (high blood sugars). Further review of Resident #1's progress notes, dated [DATE] through [DATE], showed the following: -There was no social service documentation addressing the resident's behaviors. During an interview on [DATE] at 9:40 A.M., CNA A said the following: -Resident #1 was sometimes combative with staff, balling his/her fist, pushing and shoving people if they got too close to him/her; -Resident #1 entered other residents' rooms and would sometimes lay down with opposite sex residents if they were asleep in their beds; -CNA A did not know if Resident #1 required behavior monitoring; -If Resident #1 was combative, the only intervention CNA A knew was to tell the resident he/she was safe over and over again; -CNAs have access to all residents' care plans. During an interview on [DATE] at 2:29 P.M., CNA B said the following: -He/she worked on [DATE] and witnessed the physical altercation between Resident #1 and Resident #3; -At approximately 1:00 P.M., CNA B heard Resident #3 scream, and saw Resident #1 shove him/her to the ground, causing him/her to fall and Resident #1 fell on top of Resident #3; -Resident #3 hit his/her head against a door; -Resident #1 was laying on top of Resident #3 and punched him/her in the upper body and chest; -Two staff members had to pull Resident #1 off of Resident #3 because he/she kept hitting him/her; -CNA B left the unit to get the nurse; -Earlier that day, Resident #1 was agitated and walking up and down the hall; -CNA B accidentally got in Resident #1's way, and he/she grabbed the CNA's arm and hit it; -CNA B was not familiar with Resident #1 as it was only his/her second time working on the memory care unit; CNA B reported the incident to certified medication technician (CMT) D on duty; -CMT D said Resident #1 would hit anyone who got in his/her way while he/she was pacing the hall and advised CNA B to stay out of Resident #1's way; -CNA B did not know how to protect the other residents on the unit from Resident #1 hitting them. CMT D said when Resident #1 was agitated they just stayed out of his/her way; -CNA B did not have access to residents' care plans and expected nurses to tell him/her what behaviors to look out for and how to intervene during report at the beginning of the shift. During an interview on [DATE] at 10:55 A.M., the social services director said the following: -She was not aware of Resident #1 pushing or shoving others, or of any other behaviors; -Nursing staff were expected to tell the social service team or the administration team when a resident exhibits a behavior so they can document the behavior in the resident's medical record, address the problem in the care plan with appropriate interventions, and consult family members for their input. During an interview on [DATE] at 11:24 A.M., CNA C said the following: -He/she worked on [DATE] and witnessed the altercation between Resident #1 and Resident #3; -CNA C heard Resident #3 calling out and saw Resident #1 and Resident #3 falling to the floor, with Resident #1 on top of Resident #3; -Resident #1 was punching Resident #3 and CMT D had to help CNA C pull him/her off of Resident #3; -CNA C assisted the nurse during a head to toe assessment of Resident #3 and saw the resident's left hip was starting to bruise and was visibly swollen. The resident was complaining of a lot of pain at his/her left hip; -The former administrator took his/her statement and told staff to keep an eye on Resident #1. There were no other interventions given for Resident #1; -Resident #1 had a history of [REDACTED]. -Earlier on [DATE], CNA C saw CNA A standing in a doorway of a room Resident #1 wanted to enter. Resident #1 pushed CNA A out of the doorway, grabbed his/her arm and dug his/her fingernails in his/her arm, breaking CNA A's skin; -The nurse did not tell them to document any behaviors or what interventions to use for Resident #1. During an interview on [DATE] at 11:41 A.M., CMT D said the following: -He/she worked on [DATE] and witnessed the altercation between Resident #1 and Resident #3; -He/she heard screaming, ran down the hall and saw Resident #1 on top of Resident #3, hitting him/her with a balled fist; -CMT D and CNA C pulled Resident #1 off of Resident #3. Resident #1 started pacing the hall like nothing had happened; -Resident #1 had a history of [REDACTED]. If someone tried to stop him/her, Resident #1 would become combative; -There were no instructions for one on one supervision of Resident #1 until [DATE]. During an interview on [DATE] at 1:10 P.M., Nurse E said the following: -He/she worked on [DATE] and assessed Resident #3 after the resident to resident altercation; -Resident #3's left hip was bruised, visibly swollen, was poking out and appeared fractured. During an interview on [DATE] at 1:57 P.M., the Director of Nursing (DON) said the following: -She assessed Resident #3 after the resident to resident altercation; -Resident #3 had a small bump on the back left side of his/her head and a red mark on his/her left hip; -Resident #3 would not actively move his/her legs and complained that everything hurt, wincing in pain when we passively moved his/her legs to check range of motion; -Resident #1 was in his/her room while the DON was assessing Resident #3; -The DON left the unit to do paperwork for the investigation and when she came back approximately twenty minutes later, Resident #3 was crying out in pain and inconsolable; -The resident's left hip was much worse, bruising was darker, more swollen . it looked much, much worse; -The resident was sent to the hospital via emergency ambulance. During an interview on [DATE] at 10:55 A.M., the Assistant Director of Nursing (ADON) said the following: -Care plans should have behavioral goals with interventions that were personal to each resident; -Resident #1 paced up and down halls, went in and out of other resident's rooms, and was typically able to be re-directed; -She was not aware Resident #1 had prior altercations with other residents prior to the incident on [DATE]. During an interview on [DATE] at 3:11 P.M., the former administrator said the following: -Resident #1 had no behaviors prior to the incident on [DATE] and it was the first time he/she ever shoved anyone else; -The entire administrative team discussed care plans and the MDS coordinators were ultimately responsible to write care plans with appropriate interventions; -Resident #1 and Resident #3 were separated after the incident because Resident #3 was sent to the hospital; -Resident #1 was put on one on one supervision on [DATE], after he learned Resident #3 died ; -He did not know how the facility protected the other residents from Resident #1 prior to the one on one supervision on [DATE]; -Nursing staff were expected to document in the progress notes what occurred after the incident; -If a resident with dementia paced the halls and shoved residents and staff out of their way, it was only a problem on a case to case basis; -He was not aware Resident #1's care plan addressed a past resident to resident altercation; -Interventions were on care plans to notify staff members on how to care for the residents; -New staff were expected to rely on regular staff to give details on resident behaviors and interventions; -The danger of a resident shoving another resident was physical injury and emotional injury. During an interview on [DATE] at 4:02 P.M., the senior administrator said the following: -She completed an investigation on [DATE] and found Resident #1 had a history of [REDACTED]. -If Resident #1 was agitated earlier that day, staff could have used other interventions if they were listed on the care plan which potentially could have helped the situation; -There was no documentation in Resident #1's medical record showing there were interventions immediately after the altercation to protect other residents from Resident #1. -She expected care plans to detail interventions so staff know what works with each resident in order to provide appropriate care to each individual resident; -Residents were expected to have one on one supervision after a resident to resident altercation to ensure safety of the other residents. During an interview on [DATE] at 10:51 A.M., the medical director said the following: -She expected facility staff to inform her of any resident's change of condition; -She expected facility staff to inform her when residents are aggressive, shoving staff or other residents; -She was not aware of Resident #1's behaviors of shoving staff or other residents; -Aggressive residents were sent out for a psychiatric evaluation at a hospital for stabilization and to create a plan to address the aggressive behaviors with pharmaceutical and non-pharmaceutical interventions; -The facility's failure to treat Resident #1's behaviors put the other residents in imminent danger; -She had access to a limited view of Resident #3's hospital record which showed he/she sustained a pelvic fracture from the fall and was not a candidate for surgery. The resident died of ischemic bowel (artery that supplies blood to bowel is blocked or narrowed). MO 324 MO 198 MO 700

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This resulted in one resident with a history of pressure ulcers developing a new unstageable (depth unable to be determined) pressure ulcer which required surgical debridement (removal of dead tissue) when the facility failed to monitor the resident's skin, accurately assess and document the wound observations and obtain treatment orders timely after staff identified the development of the pressure ulcer (Resident #43). In addition, issues were identified with two additional residents when the facility failed to follow physician orders, accurately assess and document wound observations, and use proper technique when treating wounds to prevent infection (Residents #122 and #272). The facility identified six residents with pressure ulcers, five were included in the sample of 25 and issues were identified with three. The census was 126. 1. Review of the facility's wound tracking reports, showed no wound tracking completed for residents at the facility the last two weeks in (MONTH) 2019 and the first week in (MONTH) 2019. During an interview on 4/25/19 at 2:31 P.M., the wound nurse said she measures wounds weekly and tracks wounds on the wound reports. She was on maternity leave during the timeframe the wound reports were not completed. 2. Review of the facility's skin integrity manual, skin integrity prevention and management policies and procedures, revised 1/1/06, showed: -Purpose: To assure that patients admitted without pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) do not develop pressure ulcers unless the individual patient's clinical condition demonstrates that the pressure ulcer was unavoidable. To ensure that patients having pressure ulcers receive the necessary treatment and services to promote healing and prevent infection and prevent new pressure ulcers from developing; -Objectives: -To provide guidelines for early assessment and intervention geared to preventing the development of pressure ulcers; -To provide guidelines for immediate and ongoing communication between center staff, physicians, patients and their families regarding those risk factors and interventions; -To provide guidelines for systems for communicating nursing interventions between shifts and to all nursing staff; -To provide guidelines for early and ongoing identification of patients with pressure ulcers; -To define standards for early intervention and treatment of [REDACTED].> -To provide guidelines for immediate and ongoing communication with physicians, patients and their families regarding wound treatment and wound status; -To provide guidelines for tracking and comprehensive documentation of all pressure ulcers; -Assessment guidelines: Admission, readmit and return from transfer assessments initiated promptly; -Tools: Braden (used for predicting pressure ulcer risk), Resident Assessment Instrument (RAI), admission nursing assessment, history, diagnosis list, medication list, skin assessment record, wound assessment record; -Wound assessment includes type, stage, location, measurement of site (Length, width, depth). Exudate (drainage) to include type, odor, amount, and color. Wound bed to include necrotic (dead) tissue, slough (moist dead tissue), [MEDICATION NAME] (a fibrous protein involved in the clotting of blood), granulation (new tissue growth), epithelization (formation of granulation tissue), tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue)/undermining (wound open underneath the border of the wound). Periwound (skin around the wound) and wound edges appearance to include description and measurement. Presence of pain. Presence of signs and symptoms of infection. Peripheral pulses, capillary refill (return of blood to the blood vessels after pressure applied), [MEDICAL CONDITION] (swelling), color and temperature of skin. At the time of diagnosis, it is important to document the clinical basis (underlying condition contributing to the ulceration, ulcer edges and would bed location shape condition of surrounding tissue) which permit determination of the ulcer type, especially if the ulcers characteristics are consistent with a pressure ulcer but it is determined not to be one; -Ongoing assessment: Braden within 24 hours of admission and weekly times 4 weeks. Thereafter, it is completed in conjunction with completion of Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment. When the score falls to 14 or below, a new assess is to be done monthly; -Weekly skin and wound assessments: -Include type, stage, location, measurement of site, exudate, wound bed, periwound, presence or absence of pain, presence or absence of signs and symptoms of infection. Response to treatment; -Daily pressure ulcer monitoring: -When a pressure ulcer is present, daily monitoring will include an evaluation of the ulcer if no dressing is present, and evaluation of the status of the dressing if present, the status of the area surrounding the ulcer, the presence of possible complications such as signs of increasing area of ulceration or soft tissue infections; -Daily skin inspection monitoring: -Daily skin inspection is performed by caregivers during baths and/or assistance with activities of daily living (ADLs). Change in skin integrity and/or signs and symptoms of complications are reported to the licensed nurse; -Prevention guidelines: -Identification of patients at risk, implementation of interventions/prevention strategies, care process includes efforts to stabilize, reduce or remove underlying risk factors (pressure redistribution, moisture management, nutritional assessment/support, management of underlying psychological deficits that cause increased risks. Includes physician notification of patient's deterioration and/or poor response to interventions. Weekly skin assessments and daily skin inspections. 