Every finding on record at Avenir at Maple Grove

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1, and #2) of five sampled residents, received incontinence care in a timely manner to prevent odors and maintain hygiene. Staff failed to check or change residents who were dependent on staff for assistance with incontinent care for over four hours. The facility census was 52.Review of the facility policy Activities of Daily Living, dated 1/1/26, showed a resident who was 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 #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/5/26, showed the following:-Diagnoses included heart failure, kidney disease and dementia;-Moderate cognitive impairment;-Always incontinent of bowel and bladder;-Dependent on staff for toileting hygiene and lower body dressing. Review of the resident's Care Plan, dated 10/28/25, showed the following:-The resident was incontinent of bowel and bladder;-Cleanse skin, pat dry and apply barrier cream after each incontinent episode;-The resident utilized briefs for incontinence; -Check the resident every two to three hours and as needed for incontinence;-The resident required moderate to maximum assistance from staff with personal hygiene. Observation on 3/5/26 at 10:08 A.M. showed the following:-The resident was in bed. A strong odor of urine permeated the room;-Certified Nurse Assistant (CNA) A and CNA B removed the resident's urine-soaked incontinence brief. The bed pad under the resident was also saturated with a ring of urine;-The resident's skin had imprints of the brief and a bright, pink, inflamed area to the resident's left inner buttock along with an area of macerated skin (a soft white and wrinkled skin condition caused by prolonged moisture) to the coccyx area (tailbone). During an interview on 3/5/26 at 2:00 P.M. the resident said his/her arms and legs did not work as they should, and he/she depended on staff to take care of him/her. He/She did not like to be wet. During an interview on 3/5/26 at 10:45 and 1:30 P.M. CNA A said the following:-His/Her shift started at 6:00 A.M. He/She did not complete walking rounds with the previous shift, so he/she was not sure when Resident #1 was last changed;-He/She had not changed the resident since the start of his/her shift at 6:00 A.M. (over four hours). Licensed Practical Nurse (LPN) C told CNA A the resident was incontinent of urine at 7:30 A.M. LPN C told CNA A and CNA B to change the resident after he/she finished breakfast. CNA A was busy with breakfast and did not get the resident changed until after 10:00 A.M. During an interview on 3/5/26 at 10:50 A.M. and 1:45 A.M. CNA B said the following:-Staff were to do walking rounds with the previous shift to assure the residents were dry and when they were changed last, but it did not normally get done;-He/She was not sure what time the previous shift had changed Resident #1;-He/She should check and change incontinent residents every two hours;-He/She did not get Resident #1 changed for over four hours on his/her shift; -The resident had skin irritation as a result. 2. Review of Resident #2's Care Plan, dated 1/13/26, showed the following:-The resident had a communication problem related to a head injury;-The resident had potential/actual skin impairment related to impaired mobility;-The resident had bladder incontinence and used disposable briefs;-Provide perineal care after each incontinent episode to remain odor free;-The resident required total assistance with personal hygiene. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses included traumatic brain injury;-Severe cognitive impairment;-Dependent on staff for activities of daily living;-Always incontinent of bowel and bladder. Observation on 3/5/26 at 10:35 A.M. showed the following:-The resident was in bed and an odor of urine permeated the room;-CNA A and CNA B removed the resident's incontinence brief, which was saturated with dark, yellow urine;-There were red imprints from the incontinence brief to the resident's skin. During an interview on 3/5/26 at 10:45 and 1:30 P.M. CNA A said the following:-He/She was not sure when night shift changed Resident #2. The first time he/she checked and changed the resident was after 10:00 A.M. (approximately four and a half hours);-The residents on the hall he/she was assigned required a lot of care. Getting the residents up for breakfast was the priority. Incontinent residents should be checked and changed every two hours, but it was difficult to get done. During an interview on 3/5/26 at 10:50 A.M. and 1:45 A.M. CNA B said the following:-Staff were to do walking rounds with the previous shifts to assure the residents were dry and when they were changed last, but it did not normally get done;-He/She was not sure what time the previous shift had changed Resident #2;-He/She should check and change incontinent residents every two hours;-Resident #2 had wounds and had not been changed for over four hours. The residents on the hall required heavy care, and it was hard for staff to get residents changed in a timely manner. During an interview on 3/5/26 at 12:00 P.M. LPN C said the following:-Residents that were incontinent of bowel and bladder should be checked for incontinence every two hours and changed as needed;-Staff were expected to complete walking rounds with the previous shift to determine when the residents were changed last;-At 7:30 A.M. he/she observed Resident #1 was wet with urine. He/She asked CNA A and CNA B to change the resident at that time;-Four hours or more was too long to go without checking and changing a resident who was incontinent. Leaving a resident wet for long periods could lead to new skin issues or worsening skin conditions;-Resident #1 had recently been diagnosed with moisture associated skin disorder (MASD, inflammation and erosion of skin caused by prolonged moisture such as urine, stool or sweat) to his/her buttock. During an interview on 3/5/26 at 1:20 P.M. the Director of Nursing said the following:-Staff on the oncoming shift should do walking rounds with the off going shift. Staff were to ensure residents were clean and dry and determine when the residents were changed last;-Four hours was too long for staff to go without checking and changing an incontinent resident;-Residents were at risk for skin irritation or moisture associated skin disorder if not changed in a timely manner;-Resident #1 was diagnosed with MASD to his/her left buttock recently. During an interview on 3/5/26 at 2:10 P.M. the Administrator said the following:-He would expect staff to check and change incontinent residents every two to three hours or as needed;-If staff were aware a resident was incontinent of urine the resident should be changed immediately, not wait until after breakfast;-A resident left wet for a long period could lead to skin irritation. Complaint # 2739922

Based on observation, interview and record review, the facility failed to provide food items at a safe and appetizing temperature. Five residents (Resident #4, #3, #2, #1 and #5), of five sampled residents, reported staff served foods in the dining room and resident rooms that should be hot at service, cold. The issue had been reported repeatedly through the Resident Council with no resolution. The facility census was 58.Review of the facility policy, Food Safety Requirements, last reviewed/revised 09/25/23, showed the following: -It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -Holding: staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include but are not limited to timely distribution of all meals/snacks. The facility did not provide a policy related to food temperatures following request. 1. Review of the Resident Council meeting minutes showed the following: -On 09/02/25: Dietary: residents reported the food served was cold or burnt; -The meeting minutes showed no documented follow up after this concern;-On 10/6/25: Dietary: residents reported they still received cold food; -The meeting minutes showed no documented follow up after this concern; -On 11/03/25: Dietary: residents reported food was still cold; -The meeting minutes showed no documented follow up after this concern. 2. Review of the dietary Temperature Record for November 2025, showed no food temperature recordings for breakfast, lunch and dinner for the following dates: 11/10, 11/11, 11/12, and 11/13. 3. Observation on 11/13/25 showed the following: -At 12:00 P.M., staff, to include administration, served lunch trays to residents in the dining room. Dietary staff served individual trays from a window in the kitchen to waiting staff on the outside of the window. One tray went out at a time; the plates on the tray were covered with a plastic domed lid with no plate warmer;-At 12:45 P.M., staff, to include administration, served lunch trays to residents on the south hall; the plates were covered with a plastic domed lid and sat on a tray, without a plate warmer; -At 1:00 P.M., staff served the last hall tray on the south hall. Observation of food temperatures for the test tray on 11/13/25 at 1:00 P.M. from the south hall, taken with a metal stem type thermometer, showed the following: -Tuna noodle casserole: 106.0 degrees Fahrenheit; -Lima beans: 84.0 degrees Fahrenheit; -Ice Cream in a Styrofoam container: liquefied on the top and around the sides (the Styrofoam ice cream cup had not been kept in a tray of ice prior to service and had partially melted). 4. Observation on 11/13/25 showed the following: -At 5:30 P.M., staff, to include administration, served supper trays to residents in the dining room. Dietary staff served individual trays from a window in the kitchen to waiting staff on the outside of the window. The plates were covered with a plastic domed lid and sat on a tray, without a plate warmer;-At 5:45 P.M., staff served supper trays to residents on the north hall; the supper trays were served from a mobile food cart; the plates were covered with a plastic domed lid, but were not on a plate warmer; -At 6:00 P.M., facility staff served the last hall tray on the north hall. Observation of the food temperatures for the test tray on 11/13/25 at 6:00 P.M. from the north hall, taken with a metal stem type thermometer, showed the following: -Macaroni and cheese: 95.0 degrees Fahrenheit; -Green beans with mushrooms and onions: 80.0 degrees Fahrenheit. 5. During an interview on 11/13/25 at 11:00 A.M., Resident #4 said the following: -He/She always eats in the dining room; -The food was usually cold, he/she expected it to be hot, but it never was. 6. During an interview on 11/13/25 at 11:45 A.M., Resident #3 said the following: -He/She eats in the dining room and in his/her room at times; -The food was always cold; -He/She was the president of the Resident Council, and many residents had complained about the food being cold for a while, but nothing had been done; -When he/she ate in the dining room, the food at best was lukewarm. 7. During an interview on 11/13/25 at 1:45 P.M., Resident #2 said the following: -He/She eats in the dining room at times; usually he/she ate in his/her room; -The food was cold regardless of where it was served. 8. During an interview on 11/13/25 at 2:20 P.M., Resident #1 said the following: -He/She always eats in his/her room; -The food was never hot; all meals served were cold; -Today's lunch was cold;-He/She told staff before his/her food was cold, but staff did not offer to reheat the meal. 9. During an interview on 11/13/25 at 4:40 P.M., Resident #5 said the following: -He/She always eats in the dining room and the food was cold; -It did not matter which meal was served; all meals were cold; -Most of the time he/she did not ask staff to reheat his/her food, but last week the facility served soup, and it was cold, so he/she asked staff to reheat the soup. 10. During an interview on 11/13/25 at 3:25 P.M., Certified Nurse Assistant (CNA) B said the following: -CNA staff were responsible to pass trays at mealtimes to residents in the dining room and resident rooms; -Residents complained about food being cold, whether they ate in the dining room or in their room. 11. During an interview on 11/13/25 at 3:35 P.M., Dietary [NAME] A said the following: -He/She was not aware residents complained of cold food; -If food was returned to be reheated, it was usually just soup; -Dietary staff were responsible to check food temperatures before serving a meal; -He/She just started as a cook and was not aware of what the food temperatures should be. 12. During an interview on 11/13/25 at 5:15 P.M., the facility Activity Director said the following: -He/She was responsible for Resident Council Meetings; -Several residents complained about the food being cold during the last few resident council meetings; -He/She reported the residents' complaints of cold food to the dietary manager and the facility administrator; -He/She was not sure what interventions were put in place to prevent the food from being cold; -The last resident council meeting was on 11/03/25 and the residents in attendance still complained of cold food. 13. During an interview on 11/13/25 at 5:30 P.M., Licensed Practical Nurse (LPN) C said the following: -Residents complained of cold food all the time; -Resident #1 and his/her family used to complain all of the time about cold food; staff were told by administration to deliver Resident #1's meal tray first from the hall cart, but no other interventions for other residents were initiated. 14. During an interview on 11/13/25 at 06:50 P.M., the administrator said the following: -He was aware residents complained of food being cold; -The facility received a new steam table in the last two weeks so he thought that would help; -Dietary staff were responsible for recording food temperatures; -He was not aware food temperature logs had not been completed by dietary staff for November 10th, 11th, 12th, or 13th. MO#2665567

Based on interview and record review, the facility failed to ensure the Dietary Director had the appropriate competencies and skills set to carry out the function of the food and nutrition services. The facility census was 49. Review of the facility's undated job description for Director of Food Service/Dietary Manager Department, showed the following: -The Food Service Manager position is responsible for planning, organizing, developing, and directing the operations of the Dietary Department in accordance with federal, state, and local regulations and consistent with facility guidelines; -Functions with a moderate degree of independence and is evaluated on overall department performance based on resident satisfaction, employee performance, department safety, and department sanitation; -Directs and supervises production, preparation and service of resident meals; -Processes tray cards, ensure accuracy of physician orders, monitors tray assembly for compliance, diet accuracy and resident preferences; -Completes initial resident interviews, reviews and processes resident preferences; -Manages department personnel. Employs, trains, and schedules staff; -Attends care plan meetings. Completes or assists in the completion of the MDS forms and documents care plans and care plan updates based on changes in diet orders and/or nutritional status as assigned; -Reviews admission progress notes, quarterly notes, and additional progress notes related to condition changes with the Consultant Dietitian; -Reviews seasonal menus and recommends changes related to resident preferences; -Conducts or assistas in staff education. Attends continuing education programs; -Monitors quality performance. Conducts audits and completes reports, as assigned; -Adequate education and training is required to support competent performance. Completion of the Dietary Manager course recommended. Sanitation certification through a National Food Protection Association or Serv Safe required; -Three years of stable food service experience desirable. Two years healthcare, food service management experience required in hardship and with interim assignment. Review of the facility's current employee list, dated 4/28/25, showed the Dietary Director started employment with the facility on 7/14/21. During an interview on 4/30/25 at 12:46 P.M., the Dietary Director said the following: -She had not completed food safety and managment training with topics such as foodborne illness, sanitation, and food purchasing/receiving; -She had prior food service experience and was the assistant dietary manager at the facility's sister facility; -When she began employment in her current position a few years ago, she started a food safety training course but had not completed the training. During an interview on 4/30/25 at 1:57 P.M., the Administrator said he was unaware the Dietary Director did not have the required food safety and management training.