3. Review of Resident #43's quarterly MDS dated [DATE], showed: -Cognitively intact; -Rejection of care: Behavior not exhibited; -Extensive assistance required for bed mobility, transfers, dressing and toilet use; -Bathing: Two person physical assist; -Always incontinent of bowel and bladder; -Diagnoses included stroke, dementia, [MEDICAL CONDITION]/[MEDICAL CONDITION] (weakness or paralysis on one side of the body) and [MEDICAL CONDITION] disorder; -At risk for pressure ulcers; -No current unhealed pressure ulcers. Review of the resident's medical record, showed no MDS completed in (MONTH) 2019. Review of the resident's paper care plan, located in the hard chart, dated 12/20/18, showed: -The care plan did not address pressure ulcer with goals and interventions; -The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions. Review of the resident's electronic care plan, last reviewed/revised 4/16/19, showed: -Diagnoses included [MEDICAL CONDITION] and [MEDICAL CONDITION] after stroke. No [DIAGNOSES REDACTED].>-Problem: Assistance required in performing, improving and maintaining some ADLs: -Total Hoyer (mechanical lift) with assist of two; -Prefers showering during the evening on Wednesday/Saturday; -Incontinent undergarments; -Provide perineal care following incontinent episodes. Apply moisture barrier cream as needed. Incontinent of bowel and bladder; -The care plan did not address pressure ulcers with goals and interventions; -The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions. Review of the resident's Braden assessments, dated 6/29/18, 9/21/18 and 4/9/19, showed a score of 17 (12 or less is high risk). Review of the resident's paper and electronic physician order [REDACTED]. -An order dated 9/19/17, for weekly skin assessments on Mondays; -An order dated 7/26/18, to apply skin prep (protective barrier wipe) to the coccyx (tailbone area) dermaLevin (water proof adhesive foam dressing) once daily on the 7:00 A.M. through 7:00 P.M. shift. Review of the resident's progress notes, showed: -On 10/16/18, skin: No rash or skin breakdown; -On 1/17/19, skin: No rash or skin breakdown. During an interview on 4/25/19 at 2:31 P.M., the wound nurse said the resident originally had an order for [REDACTED]. Review of the resident's weekly wound assessment record, showed: -On 2/3/19, no new or concerning skin issues noted. Skin is dry and intact and warm; -On 2/11/19, no new skin issues noted; -On 2/15/19, sacral (is at the bottom of the spine at the coccyx) unstageable, wound measured 5 by 3.5 (no unit of measurement specified). No exudate. Wound base moist, no odor or signs and symptoms of infection, no eschar (hard dead tissue) or slough, granulation tissue present periwound redness and maceration (skin deterioration caused by moisture). NOTE: Wound noted with 100% slough mild periwound maceration. Mild odor noted. No redness or warmth noted, air loss mattress replaced. Staff educated to provide 2 hour position changes. Resident noted with non-compliance at times resident noted change position to back after turned on side. Education provided and resident agrees to comply to position changes. Treatment completed. Further review of the resident's POS, showed: -No treatment order obtained for the sacral wound on 2/15/19 through 2/21/19; -An order dated 2/22/19, for sacral area treatment, cleanse with wound cleanser, apply Santyl (sterile enzymatic [MEDICATION NAME] ointment) apply [MEDICATION NAME] (occlusive absorbent dressing) or Allevyn (adhesive absorbent dressing) daily and as needed; -An order dated 3/8/19, for Santyl topical daily and as needed (no location specified); -Verbal order (no date specified) may have wound consult at wound clinic; -An order dated 3/10/19, please refer to medical center wound clinic as soon as possible (ASAP); -An order dated 3/14/19, to send to the hospital; -An order dated 3/19/19, reschedule appointment at wound clinic ASAP; -An order dated 3/21/19, for Santyl ointment 250 unit/gram topical once a day, 7:00 A.M. through 7:00 P.M. shift. Cleanse wound with wound cleanser, apply Santyl, pack and cover with saline moistened 2 by 2 (gauze) and cover with dry dressing. Order discontinued 3/25/19; -An order, dated 3/25/19, for Biostep AG (collagen dressing with silver targets and deactivates excess matrix metalloproteinase (MMPs, a group of enzymes that are responsible for the degradation of most extracellular matrix proteins during growth and normal tissue) to optimize wound closure for chronic wounds) bandage 4 by 4 (gauze) topical once a day on the 7:00 A.M. through 7:00 P.M. shift. Cleanse area with normal saline or wound cleanser before applying dressing. Further review of the resident's progress notes, showed: -On 2/22/19, wound to coccyx/sacral area noted with 100% slough and foul odor. New order for Santyl noted. Area cleansed and treatment done. Position changed. Resident complained of pain 10/10 (on scale of 0 to 10, 0 indicates no pain 10 is severe pain) new air loss mattress replaced; -On 3/1/19, skin: Large sacral decubitus (pressure ulcer) unstageable; -On 3/5/19, resident educated on importance of repositioning while in bed and getting up from bed even if only for meals related wound on coccyx. Further review of the resident's weekly wound assessment record, showed: -On 2/22/19, no wound location or stage listed. Wound measured 6.2 x 4.5 (no unit if measurement specified), exudate, wound base moist, eschar, granulation present, periwound redness and maceration present, pain present, no signs and symptoms of infection. NOTE: Wound to sacral noted to increase in size. Continues with 100% slough. Periwound redness. Discoloration noted. Resident complains of pain at all times, scheduled pain medications and as needed given per order as needed. Resident continues with noncompliance of position change at times. Continue with education and importance of alternating pressure relief, will continue to monitor; -On 2/25/19, has same wound to coccyx but no other skin issues. Treatment order is still in place, dressing dry and intact; -On 3/4/19, alteration in skin integrity. Resident still has open area to coccyx, treatment in place and no signs and symptoms of any change to wound. Review of the resident's hospital records, dated 3/7/19, showed: -The resident admitted to the hospital on [DATE]; -Wound care: Nurse consulted for decubitus. Patient admitted with a deep sacral ulcer. Patient is pleasant and cooperative. He/she arrived to the emergency department by ambulance. Chief complaint is weakness and increasing slow to respond over this week; -Sacral ulcer: Open through epidermis (top layer of skin), dermis (lower layer of skin) to subcutaneous tissue (hypodermis, under the skin layer). Malodorous (bad odor), moderate serosanguineous (yellowish drainage will small amounts of blood) drainage. Gaping, necrotic white and yellow slough covering base of ulcer. Unable to stage; -Recommendation: sacral ulcer: daily apply triad paste (helps to maintain optimal wound healing environment) dime thick to sacral ulcer. If incontinent, clean area, leave adhered triad in place. Use sea-cleans wound cleanser to completely clean and then reapply triad. Cover with [MEDICATION NAME] (absorbent dressing) 4 by 4. ROHO mattress (pressure releasing mattress) on bed. Review of the resident's hospital records, dated 3/19/19, showed: -admitted to the hospital 3/14/19: -Chief complaint: Wound on bottom, sent by skilled nursing facility for increased lethargy (sleepiness) and [MEDICAL CONDITION] (low blood pressure); -Recently admitted to the hospital with [REDACTED]. -Sacral decubitus ulcer approximately 4 by 4 centimeters (cm); -Assessment and plan: metabolic [MEDICAL CONDITION] (disorder where medical problems such as blood infections or liver or kidney failure cause brain damage) secondary to dehydration [MEDICAL CONDITION] (blood infection) presumably from infected decubitus ulcer and urinary tract infection. Sacral decubitus ulcer infected, wound care consulted. Review of the resident's electronic wound notes, showed on 3/22/19, pressure ulcer, stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) to sacrum, not present on admit. Measured 4 cm by 3 cm. On 4/19/19, pressure ulcer measured 4 cm by 3.5 cm. Review of the resident's wound clinic notes, dated 3/25/19, showed: -Sacrum pressure ulcer measured 4.7 cm length by 4 width by 0.5 depth; -Undermining: Yes; -Stage III; -Large amount of exudate; -Pre-procedure [DIAGNOSES REDACTED]. There was an excisional skin/subcutaneous tissue debridement (surgical removal of dead tissue) with a total area of 16 square cm. Post debridement measurements: 4.7 cm length by 4 cm width by 0.5 cm depth. Post debridement stage noted as stage III. Requires further debridement. Review of the shower book, located at the nurse's station, which contained showers sheets completed for (MONTH) 2019 and reviewed on 4/23/19 at 12:14 P.M., showed the following for the resident: -On 4/20/19- Refused, stated he/she got a shower from hospice; -No further documentation of showers provided or refused in April, 2019. Observation on 4/23/19 at 3:12 P.M., showed Nurse Y provided wound care for the resident. He/she removed the dressing, dated 4/22, saturated with green tinged drainage. Nurse Y measured the wound as 4.7 cm length by 5.3 cm wide. The wound bed pink; During an interview on 4/24/19 at 8:50 A.M., medical records personal said the information provided is all that could be found on the resident's pressure ulcer. On 4/24/19 at 12:44 P.M., a call placed to the resident's primary care physician by the surveyor. As of 5/7/19, no return call received. During an interview on 4/25/19 at 2:31 P.M., the wound nurse said when she first saw the resident's wound, it was unstageable. The resident went to the hospital and it was debrided. When the resident returned, it was identified as a stage III. Seven days is too long between identifying a wound and obtaining a treatment order. The resident originally had an order for [REDACTED]. 