Based on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not practice proper hand hygiene or hair restraint usage. Staff did not ensure food items were labeled or dated and did not ensure dented cans of food were removed from use. Staff did not ensure the dishwashing machine water temperature gauge was functioning and the appropriate chemical sanitizer was being applied to dishes. Staff did not maintain surfaces and equipment to be free from a buildup of debris or ensure items were stored dry and in a sanitary manner. The facility census was 49. 1. Review of the facility's undated policy, Hand Washing Procedure, showed the following: -Turn on faucets and adjust water temperature for comfort; -Wet hands with water, spread a thin film of soap over entire skin surface, wash thoroughly using friction to all surfaces of hands, paying particular attention to fingernails and rings; -Add more water for additional suds if needed; -Rinse thoroughly under running water so that water runs off fingertips; -Dry with paper towels; -Turn off water faucets with paper towels; -Discard paper towels in proper container; -When to wash hands: -After touching any contaminated surfaces; -Before and after passing trays and handling food; -After wearing gloves. Review of the facility policy, Food Safety Requirements, revised 9/25/23, showed the following: -Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; -Staff shall wash hands prior to handling clean dishes and shall handle them by outside surfaces or touch only the handles of utensils; -Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects; -Staff shall wash hands according to facility procedures; Observation on 4/28/25 from 12:14 P.M. to 12:45 P.M., in the kitchen, showed the following: -Cook A washed his/her hands at the handwashing sink, turned the faucet off with his/her clean hands, and obtained paper towels to dry his/her hands; -He/She used his/her clean hands and the paper towels to grasp and open the lid of a trash can and discard the paper towels; -He/She donned gloves and used his/her gloved hands to poke holes and open the foil covering of food items on the steam table; -He/She served food items from the steam table onto resident's plates and touched resident meal cards, clean plates, trays, and serving utensil handles; -When the serving utensil slid into the pan of mashed potatoes (the handle of the utensil made contact with the mashed potatoes), he/she used his/her gloved hand to grasp the serving utensil and continued serving mashed potatoes with the utensil. Observation on 4/29/25 from 12:25 P.M. to 1:02 P.M., in the kitchen, showed [NAME] A served food items onto plates for residents from the steam table during the lunch meal service. He/She dropped a resident meal card on the floor, picked up the meal card and placed it on the steam table counter and then onto the resident's meal tray. He/She did not wash his/her hands or change his/her gloves and continued serving food to residents. During an interview on 4/30/25 at 11:12 A.M., [NAME] G said staff should wash their hands by wetting them, lathering for 20 seconds, rinsing, drying, and turning off the faucet handles with a paper towel. During an interview on 4/30/25 at 12:46 P.M., the dietary manager said the following: -She expected staff to practice proper handwashing and gloving; -When washing staff's hands, staff should use a paper towel to turn off the faucet handle. 2. Review of the facility policy, Food Safety Requirements, revised 9/25/23, showed the following: -Dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food; -Hair nets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. Observation on 4/28/25 at 7:59 A.M., in the kitchen, showed Dietary Aide C placed food and beverage items on residents' food trays during the breakfast meal service. He/She had 2-inch long facial hair and did not wear a beard restraint. Observation on 4/30/25 at 9:32 A.M., in the kitchen, showed Dietary Aide C scooped pudding into bowls at the food preparation counter. He/She had 2-inch long facial hair and did not wear a beard restraint. Observation on 4/30/25 at 10:34 A.M., in the kitchen, showed Dietary Aide C prepared beverages in a pitcher at the preparation counter. He/She had 4-inch long hair on his/her head 2-inch long facial hair and did not wear a hair or beard restraint. During an interview on 4/30/25 at 11:12 A.M., [NAME] G said staff should wear hair restraints in the kitchen. During an interview on 4/30/25 at 12:46 P.M., the dietary manager said she expected staff to practice proper hair restraint usage in the kitchen. 3. Review of the facility policy, Food Safety Requirements, revised 9/25/23, showed the following: -Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; -Facility staff shall inspect all food, food products and beverages for safe transport quality upon delivery/receipt and ensure timely and proper storage; -Follow contract/vendor procedures when food arrives damage or concerns are noted, remove these foods from use; -Refrigerated storage - labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its used by date, or frozen/ discarded and keeping foods covered or in tight containers; -Foods and beverages shall be distributed and served to residents in a manner to prevent contamination. Observation on 04/27/25 at 10:33 A.M., in the walk-in cooler located adjacent to the kitchen, showed the following: -An unlabeled and undated clear container of chicken and dumplings; -An unlabeled plastic zipper bag containing opened Swiss cheese; -An unlabeled plastic zipper bag containing open ham slices; -An unlabeled plastic zipper bag containing orange colored shredded cheese; -A cart containing two trays stacked one on top of the other, with 25 bowls containing butterscotch pudding on each tray. The top tray contained 25 bowls that were uncovered and open to air. Observation on 04/27/25 at 10:42 A.M., in the refrigerator located in the kitchen, showed 18 unlabeled cups of pudding. Observation on 4/28/25, at 7:49 A.M., in the walk-in cooler located adjacent to the kitchen, showed an unlabeled and undated clear square container of pasta mixed with red-colored sauce. Observation on 4/30/25 at 9:49 A.M., in the dry food storage room located adjacent to the kitchen, showed a 6-pound 12-ounce can of beans had a moderate amount of dent damage to the side of the can. A 50-oz can, located with cans of chicken noodle soup, was missing the label and did not have any identification of the food contents written on the can. During interviews on 4/30/25 at 9:49 A.M. and 12:46 P.M., the dietary manager said the following: -Food items should be labeled and dated; -Dented food cans should be not be in the dry food storage room and should be returned to the vendor; -Staff should tape labels back onto cans or use a marker to write the food contents on the can if the labels came off. 4. Review of the facility's policy, Sanitation - Warewashing: Warewashing and Storage, revised January 2024, showed the following: -Purpose: to ensure food is prepared and served in clean food-safe supplies. To maintain compliance with federal, state, and local regulations governing food safety and to support infection control; -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines as follows: -All dinnerware, utensils, preparation, and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approveddish machinee and shall be air dried prior to storage; -The dish machine, if low temp, shall use a detergent, a rinse drying agent, and sanitizer. The sanitizing temperature for a low temperature machine shall be above 110 degrees or at an appropriate temperature to activate the sanitizer to a minimum of 50 parts per million (PPM); -The pot sink shall be a three sink unit with detergent in the first sink, clear rinse water in the second, and sanitizer in the third and final sink. Pots and pans washed in the pot sink may be sanitized in thedish machinee; -Test strips shall be available for the pot sink and low tempdish machinee sanitizer. Results shall be checked and recorded daily. Observation on 4/30/25 at 9:25 A.M., in the kitchen dishwashing area, showed the temperature gauge on the dishwashing machine was not working. Dishwasher B used a chlorine test strip to measure the sanitizer concentration of the dishwashing machine but there was no color change on the test strip. During an interview on 4/30/25 at 9:25 A.M., Dishwasher B said the dishwashing machine temperature gauge had not worked for awhile. He/She was unaware the sanitizer concentration level was not registering on the test strip. The test strip was white and was supposed to change to purple in the range of 200 PPM. During an interview on 4/30/25 at 9:36 A.M., the dietary manager said she was unaware the dishwasher machine temperature gauge was not working and the sanitizer concentration level was not registering on the test strip. The facility leased the dishwashing machine and she would need to contact the vendor. The last time the dishwashing machine was serviced was in September or October of 2024. 5. Review of the facility policy, Food Safety Requirements, revised 9/25/23, showed all equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Observation on 4/28/25, from 7:49 A.M. to 8:39 A.M., during the dietary tour, showed the following: -The floor of the walk-in cooler was sticky. There was a pool of pink liquid and dried yellow debris visible on the floor; -On the shelves of the walk-in cooler, a half-full jug of cooking oil was coated in a sticky residue with black debris and specks around the jug's handle, lid, and spout; -The large chest freezer, located in the dishwashing area of the kitchen, had an excess accumulation of frost and ice buildup and there were various bits of food and trash debris in the bottom of the freezer; -Metal steam table pans, stacked on a shelf in the dish storage area, were stacked together and moisture was visible between the pans when separated; -The ice machine, located outside the kitchen in the adjacent dining room, had dried white drips across the exterior and interior surfaces of the machine. The hardware on the ice machine's interior side of the door was rust-colored. The ice scoop holder, mounted on the side of the machine, had moist brown debris and crusted white debris in the bottom of the holder that made contact with the metal ice scoop. Observation on 4/28/25 at 12:09 P.M., in the kitchen, showed the following -The metal vent, located above the two-compartment sink, had black debris on the vent and around the ceiling of the vent. The ceiling in this area was discolored brown and the paint around the vent was peeling; -The mixer, located on the food preparation counter, had dried food debris splattered on the food shield and mixer's exterior surface (no staff were in the area or actively using the mixer). Observation on 4/30/25 from 9:21 A.M. to 9:32 A.M., in the kitchen, showed the following: -The food processor, located on the food preparation counter, showed visible moisture that dripped down the interior surface of the food processor container (no staff were in the area or actively using the food processor); -The dishwashing machine had a moderate amount of crusty white debris on the exterior and interior surfaces of the unit. During an interview on 4/30/25 at 9:58 A.M., the maintenance director said he cleaned and sanitized the inside of the ice machine monthly. He did not routinely clean the outside of the machine and assumed dietary staff did this task. He had repaired the door to the ice machine with screws and hardware because a new door was expensive. He was not aware the rusting screws could contaminate the ice. During an interview on 4/30/25 at 12:46 P.M., the dietary manager said the following: -She expected food to be stored, prepared, and served under safe and sanitary conditions; -Staff were to clean and sanitize the facility ice machine scoop and scoop holder twice per week. She wasn't sure who cleaned the outside of the ice machine; -The chest freezers needed to be defrosted at least monthly but it had been a couple of months since this had been done; -The walk-in cooler and freezer floors should be cleaned weekly or more frequently if needed. 44665

Based on interview and record review, the facility failed to ensure all staff members were provided with written documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine and/or refusal of the vaccine. Further review showed the facility failed to maintain documentation related to staff COVID-19 vaccination status, whether received or declined. The facility census was 49. Review of the Centers for Medicare and Medicaid Services (CMS) memo, QS0-25-14-NH, dated 03/10/25, showed the following: -The LTC facility must develop and implement policies and procedures to ensure all the following: -When COVID-19 vaccine is available to the facility, each staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the staff member has already been immunized; -Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine; -The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: -That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; -Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; -The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN); -GUIDANCE: In order to protect LTC residents from COVID-19, each facility must develop and implement policies and procedures that meet each staff member's information needs and provides vaccines to all staff that elect them; All staff must be educated on the COVID. Education must cover the benefits and potential side effects of the vaccine. This should include common reactions, such as aches or fever, and rare reactions such as anaphylaxis; -LTC facilities must offer staff vaccination against COVID-19 when vaccine supplies are available to the facility. Screening individuals prior to offering the vaccination for prior immunization, medical precautions and contraindications is necessary for determining whether they are appropriate candidates for vaccination at any given time. The vaccine may be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity; -The facility must maintain documentation that each staff member was educated on the benefits and potential side effects of the COVID-19 vaccine and offered vaccination or provided information on obtaining the vaccine unless medically contraindicated or the staff member has already been immunized. Compliance can be demonstrated by providing a roster of staff that received education (e.g., a sign-in sheet), the date of the education, and samples of the educational materials that were used to educate staff. The facility must document the vaccination status of each staff member (i.e., immunized or not). A COVID-19 vaccine policy was requested but not provided by the facility. Review of an untitled document provided by the facility, dated 05/22/23, showed the following: Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic: -Encourage everyone to remain up to date with all COVID-19 vaccine doses; -Health care providers, residents, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. 1. Review of the facility's list of new employees, dated 08/11/2023 through 04/27/2025, showed the facility hired 146 new employees during this time period. Review showed the facility had no documentation to show staff had been educated on the the benefits, risks and potential side effects associated with the COVID-19 vaccine and/or had been offered or refused the vaccine. During an interview on 05/09/25 at 1:52 P.M., Certified Nurse Assistant (CNA) J said the following: -He/She had worked at the facility for approximately two years; -The facility had talked to him/her about the COVID-19 vaccinations; -The facility had offered a refusal form; -The facility had informed him/her he/she could get the COVID-19 vaccination from the health department. During an interview on 05/09/25 at 2:00 P.M., CNA K said the following: -He/She had worked at the facility for approximately six months; -The facility had talked to him/her about the COVID-19 vaccinations; -The facility had offered a refusal form; -The facility had informed him/her he/she could get the COVID-19 vaccination from the health department. During an interview on 04/29/25 at 12:37 P.M., the Director of Nursing (DON) said the following: -Staff were verbally informed about the latest COVID-19 vaccines; -There was no documentation of staff education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine and/or refusal of the vaccine; -There was no documentation of staff who had received the COVID-19 vaccine; if staff received it off-site, which was what they were advised they could do, they did not provide proof of the vaccination.

Based on observation and interview, the facility failed to maintain the facility walls, ceilings, sink counter' and dining room/TV room chairs in good repair. The facility also failed to ensure the parking lot and driveway in front of the facility were free of damage and large potholes. The facility census was 49. Review of the facility's policy, Resident Rights, revised 05/04/22, showed the residents had a right to a safe, clean, comfortable, and homelike environment. 1. Observation on 04/29/25 at 8:12 A.M., in occupied resident room [ROOM NUMBER], showed a laminated countertop surrounded the sink. An approximate 6 foot section of the counter was damaged where the particle board showed through the laminated surface. The surface was very rough and had uneven edges directly in front of the sink. Observation on 04/29/25 at 8:13 A.M. in occupied resident room [ROOM NUMBER], showed the following: -An approximate 4 foot by 3 foot section of the wall, located under the sink, had multiple full length cracks. An approximate 1 foot by 1 foot section of the white painted wall, located adjacent to the plumbing under the sink, had a dark yellow, light brown discoloration. -There was an approximately 4 foot long crack in the ceiling adjacent to the sprinkler head. An approximate 3 inch by 3 inch section of the ceiling was falling downward and was pulled away from the ceiling. 2. Observation on 4/27/25 at 10:15 A.M. in occupied room [ROOM NUMBER] showed multiple scuffs and scrapes in the paint on the wall behind the resident's bed. Observation on 4/28/25 at 9:10 A.M. in occupied room [ROOM NUMBER] showed the following: -Multiple large white scrapes on the wall behind Bed 2; -The scrapes were deep and exposed dry wall underneath. 3. Observation on 4/29/25 at 7:08 A.M. in the TV area showed the following: -Three tan upright chairs positioned around the TV area; -The tan covering on the arms of the chairs was worn and exposed gray cloth material underneath. Observation on 4/29/25 at 2:04 P.M. showed 18 of the 29 chairs in the dining room were in poor condition with tears and rips in the vinyl seating exposing the material underneath. During an interview on 4/30/25 at 1:20 P.M., the Activity Director said the following: -She had noticed the torn chairs in the dining room/TV room; -She did not report the chairs to the Administrator as she figured he would also see the condition of the chairs; -She thought since housekeeping cleaned the chairs daily, and they would report to the Administrator. During an interview on 4/29/25 at 8:45 A.M., Housekeeper M said the following: -Housekeeping staff were responsible for cleaning the chairs in the dining room and TV area; -He/She tried to wipe the chairs off the best he/she could; -Most of the dining room chairs were in poor condition; -Everyone could see the poor condition of the chairs as they passed through the dining room and TV area; -In the past, he/she reported the condition of the chairs to administration and nothing was done. During an interview on 4/30/25 at 2:49 P.M., the Housekeeping Supervisor said the following: -Housekeeping staff were responsible for cleaning the chairs in the dining room and TV area; -The chairs were hard to clean. -She reported the poor condition of the chairs to the Administrator more than once; -They only had four spare chairs to replace the chairs in the dining room which was not enough. 4. Observation on 4/30/25 at 7:30 A.M., of the facility's exterior entrance and parking lot, showed the following: -Several potholes, approximately 2-foot wide by 3-foot long by 3-inches deep, were visible in the parking lot and created an uneven surface; -Multiple areas of concrete were cracked and broken around the main entrance. These areas created an uneven surface and were approximately 3 inches deep; -Along the southwest driveway of the main entrance, a depression in the asphalt approximately 4-foot wide by 6-foot long by 4-inches deep that created an uneven surface. During an interview on 04/28/25 at 4:17 P.M., Resident #37 said the following: -He/She has permission to sign out and go outside of the facility to the park or surrounding areas; -The facility parking lot was dangerous, and he/she was worried that someone was going to get hurt; -The facility parking lot had some really deep pot holes; -He/She had trouble getting through the parking lot in his/her wheelchair. 5. During interviews on 04/30/25 at 2:07 P.M. and on 05/12/25 at 9:31 A.M., the Maintenance Director said the following: -He was responsible for the repairs to the entire facility; -He knew there were repairs that needed to be done in room [ROOM NUMBER], but the roof leaked and it would do no good to complete the repairs under the sink without first repairing the roof; -He knew the laminated particle board counters surrounding the sinks were in disrepair; -He was aware of the condition of the walls in some of the rooms behind the bed; -The scrapes and scuffs were due to staff hitting the beds up against the walls; -Housekeeping staff were responsible for the chairs in the dining room and TV area. During interviews on 4/30/25 at 1:57 P.M. and 3:00 P.M. and on 5/13/25 at 2:10 P.M., the Administrator said the following: -The facility's driveway and parking lot were in poor condition and in need of repair. The facility had recently obtained a quote to have repairs made; -He was aware the dining room and TV room chairs were in poor condition; the chairs were old; -The Maintenance Director was responsible for the general upkeep of the building; -Staff were to send the maintenance staff a ticket when they saw something that needed to be fixed; -He was aware of some ceilings, walls, and sink tops which needed repairs; -The building should be in good repair. MO 252730