4. Review of Resident #122's medical record, showed: -admitted [DATE]; -Medical diagnoses included: -Pressure ulcer of the sacrum, stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining (wound open underneath the border of the wound) or tunneling (channels or tracks that extend from a wound into and through the surrounding tissue or muscle)); -[DIAGNOSES REDACTED] (infection of the bone) of vertebra and sacrum region; -Pseudomonas aeruginosa (a bacterial infection highly resistant to antibiotics); -Braden Scale dated 4/21/19, showed a score of 12, indicating the resident was at high risk for a pressure ulcer. Further review of the medical record, showed no MDS completed in (MONTH) 2019. Review of the resident's hospital admission paper work, dated 4/12/19, showed: -BioFlo Peripherally inserted central catheter (PICC, a thin flexible tube inserted in a smaller vein in the upper arm and guided into a large vein above the right side of the heart used to give intravenous (IV) fluids or medications) inserted in the resident on 4/9/19. Review of BioFlo PICC manufacture' instruction for use, showed flush instructions per manufacture: -Always aspirate first to confirm blood return; -Flush each lumen with sterile normal saline per directions for use or per institutional protocol; -Flush after every use or every 12 hours if not in use; -Close clamp after flushing. Open clamp before use; -Flush the catheter with a minimum of 10 milliliter (ml) of sterile normal saline, using pulse or stop start technique; -Following saline flush, lock with [MEDICATION NAME] saline per directions for use or institutionalized protocol. Review of the resident's electronic POS on 4/22/19 at 3:55 P.M., showed: -Orders dated 4/12/19, for: -Mercopenem (antibiotic to treat infections) 1 gram reconstituted with sodium chloride 0.9% 100 ml, give IV every eight hours, 6:30 A.M., 2:30 P.M. and 10:30 P.M.; -[MEDICATION NAME] (used to prevent blood clots) 100 units/ml, 5 ml. Flush port-a-cath (a small chamber or reservoir implanted under the skin with a thin, flexible tube threaded into a large vein above the heart) before and after each use, every eight hours; -Orders dated 4/15/19, showed: -Normal saline flush, sodium chloride 0.9%. Flush IV with 3 ml before and after use, every eight hours; -Change PICC dressing weekly; -Flush sacral wound with normal saline once a day; -Dakin's solution (used to cleanse wounds to prevent infection); Special Instructions: Wet Kerlix (absorbent, woven gauze used for wound care) with Dakin's and pack sacral wound once a day; -Cover sacral wound with dressing once a day; -Turn every two hours, keep off back. Review of the resident's care plan, dated 4/15/19, showed: -Problem: Resident was admitted with an infected stage III pressure ulcer to sacrum; -Goal: Resident will respond to ulcer treatment as evidenced by improved wound healing with less pain and drainage or positive lab results through the next review; -Approach: Administer treatment as ordered; Assess condition of surrounding skin; Assist/encourage resident to turn and reposition to alleviate pressure to sacrum; Institute antibiotic therapy as ordered; Record the amount, type, and odor of drainage from the wound; -Problem: Resident requires IV antibiotics related to wound infection; -Goal: Resident will not exhibit signs of complications from the IV; -Approach: Administer IV meds per physician orders. During an interview on 4/25/19 at 2:35 P.M., the wound nurse said nursing staff should document daily progress notes describing the condition of the wound after providing treatment or changing dressings. Without daily progress notes detailing the condition of the wound, it is difficult to track the healing process of the wound as well as if the current treatment orders are appropriate to promote healing of the wound. Review of a wound progress note, dated 4/19/19 at 12:33 P.M., showed: -Wound Type: Pressure Ulcer; -Wound Location: Sacrum; -Measurements: -Length- head to toe direction- 7.5 cm; -Width - side to side direction - 8.5 cm; -Depth - measure deepest part of visible wound- 2 cm; -Exudate: -Amount: light; -Color and consistency: serosanguineous (pale red to pink, thin and watery); -Stage IV with tunneling present; -Tissue: -60% of wound covered by granulation tissue; -40% of wound covered by slough tissue; -Well defined wound edges; -Skin surrounding wound: pink, normal. Review of the resident's medical record on 4/29/19 at 12:22 P.M., showed there were not any progress notes describing the condition of the wound after nursing staff changed the daily dressing. Observations on 4/22/19 at 7:00 A.M., showed resident asleep in bed with the head of the bed raised approximately 30 degrees, slumped slightly over to the left side with his/her feet pressed up against the foot board. The resident's PICC line was connected to the IV pump which was infusing Mercopenem at a rate of 100 ml/hour. Observations on 4/23/19, showed: -At 7:25 A.M., the resident asleep in bed, slumped over to the left side, head of bed raised at approximately 20 degree, legs outstretched in front of him/her and his/her feet pressed flat against the foot board. The resident's PICC line connected to the IV pump which administered Mercopenem at a rate of 100 ml/hour; -At 12:55 P.M., 1:18 P.M., and 1:43 P.M., the resident awake, sat upright in bed with the head of bed raised to approximately 40 degrees, slumped over slightly to the left side, legs outstretched in front of him/her with knees slightly bent, feet pressed up against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum; -At 1:45 P.M., Licensed Practical Nurse (LPN) N gathered supplies from the treatment cart and entered the resident's room to change the dressing on the resident's Stage IV pressure ulcer located at his/her sacrum. After setting the treatment supplies on a barrier on top of the resident's bedside table, LPN N washed his/her hands and donned gloves and then removed the bowel movement filled brief from the resident. Bowel movement was visible on the wound dressing and underneath the wound dressing. LPN N removed the dressing from the wound, exposing the wound bed. There was a moderate amount of bowel movement inside of the wound bed and there was no Kerlix packed inside the wound. LPN N took off his/her gloves, cleansed his/her hands and donned new gloves. He/she then took wet, soapy wash cloths and wiped the rectum, buttocks and the wound bed free of bowel movement. LPN N measured the wound and verified the pressure ulcer was approximately 8 cm long and 9 cm wide with a depth of approximately 2 cm. The resident's proximal vertebrae were visible (located at the top of the wound, closest to the head), with slough present at the 12 o'clock to 3 o'clock position that covered approximately 40% of the wound base. Eschar present at the top of the wound that covered approximately 5% of the wound base, and hyper granulated tissue (an overly large amount of reddish connective tissue) located at the sides of the wound base. After cleansing the wound with normal saline, without changing gloves, LPN N took Dakin's soaked Kerlix and began to pack the wound base by unrolling the gauze and using a cotton tipped applicator to push the gauze into the wound bed. LPN N continued packing the gauze into the wound base. He/she pressed it into the wound and caused the gauze to spill out back into LPN N's hand. The skin around the edges of the wound bed bulged out due to the gauze. After removing his/her gloves, cleansing hands and donning new gloves, LPN N placed an absorbent dressing against the wound and pressed it firmly with the palm of his/her hand. LPN N took medical tape and attempted to tape down the dressing to the resident's skin. The tape only adhered to the resident's skin on two sides, and left the proximal and distal sides of the dressing open. The wound base was opened to air and to the resident's rectum. There was a gap of approximately 3 inches between the wound base and the dressing. As LPN N and Certified Nursing Assistant (CNA) O turned the resident back over to his/her back, the wound base was visible as it not covered by the dressing; -At 2:15 P.M., after the resident received wound care for his/her sacrum, LPN N and CNA O positioned him/her with the head of bed raised approximately 20 degrees, with his/her legs outstretched, without pillows underneath him/her to off load pressure. Observations on 4/24/19, showed: -At 7:54 A.M., 8:15 A.M., 8:50 A.M., 10:20 A.M., 11:07 A.M. and 11:35 A.M., the resident lay asleep in his/her bed, slumped to the left side with the head of bed raised approximately 30 degree, legs outstretched in front him/her with knees slightly bent and feet pressed against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum; -At 8:30 A.M., Nurse A gathered all supplies and prepared to administer Mercopenem to the resident. Nurse A verified approximately 6 ml of medication remained in the Mercopenem vial from the infusion administered on 4/23/19 at 10:30 P.M. During an interview on 4/24/19 at 8:35 A.M., Nurse A said when there is still medication in the Mercopenem vial after infusion, it means the entire dose of antibiotics was not administered. If it continued to happen, it would have an accumulative effect and the resident would not receive the entire antibiotic treatment as ordered. If there was medication left in the Mercopenem vial, it could be pushed back into the normal saline bag such that entire dose would be infused into the resident. Observations on 4/24/19, showed: -At 8:50 A.M., Nurse A started the Medocopenem infusion to the resident; -At 10:20 A.M., the resident's infusion pump alarm was heard beeping and the infusion stopped. It was audible in the hall outside the resident's room; -At 10:43 A.M., the resident's infusion pump continued to alarm. The resident pushed his/her call light. CNA Z walked into the resident's room and told the resident he/she is not able to adjust the resident because the electronic control to the bed is unplugged. There was a strong smell of bowel movement in the room. CNA Z left the room without assisting the resident; -At 10:51 A.M., CNA B walked into the resident's room, removed a bag of clothing from the dresser and left the room. A strong odor of bowel movement in the room. The infusion pump continued to beep and did not infuse the antibiotic. Certified Medication Technician (CMT) Q was in the hall outside the resident's room. The beep of the infusion pump audible in the hall; -At 11:07 A.M., Nurse A entered the resident's room, turned the infusion pump alarm off, readjusted the IV tubing, and started the infusion again; -At 11:46 A.M., CNA B removed a brief, heavily soiled with urine and bowel movement from the resident. Bowel movement visible on the resident's sacral pressure ulcer. The dressing not taped down to the resident's skin on all four sides and bowel movement visible in the wound bed. CNA B removed the dressing from the pressure ulcer, took a wet, soapy wash cloth and wiped bowel movement from the resident's rectum towards the wound. CNA B took another wet, soapy washcloth and used it to remove bowel movement from the resident's rectum and buttocks using a continuous sweeping motion down and around the wound base. After disposing of the soiled washcloth, the CNA tucked a clean absorbent incontinent pad underneath the resident and positioned the resident over on to his/her back and placed a pillow under his/her right hip. CNA B failed to cleanse his/her hands or don clean gloves while performing incontinent care and cleansing the wound base. During an interview on 4/24/19 at 2:24 P.M., Nurse A stated he/she would expect nursing staff to alert him/her to an alarm beeping on an infusion pump. When an infusion pump alarms, it automatically turns off the infusion which delays the antibiotic treatment to the resident. Observations on 4/25/19, showed: -At 6:45 A.M., 8:01 A.M. and 8:58 A.M., the resident lay in bed, slumped to the left side, with the head of bed raised approximately 30 degrees, legs outstretched in front of him/her with knees slightly bent and his/her feet pressed against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum; -At 8:16 A.M., approximately 15 ml of medication visible in the Mercopenem vial from the infusion which was administered previously. Observations on 4/26/19 at 4:45 A.M. 6:00 A.M. and 10:05 A.M., showed the resident asleep in his/her bed with the head of bed raised to 35 degrees. The resident slumped to the left side, legs straight in front of him/her, slightly bent at the knee, and his/her feet pressed against the footboard. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum. During an interview on 4/25/19 at 8:58 A.M., the Medical Director said: -Repositioning the resident to take pressure (off load) off of the resident's sacrum is very important; -It is especially important for Resident #122 due to the severity of the pressure ulcer; -He expects the nurses to follow physician orders. During an interview on 4/25/19 at 9:03 A.M., LPN P said the resident should be turned or repositioned every 2 hours to relieve pressure off of his/her sacral pressure ulcer stage IV. The facility had longer beds available for residents who need them. During an interview on 4/26/19 at 6:20 A.M., LPN T said: -If a resident was positioned flat on a bed with the head of the bed raised, legs out stretched with feet pressed against the foot board, it results in increased pressure located at the resident's sacrum and the pads of the feet; -Increased pressure localized at the sacrum could cause further breakdown of the resident's tissue, causing harm; -Extended beds were ordered by placing a request in the maintenance log located at the nurse's station. During an interview on 4/29/19 at 10:30 A.M., the administrator said: -Treatment orders for wound care are followed to prevent the wound from getting worse and to make sure all staff are aware of the wound; -After changing a dressing on a pressure ulcer, nurses are expected to write a daily note describing the condition of the wound so staff know the progression of the wound healing, and to ascertain if treatment is effective or not; -Staff are expected to off load pressure/reposition a resident who has a pressure ulcer stage IV to the sacrum every two hours to prevent further breakdown of the wound; -For residents whose feet are constantly pressed against a foot board, the facility has the ability to remove the foot boa (TRUNCATED)