Based on observation, interview, and record review, the facility failed to update and revise the comprehensive care plan for three residents (Resident #9, #32 and #42) in a review of 19 sampled residents. The facility failed to update Resident #9's care plan to address continued risk for skin breakdown due to recent decline and decreased mobility, failed to update Resident #32's care plan to accurately reflect his/her care needs and failed to update Resident #42's care plan with intervention for wound care and enhanced barrier precautions (EBP). The facility census was 49. Review of the facility policy, Care Planning - Interdisciplinary Team, reviewed 01/2017, showed the following: -Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; -Purpose: 1. To assess each resident's strengths, weaknesses, and care needs; 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, andwell-beingg as possible; -The policy did not address when care plan changes/revisions should be made and that the care plan should accurately reflect the resident's care needs. 1. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/07/25, showed the following: -Moderately impaired cognition; -Dependent on staff for bed mobility and transfers; -Diagnoses of other fracture, dementia and malnutrition; -No falls; -At risk for pressure ulcers (a localized injury to the skin and underlying tissue caused by sustained pressure); -No unhealed pressure ulcers; -Application of dressing to feet with or without topical medications. Review of the resident's progress notes, dated 04/10/25 at 1:30 P.M. showed the following: -Resident's right heel has 5.5 centimeters by 4 centimeters area noted; -Eschar (necrotic tissue, which is dead, dry, and often black or brown, that forms in the wound bed) around edges with pink center, area is not open; -No drainage; -Skin prep (liquid film-forming skin protectant) to area and heels floated. Review of the resident's physician's orders, dated 04/11/25, showed the following: -Skin prep to left heel preventative every shift; -Skin prep to right heel venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) twice daily. Review of the resident's progress notes, dated 04/12/25 at 1:10 P.M., showed the following: -Called to resident's room and found resident laying on floor on his/her left side; -The resident said he/she was going to stand but slid off the bed to the floor but his/her feet stayed on the floor; -The resident said he/she has left leg pain. Review of the resident's progress notes, dated 04/14/25, showed the following: -At 12:59 P.M., X-ray of left knee impression acute proximal tibula-fibula (the two long bones in the lower leg) fracture. Physician notified; -At 1:10 P.M., spoke with physician's office. New orders received to refer to orthopedics to immobilize the left leg. Non-weight bearing left leg; -At 2:14 P.M.,Interdisciplinaryy team (IDT) investigated a fall that occurred on 04/12/25. Precautionary measures are in place to prevent a fall/injury. Call light was within easy reach but was not activated. Abnormal X-ray reports, orthopedic consult scheduled for 04/15/25, non-weight bearing (NWB) /immobilizer (a medical device designed to restrict movement of the knee joint, typically worn after surgery or injury to promote healing and prevent further damage) and pain management aware, care plan was updated. Review of the resident's physician's orders, dated April 2025, showed the following: -On 04/14/25, an order for non-weight bearing to left leg; -On 04/15/25, an order for left knee immobilizer in place when up. Check skin integrity every shift. Review of the resident's care plan, revised 04/25/25, showed the following: -The resident has an Activities of Daily Living (ADL) self-care performance deficit related to weakness, past compression fractures (a type of break in a vertebra, one of the bones in the spine, where the bone collapses or is crushed) of the thoracic spine (the section of the vertebral column located in the mid-back, running from the base of the neck to the top of the rib cage); -Bed mobility: The resident is independent to reposition and turn in bed; -The resident has limited physical mobility related to impaired mobility; -The resident will walk with staff to meals. He/She uses a wheeled walker and a gait belt (safety device used by caregivers to help patients with limited mobility during transfers, ambulation, and other mobility-related activities.); -The resident has actual impairment to skin integrity related to limited mobility; -The resident has actual/potential for falls related to gait/balance problems; -No documentation regarding the venous ulcer to the right heel and treatment; -No documentation regarding the fall on 04/12/25; -No documentation regarding needing increased assistance with bed mobility, NWB status to the left lower extremity and placement of an immobilizer; -No documentation regarding pain management. During an interview on 04/27/25 at 3:19 P.M., the resident said the following: -He/She had a recent fall and horrible pain in his/her left foot; -He/She has a black blister on his/her right heel; -He/She could not walk right now; -Two staff use the mechanical lift to get him/her up out of bed. Observation on 04/28/25 at 8:30 A.M. in the resident's room, showed the following: -The resident lay in bed eating breakfast; -There was an immobilizer present on the resident's left leg; -There was an approximate quarter sized black scab present on the resident's right heel. During an interview on 04/28/25 at 9:45 A.M., the Assistant Director of Nursing (ADON) said the following: -The resident had a recent fall and a physical decline; -The resident was currently non-weight bearing on the left leg and required staff assist of two for ADLs including transfers with the mechanical lift; -The resident also had a wound on his/her right heel followed by the physician from the hospital who specialized in wounds. 2. Review of the Resident #32's admission MDS, dated [DATE], showed the following: -Moderately cognitively impaired; -Occasionally incontinent; -Independent with toileting hygiene; -Required moderate assistance from staff for personal hygiene; -Required partial assistance from staff for showering; -No documentation of refusal of cares; -The Care Area Assessment (CAAs) Summary showed the following care areas on the care plan: delirium, activities of daily living: functional/rehabilitation, and urinary incontinence; -The only mobility device the resident used was a walker. Review of the resident's care plan, revised 04/03/25, showed the following: -No documentation the resident was occasionally incontinent; -No documentation showing toileting hygiene; -No documentation showing personal hygiene; -No documentation showing showering; -No documentation of the resident's refusal of cares; -No documentation showing CAAs: delirium and urinary incontinence; -No documentation of mobility devices the resident used; -No documentation of the resident's behaviors; -No documentation of the resident having a germ phobia (a persistent fear of germs and contamination). Observation on 04/29/25 at 5:08 A.M., showed the following: -The resident stood up from sitting at the dining room table; -His/Her blue sweat pants and gray sweater were visibly wet. Observation on 04/29/25 at 5:20 A.M., showed the following: -Certified Nurse Assistant (CNA) Q and Certified Medication Technician (CMT) D tried to assist the the resident to change his/her soiled clothes; -The resident refused. Observation on 04/29/25 at 10:15 A.M., showed the following: -The resident stood up from the couch in the main sitting area and said, Spray it, spray it, spray it - there are germs; -The Assistant Director of Nursing (ADON) found a spray bottle and sprayed the surface of the couch. Observation on 04/29/25 at 2:23 P.M., showed the resident walked down the front hall, using a quad cane. During a telephone interview on 05/09/25 at 2:00 P.M., CNA K, said the following: -The resident required assistance from one to two staff members for toileting assistance; -The resident needed assistance with changing his/her soiled clothing; -The residentneededs assistance with everything when he/she was incontinent of urine; -The resident did not like germs. During an phone interview on 05/09/25 at 2:27 P.M., Licensed Practical Nurse (LPN) L, said the following: -The resident did not like staff to help him/her with his/her incontinent care and staff had asked family to help get him/her into the shower while they were visiting because he/she had been refusing to take a shower; -The resident refused staff help with his/her incontinent cares; -The resident will holler and scream at staff when staff are attempting to help with peri-care after incontinent episode; -The resident did not like germs. During a telephone interview on 05/12/25 at 10:20 A.M., the ADON, said the following: -The resident will take his/herself to the bathroom, but will not change his/her soiled clothes or soiled brief; -The resident refused staff member's attempts to change his/her clothes after incontinent episodes on 04/29/25; -She did not know if the resident used a quad cane; he/she just carried a quad cane around that he/she hooked to his/her walker; -The resident did not like germs and she put plain water in a spray bottle for staff to spray for germs when the resident requested help with germs from the staff. 3. Review of Resident #42's PPS 5 Day MDS, dated [DATE], showed the following: -One or more unhealed pressure ulcer stage one (a full thickness skin and tissue loss where the extent of the damage cannot be determined because the wound bed is covered by slough (yellow, tan, gray, green or brown dead tissue) or eschar (tan, brown or black scab) or higher; -One unstageable pressure ulcer due to coverage of wound bed by slough (yellow, tan, gray, green or brown dead tissue) and/or eschar; -The resident received pressure ulcer care; -Application of non surgical dressing with or without topical medications, other than to feet; -Application of dressings other than to feet. Review of the resident's Care Plan, revised 03/10/25, showed the following: -The resident has potential/actual impairment to skin integrity related to unstageable pressure area to his/her mid-low back overbonyy prominence; -The resident will have no complications related to pressure area of the mid-low back through the review date; -Administer treatments as ordered and monitor for effectiveness; -No documentation of enhanced barrier precautions (EBP) or guidance for the resident's wound care. Review of the resident's Physician Orders, dated April 2025, showed the following: -Treatment: open area to mid back cleanse with wound cleanser, pat dry, apply skin prep, cut circle out of center of 2 x 2 foam dressing, position cut out over the wound and secure, apply medihoney (a medical-grade honey dressing used to promote wound healing) over wound, cover with second foam dressing, change daily for skin integrity. Observation on 04/29/25 at 2:00 P.M. showed Licensed Practical Nurse (LPN) O entered the resident's room and provided wound care treatment as ordered. During an interview on 04/29/25 at 4:05 P.M. and 04/30/25 at 2:15 P.M., the MDS Coordinator said the following: -She was responsible for updating the care plans; -She and the interdisciplinary team (IDT) meet in the mornings to go over any updates, the ADON put in an IDT note, and then she puts in the new intervention, but doesn't necessarily put in dates; -She was not aware Resident #42 was on EBP; -She had worked on Resident #32's care plan, but it was not currently up to date. During an interview on 04/30/25 at 12:00 P.M. and 5:15 P.M., the Director of Nursing (DON) said the following: -The MDS Coordinator was responsible for completing and updating care plans; -The interdisciplinary team (IDT) meets to discuss and updates and/or changes in resident conditions and interventions, and she would expect those new interventions or changes to be updated to the care plan right away; -Care plans should be revised with changes in resident condition. 45563 47008

Based on observation, interview and record review, the facility failed to ensure staff provided three residents (Resident #6, #32 and #33 ), in a review of 19 sampled residents, that were unable to complete their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 49. A request was made for, but the facility did not provide, a policy for ADL care, including oral care. Review of the facility's policy, Urinary Continence and Incontinence - Assessment and Management, reviewed 01/2017, showed the following: -If the resident does not respond and does not try to toilet, or for those with severe cognitive impairment, staff will use a check and change strategy; -Check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. -Notify the supervisor and/or medical practitioner if the resident refuses the procedure. 1. Review of Resident #33's Care Plan, dated 02/25/25, showed the following: -The resident was totally dependent on staff for repositioning and turning in bed, dressing and personal hygiene; -The resident has bladder incontinence related to impaired mobility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 03/05/25, showed the following: -Moderately impaired cognition; -Inattention and disorganized thinking present, fluctuates; -Dependent on staff for toileting hygiene and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses of traumatic brain injury (TBI) (a brain injury caused by an external force, resulting in alterations in brain function or other evidence of brain damage) and seizure disorder. Observation on 04/29/25 at 7:11 A.M. in the resident's room showed the following: -The resident lay awake in bed; -The resident was incontinent of urine; -Certified Nurse Aide (CNA) E and CNA F entered the resident's room; -The resident's incontinence brief was saturated with urine; -There was a strong urine odor in the room; -CNA F removed the resident's urine soiled brief and rolled the resident to his/her left side; -CNA E applied barrier cream to the resident's peri area; -Neither CNA E nor CNA F provided peri care; -CNA E and CNA F applied a clean incontinence brief. During an interview on 04/29/25 at 7:21 A.M., CNA E and CNA F said the following: -They usually perform peri care after the resident was incontinent; -The resident was usually compliant with cares. 2. Review of Resident #32's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Occasionally incontinent of urine; -Independent with toileting hygiene; -The resident required moderate assistance from staff for personal hygiene; -No documentation of refusal of cares. Review the resident's care plan, revised 04/03/25, showed the following: -No documentation of toileting hygiene; -No documentation of incontinent episodes; -No documentation of behaviors or interventions for behaviors. Observation on 04/29/25 at 5:08 A.M., showed the following: -The resident stood up from the dining room table; -His/Her blue sweat pants were visibly soiled with urine; -The entire left side of his/her pants, spanning approximately eight inches past the fold of his/her buttock, appeared wet; -The waistband of his/her gray sweater appeared wet approximately four inches up from the waistband; -He/She sat down on the sofa in the main sitting area. Observation on 04/29/25 at 5:20 A.M., showed the following: -CNA Q and Certified Medication Technician (CMT) D tried to get the resident to change his/her soiled clothes; -The resident refused staff assistance to change. During an interview on 04/29/25 at 5:30 A.M., CNA Q said the following: -The resident normally allowed him/her to assist him/her with cares; -He/She was going to let the resident calm down and see if another staff member could approach him/her later; -Sometimes the resident could be resistant to cares. Observation on 04/29/25 at 6:20 A.M., showed the following: -The resident continued to wear the visibly soiled blue sweat pants and a gray sweater; -The activities director approached the resident and asked him/her if she could help him/her change his/her clothes; -The resident refused and sat down on the sofa in the main sitting area. Observation on 04/29/25 at 6:34 A.M., showed the following: -The resident continued to wear the visibly soiled blue sweat pants and a gray sweater; -He/She sat down on the cloth sofa in the main sitting area. Observation on 04/29/25 at 10:15 A.M., 10:57 A.M., and 11:30 A.M., showed the resident sat on the couch in the main sitting area wearing the same visibly soiled blue sweat pants and gray sweater. The area were the resident sat smelled of urine. Observation on 04/29/25 at 12:04 P.M., 1:15 P.M, and 1:32 P.M., showed the resident sat at the front, middle dining room table, wearing the same visibly soiled blue sweat pants and gray sweater. Observation on 04/29/25 at 2:23 P.M., showed the resident walked down the front hall wearing the same visibly soiled (wet) blue sweat pants and gray sweater. Observation on 04/29/25 at 4:12 P.M., showed the following: -The resident sat on the couch in the main sitting area wearing blue sweat pants and gray sweater; -He/She stood up and walked away from the couch; -He/She wore the same visibly soiled (wet) blue sweat pants; -Thegrayy couch cover he/she was sitting on had a visible three inch wet spot where he/she had been sitting; -The couch had a strong smell of urine. Observation on 04/29/25 from 5:20 A.M., when the resident was noted visiblysoiledd, to 4:12 P.M., showed staff only attempted to assist the resident with incontinence care two times, at 5:20 A.M. and 6:20 A.M. The resident remained in soiled clothing and smelled of urine at 4:12 P.M., almost 11 hrs later. During an interview on 05/12/25 at 11:06 A.M., the resident's family member said the following: -About one week ago he/she and his/her family visited the resident at the facility; -Staff had asked if one of the family members could help encourage the resident to take a shower; -Family assisted staff with the resident's shower; -He/She did not receive a phone call from the facility about the resident refusing care on 04/29/25; -He/She would have liked to have been notified so he/she could go to the facility or he/she could have sent another family member to the facility to see if the resident would have let them help him/her change his/her clothes. During an phone interview on 05/09/25 at 2:00 P.M., CNA K, said the following: -He/She was familiar with Resident #32's cares; -The resident needs pretty much assistance with everything when he/she is incontinent of urine; -The resident had refused cares in the past and he/she had asked another CNA to approach the resident to see if he/she would allow another staff member to perform his/her cares; -If the resident continued to refuse cares, he/she would tell the nurse in charge; -If the resident continued to refuse cares, the nurse in charge would contact the resident's family. During an phone interview on 05/09/25 at 2:27 P.M., Licensed Practical Nurse (LPN) L, said the following: -He/She had admitted Resident #32; -He/She received a report sheet on 04/30/25 for the resident; -The report sheet had no documentation about the resident refusing to change his/her soiled clothing all day on 04/29/25; -The resident needed assistance with peri care for incontinent episodes; -The resident was not good about letting staff assist him/her with incontinent care and staff had asked family to help get him/her into the shower while they visited; -The resident refuses staff to help with his/her incontinent cares, so staff should walk away and should try again after a few minutes. During an phone interview on 05/12/25 at 10:20 A.M., the Assistant Director of Nursing (ADON), said the following: -She was the nurse in charge of the resident's hall on 04/29/25; -The resident will take his/herself to the bathroom, but will not change his/her soiled clothes or soiled brief; -The resident refused several staff member's attempts to change her clothes after two incontinent episodes on 04/29/25; -She did not call the resident's family to see if they could encourage the resident to let staff assist; -It would not be okay for a resident to stay in the same soiled clothes all day long. During an interview on 04/30/25 at 1:10 P.M., the activities director said the following: -Resident #32 was new and did not trust a lot of staff members; -He/She could be very resistant to cares; -She and CNA Q were about the only staff members who the resident would let help with his/her cares if he/she had refused other staff members. 3. Review of Resident #6's Care Plan, revised 12/05/24, showed the following: -The resident has oral/dental health problems related to poor oral hygiene; -The resident will comply with mouth care at least daily through review date; -Provide mouth care as per ADL personal hygiene; -The resident was independent with personal hygiene and oral care; nursing staff to assist as needed; upper and lower dentures; -Anticipate and meet his/her needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Intact cognition; -No rejection of cares; -Required substantial to maximal assistance with oral hygiene; -No documentation on oral/dental status. Observation on 04/28/25 at 8:00 A.M. showed the resident sat in the main dining room with top dentures covered with food build-up. The breakfast meal had not been served yet. Observation on 04/29/25 at 4:35 A.M. showed the resident sat the main dining room with top dentures fitting loosely, teeth covered with food build-up. The breakfast meal had not been served yet. During an interview on 04/28/25 at 12:25 P.M. and 04/30/25 at 10:40 A.M., the resident said staff never assisted him/her with oral care and do did not clean his/her dentures. During an interview on 04/30/25 at 9:18 A.M., CNA R said the following: -He/She was responsible for doing oral care on the resident; -The resident pockets food in his/her mouth frequently; -The resident often refused to let staff take his/her dentures out of his/her mouth to clean them. During an interview on 04/29/25 at 5:56 A.M., LPN O said the following: -The resident was fairly independent except for oral care; -Nursing staff was responsible for assisting the resident with oral care. During an interview on 04/30/25 at 5:15 P.M., the Director of Nursing (DON) said the following: -She would expect staff to provide oral care for Resident #6; -Staff should provide pericare after incontinence episodes; -If a resident was saturated with urine, staff should provide pericare prior to applying barrier cream. 45563 47008