Based on interview and record review, the facility failed to have a system in place to track resident bowel patterns, administer medications as prescribed by the physician, assess and monitor residents for signs and symptoms of a fecal impaction, document the assessments and communicate from shift to shift regarding an ongoing situation. This affected one resident from a closed record review, that ended up being sent to the hospital due to a fecal impaction. (Resident #1) The census was 156. Review of the Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/11/16, showed the following: -Diagnoses: [REDACTED]. -Understood/understands; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 15 of 15 (cognitively intact); -Incontinent of bowel; -Urinary catheter (a sterile tube placed through the urethra into the bladder, used to drain urine); -Constipation present: question not answered; -No complaint of pain; -Non-ambulatory; -Required total staff assistance for bed mobility, transfers, bathing, toileting and dressing; -Required extensive staff assistance for personal hygiene and eating. Review of the resident's nutrition narrative note, dated 11/16/16, showed he/she received [MEDICATION NAME] (stool softener) to help move his/her bowels. Review of the resident's care plan, dated 11/22/16, showed the following: -Problem: Nutritional risk secondary to leaving 25% or more of his/her food on his/her plate. Resident currently eating meals in his/her room, consuming 50%-75% of meals. Resident needs extensive assistance when feeding; -Goal: Consume 75% or greater at meals; -Approaches included: Encourage consumption of foods high in fiber such as nuts, whole wheat, oats, raw fruit, vegetables and beans to help with constipation, prescribed medications Senna (laxative) and [MEDICATION NAME] (laxative) to help with constipation. Review of the resident's physician orders [REDACTED]. -[MEDICATION NAME] 100 mgs discontinued on 11/28/16; -[MEDICATION NAME] 17 grams every day, mix with water or orange juice. Review of the resident's nutrition narrative note, dated 12/29/16, showed he/she received [MEDICATION NAME] to help move his/her bowels. Review of the resident's physician's orders [REDACTED]. -Order dated 12/11/15: [MEDICATION NAME] (narcotic pain patch) 50 micrograms (MCG) apply one patch every 72 hours; -Order dated 6/23/16: [MEDICATION NAME] immediate release (narcotic pain medication) 5 milligrams (mg) every six hours; -Order dated 9/20/16: [MEDICATION NAME] suppository 10 mg one per rectum daily as needed (PRN) if no bowel movement (BM) for two days or for hard stools; -Order dated 11/28/16: [MEDICATION NAME] 17 grams dissolve in water or juice take by mouth daily. Review of the resident's medication administration record (MAR), dated January 2017, showed the following: -An ordered dated 11/28/16, for [MEDICATION NAME] daily: Staff initialed as administered 1/1/17 through 1/9/17. Staff documented the order was discontinued on 1/9/17; -An ordered dated 1/9/17, for [MEDICATION NAME] 17 grams in liquid BID. Staff initialed as administered on 1/9/17 at 8:00 P.M.; -From 1/1/17 through 1/9/17 staff did not administer a suppository. Review of the resident's physician's progress note, dated 1/9/17, showed the following: -Distended abdomen with stool in descending colon; -Plan: [MEDICATION NAME] suppository, tap water enema, change [MEDICATION NAME] to twice a day (BID), Obtain blood labs: Complete Blood Count (CBC, determines general health status and screens for and monitors for a variety of disorders including [MEDICAL CONDITION]) and Comprehensive Metabolic Panel (CMP, measurement of blood sugar, electrolyte, fluid balance, kidney and liver function). Review of the resident's POS dated, 1/9/2017, showed none of the orders from the physician's progress note on 1/9/17 were transcribed onto the MAR. During an interview on 2/7/17 at 11:40 A.M., Nurse B said he/she worked on 1/9/17 from 8:00 A.M. through 6:00 P.M., as the charge nurse, and was assigned to the resident. Nurse B did not see the resident's physician on 1/9/17 and was not aware of new orders written or concerns related to the resident's abdomen. Physicians document new orders on the residents' POSs and flag the POS page so the charge nurse will know there are new orders. The physician usually gives verbal orders as well. The resident had a history of [REDACTED]. Nurse B did not know why the resident refused the bowel medications. When a resident refuses medication staff are expected to initial and circle their initials on the MAR then document the date, time and reason why the resident refused the medication. There were days where the resident refused to eat anything but junk food. Nurse B said the resident had the right to refuse to eat and take medications. Certified nurse aides (CNAs) are responsible for documenting BMs in the CNA BM tracking book, which is usually located at the nurse's station. Nurses are responsible for reading the BM book and notifying the resident's physician when the resident had no BM for three days. Nurses are expected to administer PRN bowel medication and if the PRN bowel medication was not effective the nurse should notify the physician within a few hours. During an interview on 2/7/17 at 2:30 P.M., Nurse C said he/she worked a double shift from 7:00 A.M. through 10:00 P.M., on 1/9/17. He/she was not assigned to the resident but did work with Nurse B. Nurse C did not see the resident's physician or receive verbal medication orders or know of concerns regarding the resident's abdomen. Physician's document new orders on the POS, flag the POS page and leave the resident's medical record at the nurse's station. During an interview on 2/22/17 at 10:30 A.M., Nurse D said he/she worked on 1/9/17, from 2:00 P.M. through 10:00 P.M., and was assigned to the resident. When he/she arrived to work the resident's physician and Nurse B were discussing concerns regarding the resident's distended abdomen. Nurse D heard the resident's physician give verbal orders to Nurse B, to administer a tap water enema and if that was not effective to administer a suppository and to monitor the resident. After the resident's physician left Nurse B delegated Nurse D to give the enema and then if no results to give the suppository. Nurse D administered the enema at approximately 2:30 P.M. He/she reassessed the resident at approximately 5:00 P.M. and there were no results. He/she spoke to Nurse B and Nurse D agreed to administer the suppository. The suppository was administered at around 5:30 P.M. Nurse D did not know if the suppository was effective because the floor got busy and he/she did not reassess the resident. Nurse D did not recall if he/she reported the concerns to the night shift nurse. Nurse D said Nurse B said he/she would document the paperwork and Nurse D would administer the medications. Nurse D did not transcribe the new POS orders to the MAR, document the medications were administered on the MAR or document in the nurse's notes because he/she thought Nurse B was going to. During an interview on 2/22/17 at 2:30 P.M., Certified Medication Technician (CMT) E said he/she worked on 1/9/17, from 2:00 P.M. through 10:00 P.M. He/she administered [MEDICATION NAME] at approximately 8:00 P.M. No staff reported the resident was having bowel issues. During an interview on 2/22/17 at 9:17 A.M., Nurse A said he/she worked on 1/9/16, from 10:00 P.M. through 6:00 A.M. on 1/10/17. He/she did not receive information regarding the resident's distended abdomen or new bowel medication orders in change of shift nurse report. During an interview on 2/7/17 at 2:45 P.M., the DON said the resident's physician documented the orders from 1/9/17 on the wrong POS. The orders were documented on the December 2016 POS, not the January 2017 POS. Review of the physician's orders [REDACTED]. -Obtain blood labs: CBC and CMP; -[MEDICATION NAME] suppository, if no results tap water enema until clear; -Increase [MEDICATION NAME] to BID; -Record monthly vital signs. Review of the resident's POS, dated 1/10/17, showed an order administer tap water enema now, may repeat one time. No time was documented on the order. Further review of the resident's MAR, dated January 2017, showed the following: -On 1/10/17 staff initialed and circled the [MEDICATION NAME] scheduled for 8:00 A.M., indicating it was not administered. There was no explanation documented on the back of the MAR; -[MEDICATION NAME] suppository 10 mg staff initialed medication was administered on 1/10/17. There was no documentation on the back of the MAR regarding this medication or why it was administered; -Staff did not document the tap water enemas were administered on 1/10/17. During an interview on 2/7/17 at 2:45 P.M., the Director of Nurses (DON) said when a resident refuses a medication staff initial and circle the MAR. Staff should document why the medication was refused on the back of the MAR. She was not aware the resident refused the [MEDICATION NAME] on 1/10/17 at 8:00 A.M. During an interview on 2/7/17 at 2:30 P.M., Nurse C said he/she worked on 1/10/17 from 7:00 A.M. through 4:00 P.M., and was assigned to the resident. Nurse B and Nurse C administered a tap water enema and the resident had multiple BMs that morning. Nurse C was not aware the resident's abdomen was distended or that he/she was constipated until the morning of 1/10/17. The resident's physician assessed him/her on the morning of 1/10/17 and stated the fecal impaction was too high up to remove. Nurse C could not recall if the enema was documented as administered on the MAR. He/she thought Nurse D would document that because he/she documented in the nurse's note. Review of the resident's nurse's notes, showed the following: -A 12/9/16 note documented regarding unrelated issues; -No further nurse's notes documented until 1/10/17; -An untimed nurse's note, dated 1/10/17, showed the resident complained of stomach pain. The resident's abdomen was assessed as distended and firm. A PRN [MEDICATION NAME] suppository was administered that morning. The resident had a small soft BM. Two enemas were administered per physician's orders [REDACTED]. The resident's bowel impaction was too far up for removal. Labs came back showing increased white blood cells (WBCs). The physician gave orders to send the resident to the emergency room . Family aware. Review of the resident's laboratory test results, for the blood, dated 1/10/17, collected on 1/10/17 at 6:20 A.M., showed the his/her WBCs were high 40.9 (normal is 4.0-9.8) indicating inflammation. Review of the resident's situation, Background, Appearance, Review and Notify (SBAR a tool used to facilitate prompt and appropriate communication between facility staff), dated 1/10/17, showed staff documented the following: -Situation: 1/10/17, resident complained of abdominal pain, abdomen was distended and firm; -Background: Diagnosis: [REDACTED]. Vital signs, Blood pressure (B/P): 146/98 (normal 120/80), Pulse (P): 81 (normal 60 to 100), Respirations (R): 24 (normal 12-20), Temperature (T): 96.7 (normal 98.6), oxygen saturation (O2, oxygenation of the blood): 96% on room air (normal 95-100%). Resident evaluation mental status, behavioral, respiratory, cardiovascular, [MEDICAL CONDITION]/ urine elimination, skin and neurological no changes observed compared to baseline. Functional status: decreased mobility due to pain; -Appearance: resident had abdominal pain, distention, firm and absent bowel sounds in lower quadrants. Suppository administered, small pudding like BM resulted. Nurse practitioner stated abdomen was bigger and more firm than 1/9/17 assessment; -Review and Notify: No information documented. Further review of the resident's POS, dated 1/10/17, showed a physician's orders [REDACTED]. Review of the resident's hospital records, dated 1/10/17, showed he/she was admitted for abdominal pain. The abdominal CT scan showed severe constipation. All four abdominal quadrants were distended, rigid, rebound tenderness and no bowel sounds present. The abdominal CT scan also showed an extreme amount of retained colonic stool with abnormal thickening of the wall of the distal colon with pericolonic (surrounding or encircling the colon) inflammation. During an interview on 2/7/17 at 9:15 A.M., the Administrator and DON said the resident had a long history of chronic constipation. Chronic constipation was on the resident's care plan, along with multiple interventions to prevent constipation. The resident's physician was aware the resident had chronic constipation and prescribed multiple routine and PRN bowel medications to prevent constipation. Review of the resident's medical record, showed no BM tracking records for 12/2016 or 1/2017 documented. During an interview on 2/7/17 at 2:30 P.M., and 2/15/17 at 7:59 A.M., the DON said she was waiting on the BM tracking policy and any policies related to bowel pattern tracking and assessment from corporate office. She expected staff to document and track the resident's bowel movements and to administer PRN bowel medication as ordered by the physician. The BM pattern records are shredded every 30 days and had been since she had worked at the facility. The BM pattern records are not part of the resident's permanent medical record. He/she did not know who documented the [MEDICATION NAME] BID on the resident's MAR on 1/9/17. She expected staff to transfer all orders from the POS onto the MAR during their shift, to ensure the orders are up to date and that the resident receives the medication as ordered by the physician. The physicians document new orders on the residents' POS. The POS page is flagged and left at the nurse's station. When possible the physician will also give the new orders verbally to the nurse. The charge nurse was expected to transcribe the orders to the resident's MAR during that same shift. The nurse that administers medication was responsible for documenting it on the resident's MAR and if the resident refuses medication staff are expected to document the date, time and reason of refusal on the back of the MAR. Review of the facility's elimination/consumption tracking policy, revised 2/15/17, showed the following: -Purpose: Used for collection of activities of daily living (ADL) information on multiple residents on the same page. These daily tracking records provide the basis for accurate medical record summarization of objective historical data; -Policy: Tracking records are to be disposed of after the end of the month of documentation unless there is an On Notice of Potential Litigation on file; -Scope: Nurses, nurse managers and all other pertinent staff partners; -Procedures: The CNA is responsible for data entry of the resident's ADL involvement daily. The DON or designee will monitor the BM tracking form for compliance and will follow up and delegate as needed. -The previous elimination policy was not available. During an interview on 2/16/17 at 9:54 A.M. the Assistant Director of Nurses (ADON) and the administrator said they were waiting for the corporate office to send any policy related to fecal impactions. The administrator did not respond to the question if he expected policies to be available to staff at the facility. During an interview on 2/21/17 at 9:54 A.M., the DON said the facility provided all available information to the Department of Health and Senior Services (DHSS) surveyor. During an interview on 2/14/17 at 2:00 P.M., the nurse practitioner said nurse practitioners and physicians write new orders directly on the residents' POS. The POS page is flagged and kept at the nurse's station. The charge nurse is updated verbally regarding the new orders as well. The resident's physician was upset because the resident was severely constipated and had a fecal impaction. The nurses knew the resident had a history of [REDACTED]. The resident's physician said the fecal impaction was preventable. During an interview on 2/15/17 at 8:25 A.M., the resident's physician said he assessed the resident in the late afternoon on 1/9/17. He noted the resident's abdomen was distended and he felt stool on the left side of the resident's colon. The resident was cognitively impaired, therefore he/she was not interviewable. He did not know when the resident last had a BM. He documented new orders on the resident's POS and flagged the page for the nursing staff, as he usually did. He spoke to Nurse B and Nurse C regarding the concerns and new bowel medication orders. He expected staff to administer the suppository and if there were no results, to administer the tap water enema, to document the administration of medication on the MAR and reassess the resident after the bowel medication was administered. He returned to the facility on [DATE], to reassess the resident and noted the resident's abdomen was more distended. The resident complained of abdominal pain at that time. Nurse B and Nurse C then administered a suppository that morning with no results. A tap water enema was administered, which had minimal results. He did a rectal exam and noted the fecal impaction was too far up to remove at the facility. The lab results came back and showed high WBCs and the resident was transferred to the hospital. The fecal impaction was preventable and should have never occurred. Facility staff were aware the resident had chronic constipation and should have monitored his/her BM patterns to ensure he/she was not constipated. He expected staff to track the resident's BMs and to administer the prescribed PRN bowel medication if the resident had no BM for two days. If that was not effective staff should have notified him. He expected the facility to have policies in place for BM tracking and a policy for the prevention of a fecal impaction. MO 942

Based on interview and record review, the facility failed to provide protective oversight to prevent or minimize the risk of harm for two of six sampled residents (Resident #4 and Resident #5). Both cognitively and physically impaired residents went outside on the patio unbeknownst to staff. Resident #4 suffered heat exposure, sunburn and acute renal failure after remaining outside in direct sunlight on a day when the heat index reached 98 degrees Fahrenheit (F). Resident #5 fell from his/her wheelchair attempting to propel his/her wheelchair back inside from the patio. The census was 160. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/8/16, showed the following: -admitted [DATE]; -Severe cognitive impairment; -Wheelchair mobility; -[DIAGNOSES REDACTED]. -Total dependence on assistance of one with locomotion, toilet use, personal hygiene and bathing. Review of the resident's fall risk scale, dated 7/8/16, showed a total score of 7 (score of 6-10 indicates moderate risk, requiring moderate risk interventions). Review of the resident's care plan, dated 7/12/16, showed the following:-Recent fall and continued risk for falls related to decreased mobility and dementia; -Staff to assist the resident with all transfers, mobility and toileting; -7/12/16, staff to remind the resident to remain seated. Review of the resident's family nurse practitioner progress note, dated 7/21/16, showed the resident had three falls within the prior week. The resident had small black and blue bruises on the right and left outer arms from falls. He/she had a large scratch on the right lower back and an old, scabbed over skin tear on the right elbow from a fall. The resident was assessed as alert, oriented to person, confused and a high fall risk. Review of the resident's post fall nursing assessments, showed on 8/2/16 at 2:45 P.M., staff found the resident on the floor with an approximately 4 cm skin tear to the right elbow. Further review of the resident's care plan, updated 8/12/16, showed he/she was not to be left in his/her room and needed to sit where he/she could be observed. Review of the resident's post fall nursing assessments, showed on 8/15/16 at 3:30 P.M., staff found the resident lying on the floor with his/her head underneath the wheelchair without injury. Review of the resident's incident investigation, dated 8/29/16, showed on 8/28/16, staff assisted the resident from the dining room after lunch at around 1:30 P.M. No one witnessed him/her being pushed out onto the patio. During an interview on 9/18/16 at 2:00 P.M., Weekend Manager D said on 8/28/16, he/she locked the patio door at the rear of the lobby at approximately 10:00 A.M. due to the heat outside. He/she monitored the weather via a weather application on his/her smartphone. Whenever the application showed that it felt like 90 degrees F, he/she locked the patio doors. There was a sign on the door, which had been there for over a month, informing residents that they were not allowed outside without friends or family due to the high temperature outside. The patio door at the rear of the lobby had a control panel with a knob on the top left corner which had various settings including on, off and automatic. Weekend Manager D used that knob to lock the patio door. However, residents who could stand kept unlocking the door. Consequently, he/she made rounds at regular intervals and locked the patio door four to five additional times that day, after bringing residents back inside. During an interview on 9/6/16 at 2:19 P.M., Certified Nurse Aide (CNA) A said on 8/28/16, the day shift in House 2 was short one staff person. The unit was normally staffed with four aides. That day, they only had three. CNA B was orienting for a second day in the unit and agreed to take on eight or nine residents. Nurse C was aware of the arrangement. Consequently, although the resident was officially assigned to CNA A, CNA B was attending to the resident in addition to seven or eight other residents that day. That evened things up so that the rest of the CNAs had ten residents. The others supervised CNA B and picked up any slack. At around 12:00 P.M. on 8/28/16, CNA A changed the resident's adult brief and took the resident upstairs to the dining room for lunch. CNA A then went and passed out hall trays while CNA B fed residents. During an interview on 9/9/16 at 1:20 PM, CNA B said on 8/28/16, staff was short on House 2 because someone was running late. Consequently, he/she agreed to take on an assignment of residents. CNA B's understanding of what that meant was that no residents were actually assigned to him/her; he/she was assisting CNA A with caring for CNA A's assigned residents. CNA B was still new and learning residents' names. He/she was watching the resident that day, but only until the resident went upstairs to the main dining room for lunch. The only thing CNA B told CNA A about the resident's care needs was that he/she was a two person transfer. They did not discuss his/her required level of supervision or how long CNA B should supervise him/her. CNA A did not tell CNA B to provide notification when CNA A could no longer watch the resident. All the staff on the unit appeared to be watching him/her. While the resident was eating lunch in the second floor dining room, CNA B was on the first floor passing out meal trays in House 2. The last time he/she saw the resident was upstairs in the main dining room during lunch. During an interview on 9/8/16 at 10:09 A.M., Nurse C said the unit was not short staffed on 8/28/16. There were three CNAs, which was the normal amount. No one informed him/her that CNA B agreed to supervise any residents that day. When a CNA underwent orientation, he/she worked under a hall mentor and the other CNAs helped to orient him/her. Orientees were only allowed to assist other CNAs with their assigned residents and monitor the whereabouts of residents. During an interview on 9/12/16 at 11:50 A.M., the Staffing Coordinator said the number of CNAs working in House 2 varied from three to four. Normally, the unit was only staffed with three CNAs. On 8/28/16, there were three CNAs working in the unit. Their shift was from 6:00 A.M. to 2:00 P.M. One CNA clocked in at 6:40 A.M. During an interview on 9/19/16 at 1:14 P.M., CNA E said on 8/28/16, he/she was cleaning off tables in the main dining room after lunch. Resident #4 and three other residents were still sitting in the dining room. CNA E and a dietary aide took the residents down to the first floor at around 1:00 P.M. or 1:10 P.M. (CNA E documented in his/her written statement that this took place at either 12:50 P.M. or 1:10 P.M.) and parked the resident's wheelchair in front of the bird cage outside of the entrance to House 2. That was the last time CNA E saw the resident, prior to a visitor discovering him/her out on the patio. During an interview on 9/7/16 at 3:28 P.M., Visitor F said on 8/28/16, he/she entered the facility at around 1:00 P.M. There were a lot of residents out on the patio. Resident #4 was also out there. Visitor F noticed him/her because he/she was sitting near the glass patio door, off to him/herself with one shoe off. Review of the resident's nurse's notes, dated 8/28/16 at 3:15 P.M., showed the resident was out on the patio for an extended period of time and afterwards was unresponsive to verbal or tactile stimuli, was hot to the touch, with saliva coming from his/her oral cavity and mucous coming from his/her nasal cavity. At the nurses' station, staff documented his/her blood pressure as 142/100 (normal range, 90/60 millimeters of mercury (mm/Hg) to 120/80 mm/Hg), pulse 147 (normal range, 60 to 100 beats per minute) and respirations 18 (normal range, 12 to 18 breaths per minute). His/her temperature was unobtainable. Staff placed cold rags on his/her forehead, chest and armpits which were replaced with ice packs on the groin and head. The resident was then transferred to a room and staff placed three ice packs to his/her groin, forehead and armpits. His/her temperature was 100.2 (normal range, 97.8 to 99.1 degrees F). At approximately 3:30 P.M., he/she was arousable to verbal and tactile stimuli but was not expressing him/herself verbally. Staff administered cold fluids and sherbet and received the order to transfer him/her to the hospital. At approximately 3:50 P.M., the ambulance arrived and transported the resident to the hospital. Review of the weather history for 8/28/16, showed at 12:54 P.M. the temperature was 90 degrees F and the heat index (a quantity expressing the discomfort felt as a result of the combined effects of the temperature and humidity of the air) was 94.5 degrees F. During an interview on 9/8/16 at 10:09 A.M., Nurse C said the resident was alert and oriented times one and normally only propelled his/her wheelchair for short distances. He/she was normally seated by the nurses' station or right outside the door to the unit. On 8/28/16, Nurse C did not see the resident after lunch. However, staff did not bring him/her onto the hall after lunch. It was normal for the resident to be away from the unit from 12:00 P.M. to 1:00 P.M. During an interview on 9/6/16 at 2:19 P.M., CNA A said due to a bit of a decline in functioning, the resident did not propel his/her wheelchair. He/she pretty much stayed where staff placed him/her. CNA A left for the day at about 1:45 P.M. on 8/28/16 and last saw the resident in the lobby with other residents. It had been a hectic day with a lot of activated call lights. Some of the CNAs had a tendency to disappear or slack off. At some points, there may only be one CNA on the floor. CNA A left without giving report to the oncoming House 2 staff that day. During an interview on 9/9/16 at 1:20 P.M., CNA B said he/she could not recall whether or not he/she was still in the building when the oncoming shift arrived. During an interview on 9/7/16 at 1:58 P.M., the Administrator identified CNA G as the staff person who relieved CNA A for the evening shift on 8/28/16. During an interview on 9/8/16 at 11:36 A.M., CNA G said