Based on observation, interview and record review, the facility failed to ensure sufficient staff were on duty per the facility assessment, to meet the residents' needs. The facility census was 49. Review of the facility policy, Nursing Services and Sufficient Staff, dated 08/25/23, showed the following: -It is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Review of the facility policy, Payroll Based Journal (PBJ) (a system mandated by the Centers for Medicare & Medicaid Services (CMS) for long-term care facilities to electronically submit staffing information) Staffing Data Report, dated Fiscal Year (FY) Quarter 1 2025 (October 1-December 31) showed the following: -One Star Staffing Rating: Triggered. (a one-star staffing rating indicates that facility's staffing levels, turnover, and other staffing-related factors are significantly below average, while a five-star rating signifies that the facility's staffing is much above average); -Triggered=Star Staffing Rating Equals 1. Review of the Facility Assessment, updated 02/18/25, showed the following: -Average daily census 55; -The facility assessment included an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessment care plan; -Facility resources needed to provide competent support and care for our resident population every day and during emergencies: Staffing Plan: Based on the facility's resident population and their needs for care and support, the facility has made a good faith effort and approach to ensure the facility has sufficient staff to meet the needs of the residents at any given time; -The facility has made a good faith effort to evaluate the overall number of facility staff needed to ensure enough qualified staff are available to meet each residents' needs; -Licensed Nurses providing direct care: Registered Nurse (RN) or Licensed Practical Nurse (LPN) charge nurse: Two for each shift; -Nurse aides: 1:10 ratio days/evenings. 1:13 ratio evening/nights; Contingency Plan for Staffing: Nursing staff will stay over until their relief shows up; the Assistant Director of Nursing (ADON) was usually responsible for covering nursing shifts. During an interview on 05/16/25 at 11:20 A.M. the Payroll/Medical Records Director said the Daily Schedule showed what staff worked in the facility each day. 1. Review of thefacility'ss Daily Schedule, also showing staff on duty, dated 04/01/25, showed the following: -Facility census: 52; -One Licensed Practical Nurse (LPN) worked 6:00 P.M. to 6:00 A.M.; (Two licensed nurses were required per the facility assessment); -Three Certified Nurse Aides (CNAs) worked 10:00 P.M. to 4:30 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/01/25, showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/03/25, showed the following: -Facility census: 53; -One Registered Nurse (RN) worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/04/25, showed the following: -Facility census: 54; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/05/25, showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M.; (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/06/25, showed the following: -Facility census: 53; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/07/25 showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M.; (Two licensed nurses were required per the facility assessment); -Two CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule dated, 04/08/25, showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/09/25 showed the following: -Facility census: 53; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/10/25, showed the following: -Facility census: 55; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/11/25, showed the following: -Facility census: 54; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Two CNAs and one Task Aide worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/12/25, showed the following: -Facility census: 52; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/13/25, showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/14/25, showed the following: -Facility census: 53; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/15/25, showed the following: -Facility census: 51; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/16/25, showed the following: -Facility census: 51; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/17/25, showed the following: -Facility census: 51; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment); -Two CNAs and one Task Aide worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/18/25, showed the following: -Facility census: 51; -One RN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/19/25, showed the following: -Facility census: 51; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/20/25, showed the following: -Facility census: 51; -One RN worked 6:00 A.M. to 6:00 P.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 6:00 P.M. to 10:00 P.M. (Five CNAs were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment). Review of the Daily Schedule, dated 04/21/25, showed the following: -Facility census: 51; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/22/25, showed the following: -Facility census: 51; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/24/25, showed the following: -Facility census: 51; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/25/25, showed the following: -Facility census: 49; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Review of the Daily Schedule, dated 04/26/25, showed the following: -Facility census: 49; -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). 2. Observation on 04/27/25 at 11:00 A.M. showed one RN charge nurse on the North Hall. There was no charge nurse on duty on the South Hall. Review of the Daily Schedule, dated 04/27/25, showed the following: -Facility census: 49; -One RN worked 6:00 A.M. to 2:00 P.M. (Two licensed nurses were required per the facility assessment); -Three CNAs worked 10:00 P.M. to 6:00 A.M. (Four CNAs were required per the facility assessment); -One LPN worked 10:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). 3. Review of the Daily Schedule, dated 04/28/25, showed the following: -Facility census: 49; -One LPN worked 6:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). Observation on 04/29/25 at 4:30 A.M. showed one LPN (LPN U) charge nurse on the North Hall. There was no charge nurse on duty on the South Hall. Review of the Daily Schedule, dated 04/29/25, showed the following: -Facility census: 49; -One LPN worked 9:00 P.M. to 6:00 A.M. (Two licensed nurses were required per the facility assessment). 4. During an interview on 04/27/25 at 11:50 A.M., Resident #31 said the following: -There was not enough staff during the night; -He/She had put on his/her call light to alert staff he/she needed assistance to toilet; -He/She had been incontinent early that morning because he/she had to wait for staff to assist him/her. During an interview on 04/27/25 at 4:15 P.M., Resident #36 said the following: -The facility was short staffed at all times; -He/She had a fall in the bathroom and had to scream for help; -It usually took about 30 minutes for his/her call light to be answered and if they don't answer his/her call light or he/she could not get to it, he/she just screamed; -Staff know that he/she likes his/her shower before his/her Pastor comes on Wednesdays, but it doesn't always get done in time due to them being short staffed. During an interview on 05/16/25 at 8:20 A.M., Resident #28's family member said the following: -He/She visits the facility two to three times per week; -There have been times there was only one aide working on the hall and that's just not enough staff to provide care for Resident #28 and all the other residents on the hall. During an interview on 04/29/25 at 4:50 A.M., CNA T said the following: -He/She does his/her best to get showers done before breakfast, but if he/she does not have time, he/she tries to get them done before lunch; -He/She gets the heavy residents up on nightshift around 5:00 A.M. to help day shift and so that they are not sitting out in the dining room for too long before breakfast (breakfast is at 7:30 A.M. During an interview on 04/29/25 at 5:15 A.M., LPN U said the following: -There was usually only one nurse and two to three nurse aides for night shift; -There was not enough staff; -He/She could not spend an appropriate amount of time with the residents due to being short staffed. During an interview on 05/16/25 at 11:20 A.M. the Payroll/Medical Records Director said the Daily Schedule showed what staff worked in the facility each day. During an interview on 04/28/25 at 4:00 P.M. and 04/30/25 at 4:57 P.M., the ADON said the following: -On 04/28/25 she was the charge nurse on the South Hall; -She would prefer a charge nurse on both halls, but LPN N was recently pulled from the floor as charge nurse to the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, Coordinator position, leaving the floor short a charge nurse; -Sometimes she had to cover as charge nurse and also passing medications; -If a night charge nurse called in, she will cover the shift if she could not find coverage. During an interview on 04/30/25 at 5:15 P.M., the DON said the following: -She and the ADON are responsible for the nursing schedule; -The nursing schedule was completed based on resident acuity and the facility assessment; -She was aware the facility assessment called for two charge nurses on all shifts; -She and the ADON help out on the floor as needed; -Shepreferredd two charge nurses per shift on each hall (there are two halls); -Shepreferredd two aides at night on each hall; -There were so many call-ins, staffing was a challenge. During an interview on 4/30/25 at 2:50 P.M. the Administrator said the following: -He feels like facility staffing is pretty good if everyone shows up; -He is aware the facility assessment indicates two nurses even at night, but maybe he needs to change the facility assessment; -The facility does have some turnover; -The DON is responsible for staffing and the nursing schedule. MO 252730

Based on observation, interview and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff did not prepare and serve food according to the facility's diet spreadsheet menu for two residents (Residents #17 and #7), in a review of 19 sampled residents, and did not serve the appropriate portion sizes to five residents (Residents #17, #4, #5, #9, #25 and #29). The facility census was 49. 1. Review of Resident #17's Physician Orders, dated April 2025, showed the following: -Diagnoses included Alzheimer's disease, dementia, and dysphagia (difficulty swallowing); -An order for regular diet, mechanical soft texture, and double portions. Review of the facility's Diet Type Report, dated 04/25/25, showed the resident was to receive a mechanical soft diet and double portions. Review of the resident's Meal Card, showed no notes indicating the resident was to receive double portion. Observation on 04/27/25 at 12:38 P.M., during the noon meal, showed staff served the resident one serving of ground pork chop, one serving of mashed potatoes, one serving of sliced carrots and one serving of butterscotch pudding. Staff did not serve the resident double portions. Review of the Diet Spreadsheet Menu for lunch on 4/29/25, showed staff were to serve residents on mechanical soft diets 0.5 cup ground roast ham slices, 0.25 cup gravy, 0.5 cup macaroni and cheese, 0.5 cup mixed vegetables, and 0.5 cup pineapple delight. Observation on 04/29/25 at 12:33 P.M., during the noon meal, showed staff served the resident one serving of mixed vegetables, one serving of macaroni and cheese, one serving of pineapple desert and one serving of ground ham with no gravy or broth. Staff did not serve the resident double portions and did not serve gravy on the resident's ground ham. During an interview on 04/30/25 at 8:50 A.M., the resident said the following: -He/She had not been getting double portions; -Breakfast was very skimpy this morning; staff served one piece of bacon and cereal. 2. Review of Resident #7's April 2025 physician orders showed the resident had an order for regular diet with mechanical soft texture. Review of the facility's Diet Type Report, dated 04/25/25, showed the resident was to receive a mechanical soft diet. Review of the Diet Spreadsheet Menu, for lunch on 4/29/25, showed staff were to serve residents on mechanical soft diets 0.5 cup ground roast ham slices with 0.25 cup gravy. Observation on 04/29/25 at 12:34 P.M. and 1:18 P.M., during the noon meal, showed staff served the resident chopped ham with no gravy or broth. 3. Review of the Diet Spreadsheet Menu, for lunch on 4/28/25, showed staff were to serve residents on regular diets 0.5 cup whipped potatoes with gravy and 0.5 cup stewed tomatoes. Observation on 4/28/25 from 12:25 P.M. to 12:54 P.M., in the kitchen during the lunch meal service, showed the following: -Cook A served food items from the steam table to residents' plates; -Cook A started to run out of whipped potatoes and stewed tomatoes. He/She served a half portion (0.25 cup) of whipped potatoes and a three-quarters portion (0.375 cup) of stewed tomatoes to the last two residents, Resident #9 and Resident #25. Review of the Resident Diet Orders, printed 4/25/25, showed Resident #9 had a physician order for double portions. (Staff did not serve Resident #9 a full portion of the whipped potatoes and stewed tomatoes and did not follow orders to provide double portions to Resident #9 and #25.) 4. Review of the Resident Diet Orders, printed 4/25/25, showed Residents #4, #5, #9, and #29 with a physician-ordered double portion diet. Review of the Resident Meal Cards, showed Resident #9's card had 'double portion' handwritten on the card. No notes indicating double portions were indicated on Resident #4, #5, or #29's meal cards. Review of the Diet Spreadsheet Menu, for lunch on 4/29/25, showed the following: -Staff were to serve Resident #4 and Resident #9 (who had an order for a regular diet), 3 ounces of roast ham slices, 0.5 cup macaroni and cheese, 0.5 cup mixed vegetables, and 0.5 cup pineapple delight; -Staff were to serve Resident #5 and Resident #29 (who had orders for pureed diet) 0.5 cup pureed ham slices with pureed bread (0.5 slice), 0.25 cup gravy, 0.5 cup pureed macaroni and cheese, 0.5 cup pureed mixed vegetables with pureed bread (0.5 slice), and 0.5 cup pureed pineapple delight. Observation on 04/29/25 from 12:27 P.M. to 1:02 P.M., in the kitchen at the steam table, showed [NAME] A served food items onto residents' plates during the lunch meal service. [NAME] A did not serve double portions to any residents, including Residents #4, #5, #9, and #29. 5. During an interview on 4/30/25 at 11:12 A.M., [NAME] G said staff should follow the diet spreadsheet menu for what food items and portion sizes to serve to residents. Staff should refer to the resident's meal card for the resident's diet order. During an interview on 4/30/25 at 12:46 P.M., the Dietary Manager said the following: -She expected staff to serve residents their physician-ordered diet and to follow the diet spreadsheet menu; -She expected the residents' meal cards to match the residents' physician diet orders; -If staff started to run out of food when serving a meal, she expected them to let her or other staff know so they could make more food or obtain leftovers from the cooler. During an interview on 5/12/25 at 8:49 A.M., the facility's dietitian said staff should follow the diet spreadsheet menu and diet orders. 44665 47008