on 8/28/16, he/she was late, arriving at 3:30 P.M. During an interview at 9/12/16, the Staffing Coordinator said CNA G clocked in at 3:15 P.M. on 8/28/16. The evening shift started at 2:00 P.M. and ended at 10:00 P.M. for CNAs. During an interview on 9/1/16 at 11:59 A.M., the Director of Nursing (DON) said nurses and CNAs were expected to conduct rounds every two hours. There were no set times for rounds, they just needed to ensure that they saw the resident every two hours. During their rounds, the CNAs were to make sure that the residents were dry and toileted, had water and received a response to their activated call lights. Rounds conducted by nurses consisted of ensuring that their assigned residents were alive and breathing, safe, received their medications and received any necessary follow-up assessments. At the end of the shift outgoing staff conducted rounds with the oncoming staff. Both the outgoing staff person and their relief were expected to sign off that the joint round was completed. However, outgoing staff did not have to wait for their relief person to arrive. They were allowed to leave at the end of their shift without rounding with an oncoming staff person or giving report. When that occurred, the oncoming staff person was responsible for rounding on their assigned residents, ascertaining where they were and that they were safe. The resident was confused. His/her care plan specified that he/she should not be left alone in his/her room and needed to sit where staff could see him/her due to the fact that he/she was a fall risk. That meant that he/she should remain close to the nurses' station or outside the unit by the bird cage. If the resident started to leave the area then the charge nurse should go and redirect him/her back. If he/she refused to return then the charge nurse should document that refusal and inform his/her assigned CNA. On 8/28/16, staff last saw the resident at around 1:30 P.M. It was after lunch, so they were busy toileting residents. Oncoming staff for the evening shift was expected to arrive at 2:00 P.M., go up and down the hall in their assigned unit and ensure that none of the residents had fallen on the floor. They received report at 2:30 P.M. or 3:00 P.M. and then began working the shift at around 4:00 P.M. If someone arrived late, then everything got pushed back. Normally, the administrator, DON, receptionist and activities staff kept an eye on residents out on the patio. However, there was fewer staff on duty during the weekend. Consequently, the resident went out onto the patio leading off of the rear of the lobby without staff seeing him/her. Further review of the weather history for 8/28/16, showed at 2:54 P.M. the temperature was 90 degrees F and the heat index was 96.4 degrees F. During an interview on 9/7/16 at 3:28 P.M., Visitor F said he/she took another resident out on the patio after 3:00 P.M. It was pretty warm outside. Some of the residents were sitting under the canopy. Resident #4 was sitting right by the glass patio door in the bright sun, where he/she was sitting at 1:00 P.M. He/she appeared to be asleep and was getting pretty red. Visitor F was concerned about him/her and went to notify the activities director that the resident was outside. During an interview on 9/8/16 at 10:59 A.M., Activity Assistant H said staff normally checked on residents out on the patio by looking out as they passed by. On 8/28/16, he/she was busy with an ice cream social which began at 2:30 P.M. At around 3:20 P.M., Visitor F came to him/her and expressed concern about the resident, described as bald, being out on the patio and sitting in the sun since 1:00 P.M. When Activity Assistant H went out to check on the resident, he/she was red, not sweating and unresponsive. The resident appeared to be asleep and did not seem to want to wake up when Activity Assistant H attempted to rouse him/her. He/she did not come to and speak. The wheels on his/her wheelchair were locked. Activity Assistant H did not recall seeing the resident at the ice cream social or out on the patio during the ice cream social. During an interview on 9/7/16 at 3:41 P.M., Receptionist I said he/she could see through the sliding glass door of the patio at the rear of the lobby. However, most of the patio was not visible from the receptionist's desk. If Receptionist I took a resident outside, then he/she checked on that person every 15 minutes. He/she assisted with keeping an eye on residents out on the patio. However, Receptionist I tended to get busy during the course of the day. Consequently, he/she might not notice someone being taken outside. He/she did not recall having seen the resident on 8/28/16, prior to Visitor F discovering the resident out on the patio. Receptionist I assumed that the nurses had done a head count at change of shift, in order to account for all of the residents. During an interview on 9/18/16 at 2:00 P.M., Weekend Manager D said staff all pitched in and assisted with monitoring the patio by looking outside whenever they happened to be walking past. He/she had last checked the patio between 1:45 P.M. and 3:00 P.M. without seeing the resident out there. Weekend Manager D found the resident back up against the fence and not visible from the lobby. The resident's shoes were off, he/she was very red, drooling and conscious but unresponsive. In order to avoid alarming anyone, Weekend Manager D asked the receptionist to go and get the charge nurse. Further review of the resident's incident investigation, dated 8/29/16, showed the resident appeared red in the face, warm to the touch and was lethargic. Staff assisted the resident to his/her room where he/she was assessed and his/her vital signs monitored. He/she offered no complaints and the nurse did not note any injuries. Staff contacted the resident's physician and received orders to transfer the resident to the hospital for evaluation. He/she received intravenous fluids and returned to the facility within 24 hours. The facility investigation was determined to be inconclusive. Review of the resident's hospital discharge records, dated 8/29/16, showed on 8/28/16, paramedics documented the resident's temperature as 101.6 degrees F. The resident presented at the hospital with visible symptoms of a fever as well as sunburns to the chest, neck and head. He/she wore a wanderguard (electronic monitoring device) on the right ankle, due to the fact that he/she was an elopement risk. The resident incurred heat exposure from sitting outside for at least two hours. He/she also developed renal failure due to the heat exposure. During an interview on 9/12/16 at 7:57 A.M., the resident's physician said the fact that the wheels on the resident's wheelchair were locked while he/she was outside on the patio on 8/28/16, prevented him/her from being able to wheel him/herself back inside. The resident was demented and consequently would not have realized that the wheels were locked. Sunburn could develop within half an hour. It was difficult to say how long it took him/her to develop the fever and renal failure from heat exposure he/she was diagnosed with [REDACTED]. Continued heat exposure could have been life threatening. Review of the facility's undated policy titled, Outdoor Policy for NHC Town & Country, showed the front lobby rear patio has safety rails and a sliding door to allow the residents to go outside in a safe environment as they please, weather permitting. Weather permitting was defined by the judgment of the management of NHC Town & Country. Factors such as, but not limited to, temperature and precipitation will be used to determine if the patio options are safe for the residents. 2. Review of Resident #5's care plan, dated 3/17/16, showed the following: -Alert and oriented times two with confusion; -Monitor for shortness of breath; -Titrate oxygen to keep saturation above 90%; -Risk for falls related to decreased mobility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Wheelchair mobility -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Required extensive assistance of one with bed mobility, transfers, locomotion, toilet use, dressing and personal hygiene. Review of the fall risk scale, dated 7/3/16, showed a total score of 11 (11+ points indicates high or very high risk). It showed he/she had an altered mobility, gait or balance problem. Review of the resident's psychiatric progress note, dated 7/11/16 (no time documented), showed the resident was alert and oriented to self and hour. His/her recent memory was impaired. The resident received a [DIAGNOSES REDACTED]. According to his/her psychiatrist, the resident had delusions and episodic agitation with crying spells in the context of a urinary tract infection (UTI). Review of the resident's Situation, Background, Assessment, Recommendation (SBAR) and progress note, dated 7/29/16 with no time documented, showed the resident went out on the facility patio alone and fell attempting to propel his/her wheelchair back inside. He/she was outside by him/herself. He/she incurred an abrasion to the back and complained of pain to the left hip. An x-ray was ordered. The background portion off the assessment showed he/she had muscle weakness and Alzheimer's disease. A mental status evaluation showed that the resident was experiencing increased confusion or disorientation. Review of the resident's radiology report, dated 7/29/16, showed no acute fracture or dislocation. During an interview on 9/7/16 at 3:16 P.M., Nurse K said the resident was alert and oriented times two. On 7/29/16, activity staff had come to the unit and got the resident to take to an activity. After he/she fell , staff called a STAT (at once) call for assistance over the intercom. Nurse K assessed the resident, who said he/she was coming in from the patio when his/her wheelchair got caught on a bump and pitched him/her forward. At times, the resident experienced mild confusion. For example, he/she believed that a certain resident at the facility was his/her spouse. During an interview on 9/8/16 at 10:59 A.M., Activity Assistant H said activity staff supervised residents during activities. The resident was a little confused and tended to just wander off, rolling away in his/her wheelchair. During an interview on 9/7/16 at 3:06 P.M., CNA J said he/she checked on the resident every two hours, while the resident attended activities. The resident was very confused in the mornings, to the point that he/she did not understand that CNA J was attempting to get him/her to sit in his/her wheelchair and attempting to insert his/her dentures. As the day wore on, the resident became more alert. On the morning of 7/29/16, activity staff took the resident down to the first floor (unknown time). During activities, CNA J checked on the resident every two hours. He/she was not on the first floor when the resident went out onto the patio alone and consequently did not know how long the resident was outside. Staff found him/her on the floor. The resident could only recall that he/she had fallen. According to staff on the first floor, his/her personal safety alarm, used to prevent him/her from standing up, did not sound. Review of the resident's occupational therapy plan of care, dated 8/25/16 at 11:11 A.M., showed the resident was referred to therapy due to a decline in sitting balance and tolerance, poor positioning in his/her wheelchair due to spinal stenosis, as well as a decline in abilities to dress, groom and toilet him/herself. During an interview 9/1/16 at 11:59 A.M., the Director of Nursing (DON) said when the resident left the second floor, his/her assigned staff was expected to check on him/her every two hours, even when he/she received oxygen which needed to be titrated in order to keep his/her oxygen saturation at 90%. A staff person should go out onto the patio with any resident who had a [DIAGNOSES REDACTED]. Residents had a right to fall. The resident fell out of his/her wheelchair coming back in from the patio due to the carpeting. During an interview on 9/13/16 at 2:02 P.M., the resident's physician said the resident could propel his/her wheelchair for short distances. As for the resident's required level of supervision, he/she had good days and bad days. On good days, the resident recognized family members and his/her physician. At other times, he/she was confused and looked around the facility for his/her spouse, mistaking another resident for the spouse. MO 498