Based on observation, interview, and record review, the facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP) as required by facility policy when providing care and treatment to one resident (Resident #42), who had a wound, and also failed to ensure required signage was posted to indicate the use of EBP as required during high-contact personal care for two residents (Resident #42 and #33), in a review of three residents on EBP precautions. The facility failed to ensure staff performed proper hand hygiene when providing incontinence care to two residents (Resident #1 and #17), in a review of 19 sampled residents. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to track infections in the facility by organism and location. The facility census was 49. Review of the facility policy, Enhanced Barrier Precautions, revised 12/12/23, showed the following: -It is the policy of the facility to implement EBP for the prevention of transmission of multi drug-resistant organism (MDRO) (a germ that is resistant to many antibiotics); -Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices); -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gown and gloves; -Nursing staff may place residents with certain conditions or devices on EBP empirically while awaiting physician's orders; -An order for EBP will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers, diabetic food ulcers, unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling medical devices (e.g. central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO; Infection or colonization with any resistant organisms targeted by the Centers for Disease Control (CDC) and epidemiologically important MDRO when contact precautions do not apply; -Implementation of EBP: Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray; -High-contact resident care activities include: -Dressing; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; -Wound care: any skin opening requiring a dressing; -EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. Review of the undated facility policy, Hand Washing Procedure, showed the following: -Wash hands before beginning work; -After touching any-contaminated surfaces; -Before and after performing resident care; -After wearing gloves. Review of the facility's policy, Legionella Policy and Water Management Policy, dated September 1, 2019, showed the following: -Our facility is committed to the prevention, detection and control of water-borne contaminants: -As part of the infection prevention and control program, out facility has a water management program, which is overseen by the maintenance department and the water management team. The water management team: a. Administrator; b. Maintenance; c. Director of Nursing; d. Medical Director; -The team is to identify areas in the water system where Legionella can grow and spread in order to reduce the risk of Legionnaire's disease; -The CDC water prevention toolkit and ASHRAE recommendations have been used in developing a water management program; -Situations that could arise and lead to Legionella included scale or sediment and stagnation, and water temperatures. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 1. Review of Resident #42's Care Plan, revised 03/25/25, showed the following: -He/She had potential/actual impairment to skin integrity related to unstageable pressure area (a full-thickness skin and tissue loss where the extent of the damage cannot be determined because the wound bed is covered by slough (yellow, tan, gray, green or brown dead tissue) or eschar (tan, brown or black scab) of the mid-low back over bony prominence; -Administer treatments as ordered and monitor for effectiveness; -No documentation regarding the resident requiring EBP related to pressure ulcer/wound care. Review of the resident's PPS 5 Day Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 04/09/25, showed the following: -One or more unhealed pressure ulcer stage one (intact skin with non-blanchable redness over localized area, typically over a bony prominence) or higher; -One unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar; -Pressure Ulcer care; -Application of non surgical dressing (with or without topical medications )other than to feet; -Application of dressings other than to feet. Review of the resident's Physician Orders, dated April 2025, showed the following treatment: -Open area to mid back, cleanse with wound cleanser, pat dry, apply skin prep (a fast-drying, sterile, liquid film-forming skin protectant that prepares damaged or intact skin for attachment sites, tapes, films and adhesive dressings); -Cut circle out of center of 2 x 2 foam dressing, position cut out over the wound and secure, apply medihoney (a type of dressing that provides a moist environment conducive to wound healing) over wound; -Cover with second foam dressing, change daily for skin integrity. Observation of the resident's room on 04/27/25 at 11:25 A.M. and 4/28/25 at 8:26 A.M., showed there was no EBP signage or PPE supplies on the resident's door or inside/outside his/her room. Observation on 04/29/25 at 2:15 P.M. showed Licensed Practical Nurse (LPN) O entered the resident's room to provide wound care treatment without wearing a gown. During an interview on 04/29/25 at 2:15 P.M., LPN O said the following: -He/She was given a handout on EBP and had an in-service training on EBP; -It was his/her understanding that EBP (a gown) was only to be worn if a resident had wounds that had drainage. During an interview on 04/20/25 at 5:00 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff have been trained on EBP and completed a check-off; -It was her misunderstanding; she thought if a wound didn't have drainage, staff did not need to wear a gown. During an interview on 04/30/25 at 12:00 P.M. and 5:15 P.M., the Director of Nursing (DON) said the following: -The ADON was responsible for placing EBP signage and PPE where needed; -She would expect staff to wear appropriate PPE when providing wound care. 2. Review of Resident #33's Care Plan, dated 02/25/25, showed the following: -The resident required tube feeding (a method of delivering nutrients directly into the stomach or small intestine through a tube); -The resident was dependent with tube feeding and water flushes; -The resident had potential/actual impairment to skin integrity related to impaired mobility; -Administer treatments as ordered and monitor for effectiveness; -The resident required EBP related to feeding tube; -EBP referred to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition due to wounds or indwelling devices. Chronic wound(s), feeding tube; -Staff had received training on EBP and will comply with all designated precautions; -Appropriate personal protective equipment (PPE) (gowns, gloves, masks, face shields, booties) shall be available either immediately outside or inside room; -The resident was totally dependent on staff for repositioning and turning in bed, dressing, eating and personal hygiene. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Inattention and disorganized thinking present, fluctuates; -Dependent on staff for toileting hygiene, feeding and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses of traumatic brain injury (TBI) (a brain injury caused by an external force, resulting in alterations in brain function or other evidence of brain damage); -Had a feeding tube. Review of the resident's physician's orders, dated April 2025, showed the following: -Enteral feed (a method of delivering nutrition directly into the gastrointestinal (GI) tract through a tube) order in the evening, Jevity 1.5 calorie (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 80 milliliters (ml)/hour for 12 hours/day; -EBP for tube feeding/wounds; -Right trochanter (hip) wound: Cleanse with wound cleanser, pat dry, skin prep, apply Duoderm (dressing used to treat various types of wounds, including pressure ulcers, burns and other injuries). Change every seven days and as needed. Observation on 04/27/25 at 11:10 A.M. of the resident's room showed the following: -The resident lay awake in bed; -An organizer containing PPE hung on the outside of the resident's door; -No signage was present on or beside the resident's door to indicate the requirement of EBP for high-contact resident care activities. During an interview on 04/27/25 at 11:10 A.M., the resident said he/she had a feeding tube and had sores on his/her bottom. Observation on 04/28/25 at 3:21 P.M. of the resident's room showed the following: -The resident lay in bed with his/her eyes closed; -An organizer containing PPE hung on the outside of the resident's door; -No signage was present on or beside the resident's door to indicate the requirement of EBP for high-contact resident care activities. Observation on 04/30/25 at 7:49 A.M. of the resident's room showed the following: -The resident lay in bed; -An organizer containing PPE hung on the outside of the resident's door; -No signage was present on or beside the resident's door to indicate the requirement of EBP for high-contact resident care activities. During an interview on 04/30/25 at 4:57 P.M., the Assistant Director of Nursing (ADON) said the following: -The staff has received education on EBP; -She was responsible for hanging the EBP signs; -She hung an EBP sign on Resident #33's door but his/her roommate may have taken down the sign. During an interview on 04/30/25 at 11:58 A.M., the Director of Nursing (DON) said the following: -The ADON was responsible for hanging EBP signage; -Residents with open wounds, indwelling catheters and feeding tubes require EBP during personal care. 3. Review of Resident #1's Care Plan, revised 12/24/24, showed the following: -He/She had potential/actual impairment to skin integrity related to peripheral vascular disease (PVD) (circulatory disorder), skin tear, and moisture-associated skin damage (MASD); -Promote wound healing; -He/She has someone to assist with activities of daily living (ADL's). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Intact cognition; -At risk of developing pressure ulcers; -Required substantial to maximal assistance with personal hygiene; -Dependent on staff for toileting; -Always incontinent of bowel and bladder. Review of the resident's Physician Orders, dated April 2025, showed the following: -Barrier Cream every shift; -Barrier cream to MASD perirectal area twice daily. Observation on 04/29/25 at 6:00 A.M., showed the following: -CNA P and CNA H knocked, announced themselves, entered the resident's room, washed their hands, and donned gloves; -CNA P removed the resident's soiled brief (incontinent of urine and bowel), and used wet wipes to provide front peri care (one wipe down each side, then one down the center from front to back), and turned the resident to his/her left side; -CNA H cleaned the resident's backside, wiping his/her bottom of feces, from front to back several times; -CNA H, using the same soiled gloves, grabbed the barrier cream tube and prepared and applied barrier cream to the resident's buttock and intergluteal cleft , (the deep, midline groove between the buttocks), doffed gloves, and donned gloves (no hand washing or sanitizing in between glove change), and put a clean brief on the resident; -CNA P (using his/her same soiled gloves) put clean pants on the resident; -With soiled gloves, CNA H removed the resident's gown and dressed the resident with a clean top; -CNA P removed his/her gloves and washed hands; -CNA H removed his/her gloves and washed hands; -CNA H and CNA P finished putting socks and shoes on the resident and transferred the resident via mechanical lift from the bed to wheelchair; -CNA P tied up the soiled brief and trash in a clear bag; -CNA H placed a dirty pad and linens in a clear bag and tied the bag; -Without washing his/her hands, CNA H brushed the resident's hair, touching the resident's personal belongings and hair after touching the dirty pad and linens with his/her bare hands and removed the trash and dirty linen bags from the room; -CNA P placed the resident's glasses on him/her, then filled the resident's water bottle and pushed the resident to the dining room, after tying up the soiled brief and trash bag with his/her bare hands During an interview on 04/29/25 at 7:35 A.M., CNA H said that he/she should have changed gloves and washed hands in between dirty and clean tasks and before and after care. During an interview on 04/29/25 at 7:35 A.M., CNA P said that he/she should have changed gloves and washed hands in between dirty and clean tasks and before and after care. During an interview on 04/30/25 at 5:15 P.M., the DON said that she expected staff to wash their hands in between clean and dirty tasks and between glove changes. 4. Review of Resident #17's care plan, revised 11/25/24, showed the following: -He/She had bladder incontinence; -He/She had activities of daily living (ADL) self care performance deficit; -He/She required extensive staff assistance for personal hygiene. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her diagnoses included Alzheimer's disease; -He/She was moderately cognitively impaired; -He/She was always incontinent of bowel and bladder; -The resident was dependent on staff for toilet hygiene. Observation on 04/28/25 at 2:37 P.M., showed the following: -CNA E and CNA H donned gloves without washing their hands; -CNA E and CNA H transferred the resident using a mechanical lift from his/her broda chair (a chair or wheelchair that provides supportive positioning) to his/her bed; -CNA E unfastened the resident's disposable incontinence brief tabs and lowered the urine saturated brief toward the resident's thighs; -CNA H used disposable wipes to provide front peri-care; -CNA E assisted the resident to roll to his/her left side; -CNA H removed disposable wipes from the package with soiled gloves; -CNA H continued to provide peri-care to the resident's buttocks, removing incontinence wipes from the package several times; the resident had been incontinent of feces; -The incontinence wipes package had fecal matter on it; -CNA E applied barrier cream to CNA H's soiled gloves; -CNA H applied the barrier cream to the resident's buttocks with the same soiled gloves he/she had used to provide incontinence care; -CNA E applied a clean brief under the resident and pulled up the resident's pants; -CNA H and CNA E doffed gloves but did not wash their hands with soap and water; -CNA E lowered the resident's bed; -CNA H put a fall mat beside his/her bed; -Both staff members then washed their hand with soap and water. Observation on 04/28/25 at 4:24 P.M., showed the following: -CNA E brought the mechanical lift into the resident's room; -CNA E washed his/her hands with soap and water and donned gloves; -CNA H brought a lift sling (device used for a lift transfer) into the room and washed his/her hands with soap and water and donned gloves; -CNA E and CNA H transferred the resident using the lift from his/her broda chair to his/her bed; -CNA E released the resident's incontinence brief tabs and lowered the urine saturated brief toward his/her thighs; -CNA H used disposable wipes to provide care to the resident's front peri area; -CNA H rolled the resident to his/her right side, with soiled gloves, touching the resident on his/her right side, right upper thigh and right lower ribs with soiled gloves; -CNA H removed disposable incontinence wipes from the package; -CNA H provided peri-care to the resident's buttock; -CNA E applied barrier cream to CNA H's soiled gloves and he/she applied the cream to the resident's buttock; -CNA E applied a clean brief under the resident and pulled up the resident's pants; -CNA H and CNA E doffed gloves and applied clean gloves without washing their hands with soap and water; -CNA H moved the resident's floor mat and CNA E brought the mechanical lift into the resident's room and both staff members transferred the resident to his/her broda chair; -CNA H and CNA E doffed gloves and left the room without washing his/hands with soap and water; -CNA E pushed the resident's broda chair down the hall and to the dining room. During an interview on 04/30/25 at 4:28 P.M., CNA H said the following: -He/She should have changed his/her gloves after providing frontal peri-care for the resident; -He/She should have changed his/her gloves after providing bowel incontinence care for the resident; -He/She should not have touched the resident's body with soiled gloves. 5. Observation on 04/29/25 at 1104 A.M. - 11:21 A.M., showed the following: -room [ROOM NUMBER] hot water temperature 105.6 degrees Fahrenheit (F) (too cool); -room [ROOM NUMBER] hot water temperature 106.1 degrees F (too cool); -room [ROOM NUMBER] cold water temperature 71.4 degrees F (too warm); -room [ROOM NUMBER] cold water temperature 80.2 degrees F (too warm); -room [ROOM NUMBER] hot water temperature 101.2 degrees F (too cool); -room [ROOM NUMBER] build up of white substance around hot water and cold water handles. During an interview on 04/30/25 at 2:07 P.M., the Maintenance Director said the following: -He did not check the cold water temperatures in the building; -He did not flush any lines in vacant rooms; -He did not check any cold water temperatures; -There was no water management team; -There had been no water management team meetings. During an interview on 04/30/25 at 5:02 P.M., the ADON, said the following: -There was currently no water management team at the facility; -She had never been to any water management meetings at the facility. 6. Review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/10/25, showed the following: -The resident was cognitively intact; -Diagnosis included pneumonia (an inflammation of the lungs that causes the air sacs (alveoli) to fill with fluid) and chronic obstructive pulmonary disease (COPD) is a group of lung diseases that cause ongoing breathing problems; -The resident required oxygen therapy. Review of the resident's care plan, dated 02/13/25, showed the following: -The resident had emphysema (a progressive lung disease causing destruction of the alveoli (tiny air sacs in the lungs) and the loss of lung elasticity)/chronic obstructive pulmonary disease (COPD) (lung disease that blocked airflow and made it difficult to breathe); -Give oxygen therapy as ordered by the physician; -The resident has oxygen therapy related to COPD/emphysema; -Monitor for signs and symptoms of respiratory distress and report to the physician as needed. Review of the resident's progress note, dated 04/07/25 at 2:48 A.M., showed the following: -The resident had been complaining of shortness of breath most of the day; -The resident had increased confusion; -The resident had diminished lung sounds (weakened or quieter breath sounds heard when listened to with an instrument used to amplify and listen to internal body sounds); -The resident was sent to the hospital for evaluation. Review of the resident's progress note, dated 04/07/25 at 4:57 A.M., showed the resident was admitted to the hospital for pneumonia. Review of the resident's hospital discharge instructions, dated 04/09/25, showed the resident had a discharge diagnosis of pneumonia. Review of the resident's history and physical, dated 04/11/25, showed the resident had a diagnosis of healthcare-associated pneumonia. During an telephone interview on 05/09/25 at 7:59 A.M., the DON said the following: -The resident was diagnosed with a health care acquired pneumonia at the hospital; -The resident was sent back to the facility taking a newly prescribed antibiotic; -The hospital did not do any testing for legionella bacterium; -She did not confer with the physician for legionella bacterium testing because the resident did not exhibit any signs or symptoms; -She did not confer with the physician for legionella bacterium testing when the resident came back from the hospital with a diagnosis of facility acquired pneumonia. During an interview on 04/30/25 at 5:515 P.M. and 5:46 P.M., the Administrator said the following: -The only legionella policy was the policy which was in the water management binder; -The water management binder was from a different administration; -There currently was no water management team; -There had been no water management team meetings; -The maintenance director was responsible for checking water temperatures. 47008

Based on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. In addition, the facility failed to ensure one additional resident (Resident #2), in a review of 19 sampled residents, had appropriate clinical indications for the use of an antibiotic The facility census was 49. Review of a Centers for Disease Control (CDC) undated document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes showed the following: -Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority; -Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use; -All nursing homes should take steps to improve antibiotic prescribing practices and reduce inappropriate use; -Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions; -Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship; -Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors; -Process measures include tracking how and why antibiotics are prescribed and tracking any adverse outcomes. Review of the Updated McGeer Criteria for Infection Surveillance Tool, adapted from Surveillance Definitions of Infections in Long-Term Care Facilities, dated 2012, showed the following: Urinary Tract Infection (UTI) without indwelling urinary catheter: -UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture result; -A diagnosis of UTI can be made without localizing symptoms if a blood culture isolate is growing the same organism as the urine culture and there is no alternate site of infection; -In the absence of a clear alternative source of infection, fever or rigor, and a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident, will often be treated as UTI; -However, evidence suggests that most of these episodes are likely not due to infection or a urinary source. Review of the undated facility policy, Infection Prevention and Control Manual Antibiotic Stewardship & Multi Drug Resistant Organisms (MDROs), showed the following: -It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed; -Procedure: 1. When a resident is suspected of having an infection, the nurse will assess the resident; 2. The facility will communicate resident assessment information and relation to constitutional criteria for infection (i.e. as outlined in Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria) to the practitioner, including non-pharmacological interventions that can be accomplished in the facility based on resident assessment; 3. If laboratory and/or radiology orders are obtained, nurse will obtain appointments for ordered testing; 4. If antibiotic therapy is ordered, documentation will include: Diagnosis, medication, dose, route and duration; 5. In the event that diagnostic testing had been ordered, prompt communication of results will be provided to the practitioner; 6. Prophylactic medication use in the facility will be limited based on practitioner documentation of rationale, risks and benefits for use. 1. Review of Resident #2's hospital discharge orders dated 04/11/25 showed the following: -Bactrim DS 800-160 milligrams mg one tablet by mouth every 12 hours for 10 days; -Urine culture (preliminary results): >100,000 colony-forming units (CFU)/milliliter (mL) (normal up to 10,000 CFU/ml) urogenital flora (refers to the normal bacteria and other microorganisms naturally present in the urinary and reproductive tracts. In a urine culture, its presence, especially in mixed forms, often indicates a contaminated sample or potentially urethral irritation (the inflammation or swelling of the urethra, the tube that carries urine from the bladder out of the body), but not necessarily a urinary tract infection (UTI)) . Review of the resident's medical record, dated 04/11/25 through 04/30/25, showed no documentation of a final urine culture and sensitivity. Further review of the record showed no documentation the resident's physician was notified of the preliminary urine culture results, dated 04/11/25. Review of the resident's progress notes dated 04/11/25 at 4:00 P.M. showed the following: -The resident arrived to facility via stretcher accompanied by Emergency Medical Technicians (EMTs); -The resident continues previous orders and started on Bactrim DS for UTI. Review of the resident's Medication Administration Record (MAR) dated 04/12/25 through 04/21/25 showed the resident received Bactrim DS one tablet by mouth twice daily for 10 days. 2. Review of the facility's Infection Control/Antibiotic Surveillance Log, dated April 2025, showed the following: -Legend for urinary tract infection (UTI) and skin on the lower right hand side of the facility map; -A pink dot indicated the resident had a UTI; -One pink dot was placed on the map for room four (not Resident #2's room); -No documentation of Resident #2 being included on the form. During an interview on 04/30/25 at 8:50 A.M. and 05/12/25 at 10:20 A.M., the Assistant Director of Nursing (ADON), said the following: -The DON had taken over the responsibility of keeping the infection control and antibiotic surveillance log; -She could not remember the date the DON took over the responsibility of infection control and antibiotic surveillance. -The infection control and antibiotic surveillance log was up to date; -The dots on the surveillance map represented facility-acquired infections; -She had not charted all the infections in the facility on the surveillance map. During an interview on 04/29/25 at 12:00 P.M., 04/30/25 at 9:04 A.M. and 11:58 A.M., the DON said the following: -She and the ADON shared the responsibility of infection control in the facility; -The infection control and antibiotic surveillance log was up to date; -When mapping infections in the facility, the only infections mapped are facility-acquired infections; -When a resident was placed on an antibiotic and did not meet the criteria, conversations were had with the physician; -The conversations with the physicians were not always documented in the resident's medical record; -Resident #2 was not listed on the infection control and antibiotic surveillance log; -Resident #2 did not have a culture and sensitivity test (C&S; a diagnostic procedure used to identify and treat infections. It involves taking a sample (like blood, urine, or wound fluid) and growing any present bacteria or fungi in a lab. The culture part of the test identifies the specific type of germ causing the infection, while the sensitivity part determines which antibiotics will be effective in treating that infection.); -Resident #2 was prescribed the antibiotic during a hospital stay; -The hospital would be responsible for conducting the C&S for Resident #2; -The facility does not order C&S for any resident unless the resident exhibited signs and symptoms an infection was not getting better; -The dots on the surveillance map represented facility-acquired infections; -She had not charted all the infections in the facility on the surveillance map; -The facility did not have a policy on obtaining a culture prior to starting antibiotic treatment. 47008

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #8), in a review of 19 sampled residents, and one additional resident (Resident #28), the right to choose schedules (including waking times) and make choices about aspects of his/her life in the facility that were significant to the resident. The facility census was 49. Review of the facility policy, titled Resident Rights, revised 05/04/2022 showed the following: -The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: -a. The resident has the right to choose activities, schedules (including sleeping and waking times), assessments, and plan of care and other applicable provisions of this part; -b. The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident. 1. Review of Resident #8's Care Plan, revised 05/30/24, showed the following: -The resident liked to get up in the morning at 7:00 A.M.; -The resident required maximum assistance with dressing; -The resident required maximum assistance of two staff to transfer with the mechanical lift from wheelchair to bed and bed to wheelchair. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/25, showed the following: -Cognitively intact; -Dependent on staff for transfers. Observation on 4/29/25 at 4:38 A.M. showed the resident lay in his/her bed with his/her eyes closed. Observation on 4/29/25 at 4:59 A.M. showed the following: -Certified Nurse Aide (CNA) Q and CNA S knocked on the resident's door and entered the resident's room; -CNA Q and CNA S woke the resident; -CNA Q and CNA S provided incontinence care and dressed the resident; -CNA Q and CNA S transferred the resident via mechanical lift to his/her wheelchair. Observation on 4/29/25 at 5:07 A.M. showed CNA Q pushed the resident in his/her wheelchair to the dining room table. During an interview on 4/29/25 at 5:10 A.M., the resident said the following: -He/She got up early because staff asked him/her to; -He/She would prefer to sleep in until at least 6:00 A.M.; -He/She was not a coffee drinker so he/she just colored until breakfast; -Breakfast was not served until 7:30 A.M. Observation on 4/29/25 at 5:40 A.M. showed the following: -The resident sat in his/her wheelchair at the dining room table; -The resident said I'm hungry. Observation on 4/29/25 at 6:04 A.M. showed the resident sat in his/her wheelchair at the dining room table. Observation on 4/29/25 at 7:47 A.M. showed staff served the resident's breakfast tray. During an interview on 4/29/25 at 4:59 A.M., CNA S said the following: -Staff assist Resident #8 up early for breakfast; -He/She was unsure about what was on the resident's care plan about choice of waking time. During an interview on 04/29/25 at 5:00 A.M., CNA Q said the following: -He/She normally got some residents up for breakfast; -He/She had to get six to eight residents up early in order to have them ready for breakfast at 7:30 A.M. 2. Review of Resident #28's Care Plan, revised 2/17/25, showed the following: -The resident had impaired cognitive function/dementia or impaired thought processes; -The resident understood consistent, simple, and direct sentences; -The resident required one staff participation with transfers. He/She used a walker and gait belt; -The resident liked to get up in the morning at (specify time) - not able to answer. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Inattention and disorganized thinking present, fluctuates; -Usually understood; -Dependent on staff for dressing and personal hygiene; -Required partial/moderate assistance for chair/bed-to-chair transfer. Observation on 4/29/25 at 4:35 A.M. showed the resident lay in bed with his/her eyes closed. The lights to the room were turned off. Observation on 4/29/25 at 5:18 A.M. showed CNA S propelled the resident in his/her wheelchair to the dining room. Observation on 4/29/25 at 5:22 A.M. showed the following: -The resident sat in his/her wheelchair at the table; -The resident yawned. During an interview on 4/29/25 at 5:22 A.M., the resident said the following: -He/She would prefer to sleep in if possible; -All he/she does until breakfast is just wait and wait and wait. Observation on 4/29/25 at 5:40 A.M. showed the following: -The resident sat in his/her wheelchair at the table; -The resident rubbed his/her eyes; -The resident laid his/her hands on the table and laid his/her head on top of his/her hands. Observation on 4/29/25 at 6:04 A.M. showed the resident sat in his/her wheelchair at the dining room table. Observation on 4/29/25 at 7:47 A.M. showed staff served the resident's breakfast tray. During an interview on 5/16/25 at 8:20 A.M. Resident #28's family member said the following: -The resident has macular degeneration (an eye disease that causes vision loss) and can't see well; -The resident doesn't like to sit in the dining room for a prolonged period of time because he/she can't see what's going on around him/her; -The resident used to get up for the day around 7:00 A.M. when he/she lived at home prior to being in the facility; -He/She has asked staff to wait to take the resident into the dining room until closer to meal time. During an interview on 4/29/25 at 4:59 A.M., CNA S said the following: -Staff assist Resident #28 up early for breakfast; -He/She was unsure about what was on the resident's care plan about choice of waking time; -He/She usually gets Resident #28 up around 4:00 A.M. 3. During an interview on 05/09/25 at 1:52 P.M., CNA J said the following: -He/She worked from 6:00 A.M. to 6:00 P.M.; -There was a list of residents who needed staff to assist them up early for breakfast; -The CNAs who work night shift get the residents up who need extra assistance and transfer with a mechanical lift; -When he/she arrived at work, there were normally three residents on his/her hall who were already up and dressed; -Resident #8 was normally up and dressed when he/she arrived at work; -Sometimes Resident #8 was dressed and in bed. He/She would wake the resident up at 6:00 A.M. and get the resident out of bed. During an interview on 05/09/25 at 2:00 P.M., CNA K said the following: -He/She worked from 6:00 A.M. to 6:00 P.M.; -When he/she arrived at work, there were normally four to five residents on his/her hall who were already up and dressed; -The CNAs who worked night shift got five residents up who need extra assistance and transfer with a mechanical lift; -The CNAs who worked night shift also started prepping four or five other residents for early wake up; -Sometimes, when he/she arrived to work, residents lay in bed dressed in their day clothes; -He/She did not refer to the care plan to see when the residents would like to get up in the mornings. During an interview on 4/30/25 at 5:15 P.M., the Director of Nursing said the following: -Staff should follow the residents' care plans in regards to waking time; -If a resident was unable to voice their preference of waking time, staff should consult the resident's representative; -It would not be appropriate for staff to wake a resident who was sleeping to get them up for the day.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, according to the Resident Assessment Instrument (RAI) manual for two residents (Resident #17 and Resident #48), in a review of 19 sampled residents. The facility census was 49. Review of the RAI Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts; -It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team (IDT) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Review of the facility policy titled, Resident Assessments, revised November 2019 showed the following: 8. The Interdisciplinary Team (IDT) uses the MDS form currently mandated by Federal and State regulations to conduct the resident assessment; 12. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan. 1. Review of Resident #48's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Indwelling catheter (a flexible tube inserted into the bladder to drain urine, also called a foley catheter); -Always incontinent of urine; -Diagnosis of urinary tract infection in the last 30 days. Review of the resident's Care Plan, dated 01/08/25, showed the following: -The resident has impaired cognitive function/dementia or impaired thought processes related to altered mental status, acute cystitis ((a sudden inflammation of the urinary bladder, most often caused by a bacterial infection, also known as a urinary tract infection (UTI)) with hematuria (blood in urine), and encephalopathy (a general term for brain dysfunction, meaning the brain isn't working as it should, and can manifest in various ways, including confusion, memory loss, and personality changes); -No documentation regarding the resident's continence or presence of an indwelling catheter. Observation on 04/28/25 at 8:40 A.M. in the resident's room showed the following: -The resident sat on the side of his/her bed; -He/She was incontinent of urine; -He/She did not have an indwelling catheter. During an interview on 04/28/25 at 8:40 A.M., the resident said he/she does not and has never had an indwelling catheter. During an interview on 04/28/25 at 2:00 P.M., Certified Nurse Aide (CNA) I said the following: -The resident was incontinent of urine; -The resident does not currently have and has not had an indwelling catheter. During an interview on 04/29/25 at 2:28 P.M., the MDS Coordinator said the following: -She reviewed Resident #48's admission MDS and it was coded the resident as incontinent and had an indwelling catheter; -She may have miscoded Resident #48's MDS. 2. Review of Resident #17's quarterly MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/She had diagnoses that including diabetes (a metabolic disorder characterized by chronically elevated blood sugar (glucose) levels); -The resident had received insulin injections one time during the seven day look back. Review of the resident's care plan, revised 02/20/25, showed the following: -The resident had diabetes and used hypoglycemic medications (a type of medication used to help reduce the amount of sugar in the blood); -Diabetes medication as ordered by the physician; -Monitor and document for medication side effects and effectiveness. Review of the resident's physician orders, dated 04/29/25, showed the following: -The resident had a physician ordered regular diet, mechanical soft texture, regular consistency, double portions, start date of 04/03/25; -Trulicity (a non-insulin option that helps your body release the insulin it's already making) subcutaneous (beneath, or under, all the layers of the skin) solution pen-injector 1.5 milligrams (mg)/0.5 milliliters (ml), inject 1.5 mg subcutaneously at bed time every Wednesday, start date of 10/23/24. During an interview on 04/29/25 at 4:05 P.M., the MDS coordinator said the following: -She had coded Resident #17's quarterly MDS; -She thought Trulicity was an insulin; -She used the [NAME] Drug Guideline when inputting medications into the MDS; -She was not aware the resident was not taking insulin; -She miscoded Resident #17's quarterly MDS. During an interview on 4/30/25 at 5:15 P.M. the Director of Nursing said the following: -The MDS Coordinator was responsible for completing the MDS; -She would expect staff to complete the MDS per the RAI manual; -If a resident is incontinent of urine and does not have an indwelling catheter an indwelling catheter should not be coded on the MDS; -She would expect the MDS to reflect the resident.