Based on observation, interview and record review, the facility failed to provide protective oversight and ensure resident safety during transportation on the facility van. When the facility van driver suddenly applied the brakes, the resident did not wear a seat belt and fell from the wheelchair fracturing his/her clavicle (shoulder bone), and sustained a scalp hematoma (Resident #28). The facility also failed to fully investigate an injury of unknown origin after it was reported. Staff failed to put interventions in place to prevent the injury from occurring again in the future (Resident #29). The census was 169. 1. Review of Resident #28's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/11/16, showed the following: -Admission 2/5/16; -Understands/Understood; -Brief Interview for Mental Status (BIMS, a brief screen of cognitive status), score of 15 (cognitively intact); -No behaviors; -Required extensive assistance for toileting, bathing, transfers and bed mobility; -Required limited assistance for personal hygiene and dressing; -Non-ambulatory; -[DIAGNOSES REDACTED]. Review of the resident's daily skilled nurse's note, dated 4/8/16 at 7:25 A.M., showed the facility transporter notified the facility he/she had an accident on the highway and the resident was sent to the hospital. During an interview on 4/11/16 at 9:50 A.M., Driver R said he/she was transporting the resident to a physician's appointment on the morning of 4/8/16. The resident sat in his/her wheelchair in the van. Driver R clamped the resident's wheelchair to the floor of the van but did not put a seatbelt on him/her. The resident was alert and oriented. The resident talked about his/her dinner the night before and that he/she was excited to eat the leftovers for dinner that night. While transporting the resident, Driver R slammed on the brakes to avoid an accident on the highway. After the van came to a complete stop, Driver R looked in the rearview mirror and noticed the resident was not sitting in his/her wheelchair. Driver R observed the resident on the floor of the van next to the driver's seat. The resident did not respond to him/her at that time. The resident moaned and had a vacant stare. Driver R drove the resident to the hospital where he/she was treated for [REDACTED]. emergency room staff assisted the resident off the van. Driver R called the facility as soon as the resident was admitted to the emergency room to report the incident. He/she drove the resident to physicians appointments for a month and a half. The first time he/she transported the resident, Driver R attempted to put what he/she referred to as a shoulder strap over the resident. The resident refused the shoulder strap because it dug into his/her throat. Driver R did not tell anyone that the resident refused to wear the shoulder strap or that it dug into his/her throat. The Recreation Director trained Driver R on van safety in October 2016. Driver R asked about the shoulder straps and the Recreation Director told him/her she never used the straps. The Recreation Director instructed Driver R how to secure the resident's wheelchair to the floor of the van but did not instruct him/her on the shoulder straps or the use of seatbelts. Driver R did not ask anyone if the shoulder straps were to be used or if there were other straps available to ensure the resident's safety. Driver R did not know if the shoulder straps were to be used for residents in wheelchairs or for residents that sat on the seats on the back row of the van. The resident requested a seatbelt a few weeks ago. The resident told Driver R although he/she trusted his/her ability to drive, he/she did not feel safe in the wheelchair without a seatbelt. Driver R did not tell anyone about the resident's concern. Observation on 4/11/16 at 10:10 A.M., showed the back of the facility van had a long strap in the upper right and upper left corner of the van. Both straps had an adjustable seatbelt buckle. The end of the straps had a metal clasp. During an interview on 4/11/15 at 10:30 A.M., the Recreation Director said the facility purchased the van approximately three years ago. She drove the van prior to Driver R. She showed Driver R how to secure wheelchairs on the van's floor. She did not show Driver R any straps that would be considered seatbelts. She never used the straps on the van. She was not sure what they were or what the purpose was. To her knowledge, there were no seatbelts on the van. Observation on 4/11/16 at 10:40 A.M., showed the Recreation Director and Driver R measured the distance from where the resident's wheelchair was to the area he/she was after Driver R came to a complete stop. The distance measured 14 feet. During an interview on 4/11/16 at 2:30 P.M., the Recreation Director said when the facility purchased the van, she and the administrator figured out how to secure wheelchairs to the floor of the van together. She did not consider it training. No staff was officially trained on van safety. Driver R did not report that the resident did not feel safe and requested a seatbelt in the van. She expected staff to report resident concerns to her so she could follow up with management. Review of personnel records on 4/12/16 at 2:00 P.M., showed no documentation the Recreation Director or Driver R, received any training regarding transporting residents in the facility van. Review of the hospital record, dated 4/8/15, showed the resident sustained [REDACTED]. During an interview on 4/18/16 at 9:05 A.M., the resident's physician said it would be appropriate for the facility to have a policy and/or procedure in place to ensure residents safety while being transported in the facility van. She expected facility staff to be properly trained prior to using equipment. If seatbelts or safety straps were available on the facility van, they should have been used to ensure resident safety. During an interview on 4/11/16 at 9:15 A.M., the administrator said Driver R started transporting residents to physician appointments in October 2015. The facility did not have a policy or process for van safety. Staff were trained how to secure the residents' wheelchairs to the van floor. To his knowledge, there were no seatbelts available on the facility van. During an interview on 4/11/16 at 3:15 P.M., the administrator said the facility van had a wheelchair lift and straps to secure wheelchairs to the floor. To his knowledge, that was all the safety requirements needed. 2. Review of Resident #29's MDS, dated [DATE], showed the following: -Admission 10/9/14; -Severe cognitive impairment; -Short and long term memory problems; -No behaviors; -Required extensive assistance for eating; -Required total assistance for transfers, dressing, toileting, personal hygiene and bed mobility; -Non-ambulatory; -Incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident's certified nurse aide (CNA) care cardex, dated 2/2/16, showed the resident was a mechanical lift transfer with assistance of two staff. Review of the resaident's care plan dated 2/16/16, showed the following: -Required extensive assistance for activities of daily living; -At risk for falls due to back pain; -Staff to assist with all transfers, toileting and locomotion. During an interview on 4/11/16 at 10:50 A.M., CNA T said he/she worked 6:00 A.M. through 2:00 P.M. on 3/25/16. He/She provided care to the resident that morning and observed a red mark on the top of the resident's head. He/she propelled the resident to the nurse's station and reported the reddened area to the charge nurse. CNA T said that was the first time he/she observed the reddened area. Review of the resident's nurse's notes, dated 3/25/16, showed staff reported the resident had a bruise and laceration on the top of his/her head. During an interview on 4/11/16 at 12:00 P.M., Nurse S said he/she worked 6:00 A.M. through 2:00 P.M. on 3/25/16. A CNA propelled the resident to the nurse's station and reported the injury on the top of the resident's head. The resident had a small bruise on the top of his/her head. The laceration was scabbed over at that time. The DON was not at the facility at that time, Nurse S reported the incident to management but did not recall who he/she reported it to. Nurse S documented the assessment of the bruise and laceration in the resident's nurse's notes. Further review of the resident's medical record, showed no additional information regarding the injury of unknown origin. Review of the facility policy, dated 8/1/11, showed the following: -Policy: all events reported as possible abuse, neglect or misappropriation of resident property will be investigated to determine whether the alleged abuse, neglect or misappropriation of resident property did or did not take place. The administrator or DON will determine the direction of the investigation once notified of the alleged incident; -Procedure: the investigation is conducted immediately under the following circumstances: -when it is identified that an alleged incident may have occurred; -as soon as any partner has knowledge and reports an alleged event; -when there is a question as to whether to conduct an investigation, it is best to do so; -the results of all investigations will be completed within five working days of the incident. Depending on the result of the investigation, all necessary corrective actions will be taken. During an interview on 4/11/16 at 12:25 P.M., the DON said she was unaware of the resident's injury of unknown origin until the administrator asked her about it on 3/25/16. She was responsible for ensuring a thorough investigation was completed regarding the injury of unknown origin and to ensure additional interventions were added so this did not happen again. The DON said she did not do a thorough investigation. No staff written statements were obtained. When she interviewed staff who were assigned to the resident prior to 3/25/16, she got conflicting statements. The DON said staff did not know how to report or who to notify when an injury of unknown origin was assessed. She was not able to find out how the injury occurred. When an injury occurred, staff were expected to report the incident to the charge nurse immediately. The charge nurse assesses the resident and notifies the resident's physician and either her or the nursing supervisor. An investigation would be started immediately and interventions would be added to the resident's care plan to ensure the resident's safety. Further review of the resident's care plan, showed staff had not updated it regarding the resident's injury or implemented additional interventions to ensure the resident's safety. MO 263 MO 573

Based on observation, interview and record review, the facility failed to follow their policy and provide protective oversight by allowing a resident identified as an elopement risk and wearing a wanderguard (a battery operated door alarm system designed to monitor cognitively impaired individuals) to exit the front door of the facility propelling another resident in a wheelchair. While assisting the resident in the wheelchair with his/her jacket the wheelchair began to roll down the entrance ramp. It rolled approximately 200 feet, where it hit the curb and propelled the resident into the bushes. The resident was taken to the hospital and expired that night. (Residents #1, #2 and #3) The census was 172. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Admission [DATE]; -Understood/understands; -Brief Interview for Mental Status (BIMS) not done as resident is rarely/never understood; -Long and short term memory problems; -Severe cognitive impairment; -Ambulatory; -Independent with toileting, dressing, eating, bathing, personal hygiene, transfers, range of motion and bed mobility; -No behaviors; -Received antipsychotic medication seven of the last seven days; -Mood: short-tempered, easily annoyed at times; -[DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment, dated [DATE], showed staff documented the resident did not exhibit wandering or exit seeking behaviors in the last 90 days. The resident was cognitively impaired with poor decision making skills, had indications of dementia and a [DIAGNOSES REDACTED]. Review of the resident's diagnostic problem list, dated [DATE], showed the following Diagnoses: [REDACTED]. -Unspecified dementia with behavioral disturbance; -Restlessness and agitation; -Heart disease; -High blood pressure; -Osteoporosis (weak bones). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Understood/understands; -BIMS not done as resident is rarely/never understood; -Long and short term memory problems; -Severe cognitive impairment; -Ambulatory; -Independent with toileting, dressing, eating, bathing, personal hygiene, transfers, range of motion and bed mobility; -No behaviors; -Received antipsychotic medication seven of the last seven days; -Mood: short-tempered, easily annoyed at times. Review of the resident's care plan, dated [DATE], showed the following: -Problem: Cognitive loss: Recently moved back up to House Two. Not exhibiting delusional behaviors. Staff to continue to monitor for any behaviors including wandering; -Goal: Continue to reside on House Two without any problems including wandering in and out of other residents' rooms; -Approaches included: Staff to monitor resident's behavior and continue to update family of bipolar disorder; -Problem: Antipsychotic medications for [DIAGNOSES REDACTED].