Based on observation, interview, and record review, the facility failed to ensure staff provided care and treatment in accordance with professional standards of practice when staff failed to follow physician orders in providing continuous oxygen to one resident (Resident #49) to maintain the resident's oxygen needs, in a review of 19 sampled residents. The facility census was 49. 1. Review of Resident #1's Care Plan, revised 01/15/25, showed the following: -He/She had oxygen therapy related to chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); -Monitor for signs/symptoms of respiratory distress and report to physician as needed; -He/She has COPD/asthma; -Give oxygen therapy as ordered by the physician; -Monitor for difficulty breathing on exertion. Remind the resident not to push beyond endurance. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/21/25, showed the following: -Moderately impaired cognition; -Primary diagnosis was debility (physical weakness) and cardiorespiratory conditions (diseases and disorders affecting the heart and lungs); -Used a walker for mobility device; -Independent with walking; -He/She had shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring) and when lying flat; -He/She required oxygen therapy. Review of the resident's physician orders, dated April 2025, showed oxygen 3 liters (L) via nasal cannula every day and night for oxygen. Observation on 04/28/25 at 2:35 P.M. showed the following: -No staff present in the dining room; -The resident's oxygen concentrator and tubing sat plugged in by the kitchen door; -The resident pushed his/her walker to the nurse's station near the front entrance and asked a staff member at the desk if someone could take his/her oxygen to his/her room. The resident did not have portable oxygen tank and was not receiving oxygen at the time; -The MDS Coordinator pushed the oxygen concentrator to the resident's room ahead of the resident; -The resident walked slowly to his/her room from the main entrance nurse's station, past the dining room, past the other nurse's station, down the other hallway to his/her room without wearing any oxygen; -The resident lips were blue, and he/she was visibly short of breath; -When he/she arrived to his/her room, the MDS Coordinator was waiting in the room and asked the resident where he/she normally plugged in his/her oxygen concentrator; -The resident pointed to the end of the bed. The MDS Coordinator plugged the oxygen concentrator into the outlet and handed the resident the nasal cannula tubing to put on; -The resident sat down on the bed, put on the nasal cannula, and began taking deep breaths; -The MDS Coordinator left the room. During an interview on 04/28/25 at 2:35 P.M., the resident said the following: -He/She was very short of breath and was having trouble breathing; -Staff never checked his/her oxygen saturation levels; -Staff never provided portable oxygen tanks for him/her; -He/She was supposed to wear oxygen all of the time; -He/She normally didn't wear oxygen in the shower; -He/She didn't wear oxygen into the bathroom because the tubing wasn't long enough. Observation on 4/29/25 at 10:10 A.M. showed the following: -The resident pushed his/her walker from his/her bathroom back to his/her bed and was not wearing oxygen; -The resident sat down on the bed; -The resident leaned back against his/her propped pillows and was visibly short of breath. During an interview on 04/29/25 at 10:10 A.M., the resident said the oxygen tubing would not reach into the bathroom, so he/she just had to leave the nasal cannula near the bed and go to the bathroom without it. This made him/her very short of breath. Observation on 04/29/25 at 11:50 A.M. showed the following: -The resident self-propelled himself/herself in the wheelchair from the dining room down the hallway toward his/her room; -The resident did not have a portable oxygen tank and was not wearing oxygen; -CNA H offered to help push the resident to his/her room; -CNA H took the resident to his/her room to use the bathroom. The resident did not wear oxygen while in the bathroom; -The resident was visibly short of breath; -CNA H returned the resident to the dining room after the resident used the bathroom. -Another resident's family member at the table handed the resident the nasal cannula to apply. During an interview on 04/29/25 at 11:57 A.M., the resident said he/she was short of breath. During a telephone interview on 05/13/25 at 1:30 P.M., CNA H said the following: -He/She did not notice the resident was short of breath; -She was aware the resident was supposed to be on continuous oxygen but the resident was only without oxygen for a very short period of time. Observation on 4/30/25 from 8:19 A.M. to 8:24 A.M. in the dining room showed the following: -A housekeeper was the only staff present in the dining room; -The resident stood with his/her walker; -The resident's oxygen concentrator and tubing sat plugged in by the kitchen door; -The resident (without wearing oxygen) pushed his/her walker with a cup of coffee in one hand and pushed his/her walker with the other hand; -A visitor took the coffee cup from the resident's hand and sat it down on the table; -The resident was visibly short of breath; -The resident's breathing was labored and he/she appeared pale; -The resident continued to walk from the kitchen door to a chair in the TV area; -At 8:22 A.M., Licensed Practical Nurse (LPN) N entered the dining room and assisted the resident to a chair; -LPN N obtained the resident's oxygen concentrator and applied oxygen at 3 liters/minute via nasal cannula; -The resident's oxygen saturation was 87% on room air, (a normal oxygen saturation level is considered to be 95-100%) and his/her respirations were labored even after sitting; -After applying the oxygen, the resident's oxygen saturation was 92% on 3 liters/minute via nasal cannula; -At 8:24 A.M., the resident's oxygen saturation was 93% on 3 liters/minute via nasal cannula, and the resident said he/she felt better. During an interview on 4/30/25 at 8:24 A.M., the resident said the following: -He/She was winded without his/her oxygen; -He/She was supposed to wear oxygen continuously; -If staff was available, they pushed the concentrator for him/her but staff were often not available. Observation on 04/30/25 at 12:20 P.M. showed the following: -The resident pushed his/her walker from his/her room to the dining room without wearing oxygen; -The resident did not have a portable oxygen tank; -Certified Medication Technician (CMT) D brought the resident's oxygen concentrator to the dining room; -The resident was visibly short of breath; -LPN N checked the resident's oxygen saturation and it was at 84% on room air. During an interview on 04/30/25 at 12:25 P.M., the resident said it was a struggle getting to and from his/her room without any oxygen. During an interview on 04/30/25 at 5:15 P.M., the Director of Nursing (DON) said she expected staff to use a portable tank and keep the resident on continuous oxygen and to follow the physician orders.

Based on observation, interview, and record review, the facility failed to consistently accommodate one resident's (Resident #31's) food preferences and failed to serve an appropriate food substitute/alternate. The facility census was 49. Review of the facility policy, Food Preparation Guidelines, dated 2023, showed the following: -Strategies to ensure residents satisfaction include honoring resident preferences, as possible, regarding food and drinks; -Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed; -Alternatives shall be appealing and of similar nutritive value to the food that is being substituted; -Alternatives shall be consistent with the usual and/or ordinary food items provided by the facility; -Staff should offer residents appropriate alternatives when they choose not to consume food/drink that is initially served or when a different food/drink choice is requested; -Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray card. 1. Review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/10/25, showed the resident was cognitively intact and was able to make himself/herself understood. Review of the resident's care plan, dated 02/13/25, showed no documentation of food preferences. Review of the resident's Physician's Orders, dated April 2025, showed an order for a regular diet. Review of the Diet Spreadsheet Menu, for lunch on 4/27/25, showed staff were to serve residents on a regular diet 0.5 cup baby carrots. Observation on 4/27/25 at 12:40 P.M., during the lunch meal, showed staff did not serve carrots to the resident. Staff did not serve the resident a substitute for the carrots. During an interview on 04/27/25 at 11:50 A.M., the resident said the following: -He/She did not like rice and had told staff he/she did not like rice; -When he/she was served rice, there was nothing else he/she could have as a substitute; -He/She did not like carrots and had told staff he/she did not like carrots; -Dietary staff had not asked him/her about his/her food preferences. Observation on 04/29/25 at 1:00 P.M., showed staff served the resident mixed vegetables which contained carrots. Review of the resident's meal card on 04/29/25, showed no documentation of the resident's likes or dislikes for breakfast, lunch or dinner. During an interview on 4/30/25 at 11:12 A.M., [NAME] G said staff should refer to the resident's meal card for the resident's diet order and food preferences. If staff had questions about what to serve a resident, they could ask the dietary manager. During an interview on 04/30/25 at 2:47 P.M., the Dietary Manager said the following: -She conducted food preference interviews when a resident was admitted ; -All residents should be interviewed about their food preferences; -It was her responsibility to conduct resident preference interviews; -She had not interviewed all of the residents in the facility about food preferences since she has been working at the facility; -If a resident did not like a food, the resident would tell a certified nurse aide (CNA) and they would relay the information; -She did not know Resident #31 did not like rice or carrots; -There were alternatives if a resident did not like what is being served. During an interview on 04/30/25 at 5:16 P.M., the Director of Nursing (DON) said the following: -Staff should conduct interviews related to the residents' food preferences quarterly; -Staff should not serve resident food they do not prefer; -If a resident does not like rice or carrots, they should not be served those food items. 44665

Refer to Event ID UWJ112. Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; -Staff shall monitor food temperatures while holding for delivery to ensure proper got and cold holding temperatures are maintained. Staff shall refer to the current FDA food code; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone (Bacteria grow most rapidly in the range of temperatures between 40 and 140 F, doubling in number in as little as 20 minutes). Strategies include, but are not limited to, covering all foods when traveling a distance and using tray lines, mobile food carts or portable steam tables transported to dining areas. Review of the facility policy for Food Preparation Guidelines, dated 9/25/23, showed: -It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status; -Food and drinks shall be palatable, attractive and at a safe and appetizing temperatures. Strategies to ensure resident satisfaction include serving hot foods/drinks hot and cold foods/drinks cold. 1. Review of the Resident Council meeting minutes showed the following: -On 7/5/23: Dietary: residents report the food is still cold; -On 7/7/23 Dietary: residents report the food is still cold. Review of the facility's Monthly Concern Tracking Log, dated 8/23, showed on 8/8/23 from resident council: grievance the food is still cold with a resolution of: using hot plates, and dietary helping pass plates if needed. During an interview on 9/26/23 at 10:50 A.M., the Activity Director said the following: -The residents have been complaining about the food being cold; -He/She takes the resident's meeting minutes and then will complete a grievance form and give to the responsible department head; -He/She completed a grievance form last month from the Resident Council and gave it to the Dietary Manager; -The residents still say the food is cold at times. 2. During an interview on 9/26/23 at 11:00 A.M., Resident #12 said the following: -The food is cold at times when it comes from the kitchen; -He/She and other residents have complained and nothing has been done. 3. During an interview on 9/26/23 at 11:10 A.M., Resident #22 said when he/she ate his/her meals in his/her room; the food was always cold. 4. During an interview on 9/26/23 at 11:15 A.M., Resident #43 said the following: -He/She ate in his/her room; -Sometimes his/her food was cold. 5. Observation on 9/26/23 at 12:43 P.M., showed staff served the first tray out the dietary department in the main dining room. The meal consisted of barbeque pork chop, mashed potatoes, corn and sherbet. -There were no hot plates used to serve the food on; -No dietary staff assisted serving trays in the dining room or on the hall; (The facility implemented resolutions to the August resident council concern of the food being cold were not being followed). 6. During an interview on 9/26/23 at 12:45 P.M., Resident #39 said his/her food was not hot when served from the kitchen. 7. Observation on 9/26/23 showed the following: -At 1:03 P.M., staff served the last lunch tray in the dining room; -At 1:29 P.M., staff served the first hall tray on the 100 hall; -At 1:37 P.M., staff served the last hall tray on the 100 hall which was the last tray served. Observation of the food temperatures for the test tray on 9/26/23 at 1:38 P.M., taken with a metal stem type thermometer, showed the following: -Pork steak: 101.4 degrees Fahrenheit; -Corn: 86.9 degrees Fahrenheit; -Ice Cream in Styrofoam container: liquefied (the Styrofoam ice cream cup had not been kept in a tray of ice prior to service and had completely melted). During an interview on 9/26/23 at 3:00 P.M., Dietary Cook A said the following: -Dietary usually take food temperatures before the meal was served; -He/She did not take the temperatures due to running late; -He/She just started and was not aware of what the food temperatures should be. During an interview on 10/13/23 at 10:00 A.M. the Dietary Manager said the following: -She would expect staff to take the temperature of the food before meal service. If the food temperatures does not meet the requirements for safe food handling, then the food needs to be placed back in the oven and heated; -She has instructed her staff not to remove the entire lid to keep the food warm; -The hot plate and cover needs to be used for all trays that are delivered to the halls. During an interview on 9/26/23 at 3:30 P.M. the Administrator said he would expect the food to be kept at the correct temperatures at all times. MO 223772

Based on interviews, record review, and facility policy review, the facility failed to ensure residents and/or their responsible parties (RPs) were invited to participate in the care planning process for 2 (Resident #22 and Resident #29) of 2 residents sampled for care planning requirements. Staff interviews revealed the facility had not involved residents or their RPs in the care planning process since March of 2020. This affected all residents in the facility. Findings included: A review of the undated facility policy titled, Resident Participation - Care Conferences/Planning, revealed, Policy Statement The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Policy Interpretation and Implementation 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy further indicated, 3. The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to: a. Participate in the planning process and 4. The care planning process will: a. Facilitate the inclusion of the resident and/or representative. The policy specified, 7. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. 1. A review of an Admission Record indicated the facility admitted Resident #29 on 11/13/2020 with diagnoses that included a cerebral infarction (stroke), hemiplegia and hemiparesis of the right dominant side (right-sided partial paralysis), dysphagia (difficulty with swallowing), and disorientation. The Admission Record indicated Family Member (FM) #1 was the resident's responsible party (RP) and FM #2 was the second emergency contact. A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2023, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated it was very important to the resident to have family or a close friend involved in conversations about their care; however, the assessment indicated the resident's family did not participate in the assessment. A review of Resident #29's comprehensive care plan revealed a Focus, created on 11/13/2020, that indicated the resident had impaired cognitive function/dementia or impaired thought processes. The care plan directed staff to communicate with the resident and their family/caregivers regarding the resident's capabilities and needs. Another Focus titled All About Me - Care/ADL [activities of daily living] Preferences, initiated on 11/13/2020, indicated Resident #29 preferred to have FM #1 and FM #2 involved in discussions of their care. During an interview on 08/07/2023 at 11:54 AM, FM #1 and FM #2 stated they had not been invited to a care plan meeting in two years. FM #1 and FM #2 indicated the facility used to have the meetings but had not had one in a long time. During an interview on 08/09/2023 at 10:02 AM, the Social Services Director (SSD) stated residents and their families had not been invited to care plan meetings since March of 2020. The SSD indicated the facility had a lot of administrative changes that prevented them from conducting the care plan meetings and indicated the facility had not yet put anything into place to get the residents and their families involved in the care planning process again. During a follow-up interview on 08/10/2023 at 9:05 AM, the SSD stated the facility was supposed to hold care plan meetings quarterly but indicated they had not been done. During an interview on 08/10/2023 at 8:26 AM, the MDS Nurse/Licensed Practical Nurse (LPN) stated care plan meetings with residents and/or family members had not been done as they were supposed to. The MDS Nurse/LPN indicated care plan meetings should be held every three months but said the facility's system was broken. The MDS Nurse/LPN said residents should be notified of the care plan meetings verbally, and family members should be notified by mail by the SSD. During an interview on 08/10/2023 at 5:45 PM, the Administrator stated he realized after questions were asked that the care plan team had not been including residents and families in the care planning process. The Administrator said the SSD was new to the position and with the facility's staff turnover, it just had not happened. The Administrator said he expected residents and their RPs to participate in the care planning process and indicated he felt including them had gone by the wayside since the SSD was newer to her position. During an interview on 08/10/2023 at 5:56 PM, the Director of Nursing (DON) stated she expected staff to involve residents and their RPs in the care planning process, because she felt their participation was very important. 2. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/2023, revealed the facility admitted Resident #22 on 03/01/2018. According to the MDS, Resident #22 had diagnoses that included anemia, heart failure, hypertension, dementia, anxiety disorder, and depression. Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On 08/07/2023 at 11:22 AM, Resident #22 said the facility used to have care plan meetings but stopped doing them over two years ago. During an interview on 08/09/2023 at 10:02 AM, the Social Services Director (SSD) stated residents and their families had not been invited to care plan meetings since March of 2020. The SSD indicated the facility had a lot of administrative changes that prevented them from conducting the care plan meetings and indicated the facility had not yet put anything into place to get the residents and their families involved in the care planning process again. During a follow-up interview on 08/10/2023 at 9:05 AM, the SSD stated the facility was supposed to hold care plan meetings quarterly but indicated they had not been done. During an interview on 08/10/2023 at 8:26 AM, the MDS Nurse/Licensed Practical Nurse (LPN) stated care plan meetings with residents and/or family members had not been done as they were supposed to. The MDS Nurse/LPN indicated care plan meetings should be held every three months but said the facility's system was broken. The MDS Nurse/LPN said residents should be notified of the care plan meetings verbally, and family members should be notified by mail by the SSD. During an interview on 08/10/2023 at 5:45 PM, the Administrator stated he realized after questions were asked that the care planning team had not been including residents and families in the care planning process. The Administrator said the SSD was new to the position and with the facility's staff turnover, it just had not happened. The Administrator said he expected residents and their RPs to participate in the care planning process and indicated he felt including them had gone by the wayside since the SSD was newer to her position. During an interview on 08/10/2023 at 5:56 PM, the Director of Nursing (DON) stated she expected staff to involve residents and their RPs in the care planning process, because she felt their participation was very important. 49044