>-Goal: Will have benefits from, versus side effects through next review; -Approaches included: Administrator medications as ordered. Monitor for effectiveness of medication. Monitor for side effects from medications: delirium, mental status changes, decline in mood or behavior, deterioration in activities of daily living, gait disturbance, low blood pressure, dizziness and poor balance. Review of the resident's physician's orders [REDACTED]. -An order dated [DATE]; check placement of the resident's wanderguard bracelet (monitoring bracelet that alerts staff when the resident attempts to exit the building) every shift; -An order dated [DATE]; check function of wanderguard every night. Review of the resident's treatment administration record, dated [DATE], showed staff documented the placement and function of the wanderguard checks as ordered. Review of the resident's elopement risk assessment, dated [DATE], showed staff documented the following: -History of elopement or exit seeking prior to admission; -Exhibited wandering or exit seeking behavior in the last 90 days; -Ambulated independently; -Exhibited new behavior that would cause concern related to wandering, exit seeking or safety; -Cognitively impaired with poor decision making skills; -Elopement risk. During an interview on [DATE] at 1:00 P.M., the Director of Nurses (DON) said the resident was an elopement risk due a history of elopement attempts and wandering behavior. When staff assessed and documented the resident was not an elopement risk on [DATE], the decision was made to leave the wanderguard on. Observation on [DATE] at 11:50 A.M., showed the resident ambulated in the main lobby of the facility with a wanderguard bracelet on his/her right ankle. Observation and interview on [DATE] at 1:25 P.M., showed the resident had a wanderguard bracelet on his/her right foot. The resident said he/she had to wear it, due to forgetfulness. The resident said a tragedy occurred on [DATE]. Resident #2 was jumped by a gang right outside the main entrance of the facility. The gang killed Resident #2 and then threw him/her in the bushes like a rag doll. The resident said facility staff will not allow residents to go outside the main entrance anymore due to the gang activity. Everything happened so fast, he/she could not save Resident #2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Admission [DATE]; -Understood/understands; -BIMS score: 11 of 15 (,[DATE] indicates moderate cognitive impairment); -No behaviors; -Extensive assistance with toileting, dressing, bathing, personal hygiene, bed mobility and transfers; -Mobility device: wheelchair; -Urinary catheter; -Continent of bowel; -[DIAGNOSES REDACTED]. Review of Resident #2's nurse's note, dated [DATE] at 9:00 A.M., showed staff were called to the parking lot for a STAT (emergency) and found the resident in the bushes. It appeared he/she fell out of the wheelchair at the west end of the parking lot. It was explained that Resident #1 propelled the resident to the lobby and requested to go outside. Resident #1 propelled the resident to the bench on the main entrance ramp. Resident #1 turned away and Resident #2's wheelchair took off down the sidewalk and ended up in the bushes. The physician gave orders to send the resident to the hospital. Review of Resident #2's hospital records, dated [DATE], showed the resident sustained [REDACTED]. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) on his/her right knee and lower leg, cardiac arrest and passed away that same day. Review of the facility's initial 24 hour report, completed by the administrator, dated [DATE], showed on [DATE] at approximately 9:00 A.M., Resident #2 was sitting in his/her wheelchair in the lobby. Resident #1 propelled Resident #2 in his/her wheelchair to the door but was unable to open the door due to the wanderguard device and secured door. The receptionist put the code in for the door to open and let Resident #1 propel Resident #2 out the front entrance. Once outside Resident #1 helped Resident #2 with his/her jacket. Resident #2's wheelchair was not locked and he/she began to roll down the main entrance ramp and onto the parking lot. Resident #1 was unable to stop Resident #2's wheelchair and he/she rolled down the service entrance. At the turn of the service entrance Resident #2 fell out of his/her wheelchair into the bushes. Resident #2 was assessed by staff until emergency medical services (EMS) arrived and took him/her to the hospital. During an interview on [DATE] at 12:07 P.M., Nurse A said he/she was the charge nurse and assigned to Resident #1 on the day shift on [DATE]. At approximately 9:00 A.M., he/she responded to a STAT page to assist a resident that fell outside. Nurse A said no staff called to ask if it was okay for Resident #1 to propel Resident #2 outside the facility. Resident #1 has dementia, a wanderguard, was an elopement risk, had poor safety awareness and should not have been outside unsupervised. During an interview on [DATE] at 11:30 A.M., Nurse B said he/she worked the day shift on [DATE], responded to the STAT page and went outside to assess Resident #2. Resident #1 had a [DIAGNOSES REDACTED]. No one called him/her to ask if it was okay for Resident #1 to propel Resident #2 outside the main entrance on the morning of [DATE]. Resident #1 had very poor safety awareness and periods of extreme confusion and forgetfulness. During an interview on [DATE] at 12:10 P.M., the DON said Resident #2 went to dialysis three times a week and would go to the lobby to wait for transportation. Depending on the weather the resident would sit outside near the top of the main entrance ramp. Staff usually propelled him/her outside. Resident #2 was alert and had safety awareness. Residents with wanderguard bracelets should not go outside without staff or family supervision because they are an elopement risk and have poor safety awareness. During an interview on [DATE] at 1:45 P.M., the receptionist said she worked at the front desk from 8:00 A.M. through 4:00 P.M. On [DATE] Resident #1 propelled Resident #2 to the main entrance door. She was in another office across the hall from the main entrance desk when Resident #1 approached her, propelling Resident #2 in his/her wheelchair. Resident #1 asked her to put the code in to open the door, so they could go outside. She did not think about it and entered the code. The door opened and Resident #1 propelled Resident #2 outside the main entrance. As Resident #1 propelled Resident #2 outside she reminded them not to forget to lock the wheelchair brakes. A few minutes later, a woman ran into the facility and said a resident was rolling down the drive way headed for the bushes. She thought Resident #1 would understand to lock the wheelchair brakes because he/she was the facility's indoor taxi, he/she propelled residents throughout the facility often. The receptionist said Resident #1 was pretty alert and orientated but did forget things because he/she had the beginning stages of dementia. She knew Resident #1 had a wanderguard and said he/she should probably not be outside without staff supervision. She recalled an inservice regarding resident's at risk for elopement. She knew not to allow residents with wanderguards outside without staff supervision. She did not know why she put the code in to allow the door to open. Review of the facility's inservice records showed, on [DATE], the receptionist signed she attended the elopement risk and reporting inservice. During interviews on [DATE] at 10:35 A.M. and [DATE] at 10:10 A.M., the administrator said on [DATE] at approximately 9:00 A.M., Resident #1 propelled Resident #2 to the lobby. Resident #1 asked the receptionist to put the code in to open the main entrance door. The receptionist entered the code and both residents went outside. Resident #1 propelled Resident #2 outside and assisted him/her with his/her jacket. Resident #1 did not lock Resident #2's wheelchair and the wheelchair rolled down the main entrance ramp and approximately 200 feet down the service driveway. At the turn to the driveway the resident's front wheels hit the curb and he/she was propelled from the wheelchair. Staff, family and another resident observed the incident from the parking lot. The receptionist should not have opened the door to allow Resident #1 to propel Resident #2 outside the main entrance door. Resident #1 had a wanderguard, was an elopement risk and had poor safety awareness. Resident #1 should not be outside without staff supervision. The receptionist should have followed the guidelines for outdoor safety and not allow a resident with a wanderguard outside unsupervised. The receptionist was suspended [DATE], pending the investigation. Staff were inserviced in [DATE] regarding elopement risk residents. Staff knew residents with wanderguards are not to be outside without staff or family supervision. Staff were immediately inserviced on the new guidelines for outdoor safety on [DATE]. The new guidelines implemented for outdoor safety included, no residents in manual wheelchair are allowed to sit on the front entrance ramp anymore unless supervised by staff. Only residents that can ambulate and are alert will be allowed to sit outside the front entrance without staff supervision. Review of Resident #3's admission MDS, dated [DATE], showed the following: -Admission [DATE]; -BIMS score: 15 of 15 (,[DATE] indicates cognitively intact); -Mobility device: wheelchair. Review of the facility's investigation dated [DATE], showed a statement written by Resident #3, dated [DATE]. He/she wrote that Resident #2 came out the main entrance followed by Resident #1. Resident #1 stopped briefly to secure Resident #2's jacket. Resident #2's wheelchair brakes were not locked and Resident #2's wheelchair started rolling down the entrance ramp. He/she tried to stop the wheelchair from rolling but could not. The wheelchair picked up speed and rolled down the driveway and into the bushes. During an observation and interview on [DATE] at 1:14 P.M., the administrator pointed to Resident #3, who sat outside the main entrance in a manual wheelchair, and said he/she was the resident who witnessed the incident. At that time, no staff were outside with the resident, he/she was alone. Observation and interview on [DATE] at 1:15 P.M., showed Resident #3 sat in a manual wheelchair outside the facility's main entrance at the bottom of the entrance ramp on the right side under the porch. No staff were outside with him/her at that time, he/she was alone. The state surveyor exited the building, via the main entrance, to conduct an interview with the resident. Resident #3 said he/she witnessed the incident on [DATE]. He/she was positioned outside the main entrance at the bottom of the entrance ramp under the porch at that time. Resident #1 propelled Resident #2 out the main entrance and when they were approximately halfway down the ramp Resident #1 stopped to assist Resident #2 with his/her jacket. Resident #2's wheelchair was not locked and started to roll down the ramp. Resident #3 told Resident #2, to put the brakes on, but it was too late. Resident #3 attempted to stop Resident #2's wheelchair from rolling with his/her foot but the wheelchair picked up speed rolling down the ramp and he/she was not able to stop the wheelchair. Resident #2's wheelchair went flying down the entrance ramp and down the driveway. Resident #2 hit the curb and was propelled into the bushes. No staff were outside during this interview with the resident. Review of the facility's undated guidelines for outdoor safety, showed the following: -Before any resident goes out the front door, the division needs to be notified to make sure it is appropriate. The partner at the front desk will check the resident off on the resident roster when they go outside and make sure the division is aware; -Any resident with a wanderguard should not go outside unattended. A wanderguard book with pictures is located at the front desk on each division; -Discourage residents from sitting out in the front of the center, rather encourage them to go to the back patio that is enclosed. During an interview on [DATE] at 9:15 A.M., Resident #1's psychiatrist said he/she was alert which meant always awake. Resident #1 had dementia and episodes of extreme confusion. Due to the unpredictable episodes of confusion the resident wore a wanderguard bracelet because he/she was an elopement risk. Due to his/her confusion and elopement risk the resident should not be outside the facility without staff supervision because he/she did not have safety awareness. The psychiatrist had not been notified, by the facility, of the incident that occurred on [DATE]. During an interview on [DATE] at 9:00 A.M., the facility's medical director said Resident #1 has a [DIAGNOSES REDACTED]. He expected facility staff to follow the elopement policy and the facility's guidelines for outdoor safety and not allow residents with wanderguards outside without staff supervision. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan which showed the facility would continue to complete a comprehensive elopement risk assessment within 24 hours of a resident's admission, annually, if there were significant changes in condition resulting in an improvement or decline which would effect ambulation, agitation, confusion, an attempted elopement and readmission. The behaviors of residents with dementia and/or a history of elopement would routinely be reviewed with each care plan. The elopement risk book located at the receptionist desk will include a list of resident's with wanderguards, elopement prevention procedures and an updated guideline for outdoor safety. Staff were inserviced on the new elopement policy and guidelines for outdoor safety. Residents with wanderguards will have them checked by the charge nurse daily for function and for placement every shift. Compliance will be reviewed and reported at the quality assurance committee meeting monthly for one quarter, then quarterly times three by the administrator or designee. The facility still needs to monitor their revised policy regarding the outdoor safety guidelines. The facility will monitor residents to assure appropriate measures are taken to ensure residents with a wanderguard and/or a manual wheelchair will not be outside the main entrance of the facility without staff. 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 be taken to address Class I violation. MO 224