Based on personnel record review, interviews, and facility document review, it was determined the facility failed to ensure 6 of 6 nurse aides (NAs) selected for review completed training to receive their certification within four months of their hire dates. Findings included: A review of an undated list of the facility's nurse aides (NAs) with hire dates, revealed the facility employed 11 NAs; six of the NAs were hired more than four months prior to the survey as indicated below: - NA #10, hire date of 02/28/2022 - NA #13, hire date of 12/10/2022 - NA #14, hire date of 04/18/2022 - NA #15, hire date of 12/05/2022 - NA #16, hire date of 08/10/2021 - NA #17, hire date of 01/18/2022 (tested in Illinois, but not in Missouri) A review of NA #10's personnel record revealed the record did not include any evidence indicating that NA #10 was certified or enrolled in a certified nurse aide (CNA) training program. A review of NA #13's personnel record revealed the record did not include any evidence indicating that NA #13 was certified or enrolled in a CNA training program. A review of NA #14's personnel record revealed the record did not include any evidence indicating NA #14 was certified or enrolled in a CNA training program. A review of NA #15's personnel record revealed the record did not include any evidence indicating NA #15 was certified or enrolled in a CNA training program. A review of NA #16's personnel record revealed the record did not include any evidence of NA #16 being certified or enrolled in a CNA training program. A review of NA #17's personnel record revealed the record did not include any evidence indicting NA #17 was certified in Illinois or Missouri. The record indicated NA #17 was a rehire, with an original hire date of 10/02/2017. The facility checked the CNA registry on 10/02/2017 and NA #17 did not appear on the registry as being certified at that time. During an interview on 08/08/2023 at 3:08 PM, NA #15 stated she was hired on 12/05/2022. NA #15 said facility management told the NAs they were going to start taking classes to become CNAs in September 2023. During an interview on 08/09/2023 at 12:29 PM, NA #16 stated she was hired in dietary then moved into a NA position about two years ago. She said that about three weeks ago management staff had talked about the NAs going to training in September 2023 but that was the first time anyone had said anything about it. During an interview on 08/10/2023 at 2:05 PM, the Administrator stated the facility hired NAs who were not certified. The Administrator stated he had five NAs who were going to be enrolled in classes. The Administrator said the facility received a memorandum (memo) that said emergency waivers were ending and they had until 09/10/2023, to have all NAs who were hired prior to the end of the public health emergency (PHE) complete a state approved course. During an interview on 08/10/2023 at 3:42 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated the facility employed some NAs who were not certified yet. The DON said some NAs had been employed a while without being certified and indicated the facility was trying to get them through a program.

Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; -Staff shall monitor food temperatures while holding for delivery to ensure proper got and cold holding temperatures are maintained. Staff shall refer to the current FDA food code; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone (Bacteria grow most rapidly in the range of temperatures between 40 and 140 F, doubling in number in as little as 20 minutes). Strategies include, but are not limited to, covering all foods when traveling a distance and using tray lines, mobile food carts or portable steam tables transported to dining areas. Review of the facility policy for Food Preparation Guidelines, dated 9/25/23, showed: -It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status; -Food and drinks shall be palatable, attractive and at a safe and appetizing temperatures. Strategies to ensure resident satisfaction include serving hot foods/drinks hot and cold foods/drinks cold. 1. Review of the Resident Council meeting minutes showed the following: -On 7/5/23: Dietary: residents report the food is still cold; -On 7/7/23 Dietary: residents report the food is still cold. Review of the facility's Monthly Concern Tracking Log, dated 8/23, showed on 8/8/23 from resident council: grievance the food is still cold with a resolution of: using hot plates, and dietary helping pass plates if needed. During an interview on 9/26/23 at 10:50 A.M., the Activity Director said the following: -The residents have been complaining about the food being cold; -He/She takes the resident's meeting minutes and then will complete a grievance form and give to the responsible department head; -He/She completed a grievance form last month from the Resident Council and gave it to the Dietary Manager; -The residents still say the food is cold at times. 2. During an interview on 9/26/23 at 11:00 A.M., Resident #12 said the following: -The food is cold at times when it comes from the kitchen; -He/She and other residents have complained and nothing has been done. 3. During an interview on 9/26/23 at 11:10 A.M., Resident #22 said when he/she ate his/her meals in his/her room; the food was always cold. 4. During an interview on 9/26/23 at 11:15 A.M., Resident #43 said the following: -He/She ate in his/her room; -Sometimes his/her food was cold. 5. Observation on 9/26/23 at 12:43 P.M., showed staff served the first tray out the dietary department in the main dining room. The meal consisted of barbeque pork chop, mashed potatoes, corn and sherbet. -There were no hot plates used to serve the food on; -No dietary staff assisted serving trays in the dining room or on the hall; (The facility implemented resolutions to the August resident council concern of the food being cold were not being followed). 6. During an interview on 9/26/23 at 12:45 P.M., Resident #39 said his/her food was not hot when served from the kitchen. 7. Observation on 9/26/23 showed the following: -At 1:03 P.M., staff served the last lunch tray in the dining room; -At 1:29 P.M., staff served the first hall tray on the 100 hall; -At 1:37 P.M., staff served the last hall tray on the 100 hall which was the last tray served. Observation of the food temperatures for the test tray on 9/26/23 at 1:38 P.M., taken with a metal stem type thermometer, showed the following: -Pork steak: 101.4 degrees Fahrenheit; -Corn: 86.9 degrees Fahrenheit; -Ice Cream in Styrofoam container: liquefied (the Styrofoam ice cream cup had not been kept in a tray of ice prior to service and had completely melted). During an interview on 9/26/23 at 3:00 P.M., Dietary Cook A said the following: -Dietary usually take food temperatures before the meal was served; -He/She did not take the temperatures due to running late; -He/She just started and was not aware of what the food temperatures should be. During an interview on 10/13/23 at 10:00 A.M. the Dietary Manager said the following: -She would expect staff to take the temperature of the food before meal service. If the food temperatures does not meet the requirements for safe food handling, then the food needs to be placed back in the oven and heated; -She has instructed her staff not to remove the entire lid to keep the food warm; -The hot plate and cover needs to be used for all trays that are delivered to the halls. During an interview on 9/26/23 at 3:30 P.M. the Administrator said he would expect the food to be kept at the correct temperatures at all times. MO 223772

Based on interview and record review the facility failed to ensure one resident (Resident #1) who staff assessed as a fall risk, of three sampled residents, received treatment and care in accordance with professional standards of practice. Resident #1 fell and was not thoroughly assessed for injuries prior to transfer from the floor to the wheelchair and remained in the wheelchair for approximately four hours with no additional assessments or care provided. Approximately four hours after the fall, staff discovered blood on the table and on the resident's pants. The resident had a visible fracture of the left forearm with a puncture wound. The resident was transferred to the hospital and diagnosed with a compound fracture (broken bones that pierce the skin). The facility census was 45. Review of the facility's policy titled Significant Condition Change and Notification, dated November 2019, showed the following: -An accident or incident, with or without injury, has the potential for needed medical practitioner intervention; -Examples of significant changes in a resident's physical, mental, or psychosocial status, included head trauma, bleeding, bruises or skin tears, onset of swelling, abnormal, unusual, or new, complaints of pain, and any other abnormal findings; -When any of those situations exists, the licensed nurse will contact the resident's medical practitioner; -The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week, including holidays; -If the medical practitioner cannot immediately be reached in an emergency, the medical director will be called; -If the medical practitioner cannot be reached the Director of Nursing or the charge nurse can make arrangements for transportation to the emergency department; -Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts there is no response to the calls, the medical director will be contacted. Review of the facility's undated Fall Procedure Checklist (located at the nurses' desk) showed the following: -Provide head to toe assessment, check vital signs, range of motion and skin assessment; -Call 911 if necessary or safely transfer back to the chair or bed; -Call a fall huddle with staff and investigate the fall; -Notify the Director of Nursing, physician and resident representative; -Unwitnessed fall or fall with head trauma, start neurological checks and vital sign assessments for 72 hours per the neurological assessment policy. Review of the facility Neurological Assessment Policy dated October 2021 showed the following in part: -Neurological assessments would be completed following an unwitnessed fall or following a fall or other accident/injury involving head trauma; -When assessing neurological status attention should be paid to widening pulse pressure (difference between the top and bottom numbers of the blood pressure, a measurement of the pressure in the blood vessels) This might be indicative of increasing intracranial pressure (pressure within the skull); -Neurological assessments (neuro checks) would be done every 15 minutes for the first hour, then every 30 minutes for one hour, every hour for six hours, every 4 hours for 8 hours, every 8 hours for seven assessments for a total of 72 hours. If the schedule was interrupted due to transfer to a hospital, the schedule would be resumed upon return from the hospital; -Any change in vital signs (assessment of the resident's temperature, pulse or heart rate, respirations and blood pressure) or neurological status in a previously stable residents should be reported to the physician immediately. 1. Review of Resident #1's care plan updated 7/27/20 showed the following: -Diagnosis of generalized arthritis, Alzheimer's disease, dementia, vitamin D deficiency (vitamin deficiency resulting in bone loss); -The resident had impaired cognitive function and thought processes. Staff should monitor the resident for increased confusion and redirect, ensure the resident was clean and free of odors, keep routine consistent; -The resident was at risk for falls. Staff should anticipate and meet the resident's needs, check frequently at night and offer toileting, encourage him/her to use the toilet before meals, ensure appropriate foot wear and provide a safe environment. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] showed the following; -Short and long term memory problems; -Required extensive assistance of one staff member with transfers, locomotion on and off the unit and while toileting; -Required limited assistance of one staff member with walking in room and corridor; -Required a walker for ambulation. Review of the resident's fall report dated 11/19/22 at 7:09 A.M. showed staff documented the following: -The resident was found on the floor near the reception area in the doorway. Nursing staff went to check the resident and a dietary staff member and housekeeping staff member were assisting the resident into the wheelchair. Checked the resident for injuries starting with the back side, then head and front, noted skin tear on the right hand near the little finger with a skin flap approximately 1 centimeter (cm) by 1 cm. The resident moved all extremities (arms and legs) and swatted the nurse with his/her left hand. The resident was unable to communicate pain or discomfort. Neurological checks (assessment of the residents vital signs, and injury) were performed as well as possible with the resident. Staff could not check the resident's hand grips (test to check for weakness on one side or the other) due to resident was uncooperative. Temperature 97.4 degrees (normal 98.6 degrees), pulse 74 beats per minute (normal 60-80), respirations 16 breaths per minute (normal 12-20), blood pressure (measurement of the pressure in the blood vessels) 122/70 (normal 120/80) millimeters of mercury (mmHg), oxygen saturation (measurement of oxygen level in the blood) at 96 percent on room air (normal above 92 percent). The resident was unable to give a description of the incident; -The resident was not taken to the hospital. Injury observed at the time was a skin tear to the right hand; -Oriented to person, alert and ambulatory with assistance; -The resident was incontinent at the time of the fall, confused, and had impaired memory and gait imbalance. The resident wore improper foot wear; -No witnesses to the fall. Review of the resident's nurses' note dated 11/19/22 at 12:50 P.M. showed staff documented the resident had blood all over his/her hands. Upon further assessment the resident's left arm had trauma and puncture wound on one side of the arm. The arm appeared to be broken in two spots. Staff held the arm steady until Emergency Medical Services (EMS) arrived. EMS confirmed the break, called the emergency room physician and arranged for transport to level 1 trauma center (a higher level of care). Review of the resident's nurses' note dated 11/19/22 at 4:57 P.M. showed staff documented hospital update was received, diagnosis of open radial and ulnar (two bones located in the lower part of the arm or forearm) fracture of the arm. Review of the resident's hospital emergency department record dated 11/19/22 showed diagnosis of fall with open left forearm fracture. There was obvious deformity at the left distal forearm (lower part of the arm) and puncture wound over the deformity with a one centimeter laceration which was deep and represented an open fracture, there was no exposed bone. The fractured forearm was very unstable. X-ray report showed acute comminuted left distal radial and ulnar fractures extending to the articular surface (break in both forearm bones in at least two places with extension into the joint, usually caused by severe trauma) During interview on 12/6/22 at 11:50 A.M. Dietary Aide B said he/she saw the resident on the floor near the front door between 6:00 A.M. and 7:00 A.M. on 11/19/22. The resident was flat on his/her back trying to get up. Dietary Aide B and a housekeeper lifted the resident up off the floor and into the wheelchair. One staff member was on each side of the resident and lifted him/her under the arms. Dietary Aide B did not know he/she was not supposed to touch the resident and did not know to avoid lifting the resident under the arms.No one assessed the resident before they lifted the resident off the floor. Staff pushed the resident in the wheelchair to the dining room table near the nurses' desk. Dietary Aide B was unsure if the resident moved his/her arms. The Director of Nursing (DON) took over the situation. The DON told Dietary Aide B later, they should not have moved the resident until after the resident was assessed for injuries and should not have picked the resident up off the floor by lifting under the arms. During interview on 12/6/22 at 4:05 P.M. Certified Nurse Assistant (CNA) E said the following: -On 11/19/22 he/she worked the day shift; -The resident was already up in the wheelchair that morning when he/she arrived to work at 6:00 A.M. The resident fell early that morning and a housekeeper and dietary staff picked the resident up and placed the resident in the wheelchair after the fall. The resident sat at the dining room table in his/her wheelchair following the fall. The resident was not yelling out; -He/She did not know if the resident was toileted or transferred to bed after breakfast; -Before lunch LPN A checked the resident's blood sugar, noticed blood on the table and learned the resident had a broken arm. During interview on 12/6/22 at 5:00 P.M. CNA D said the following: -On 11/19/22 he/she worked day shift on the resident's hall. At 6:00 A.M. the resident was already up in the wheelchair in his/her room and staff assisted the resident to the dining room near the nurses' desk; -The resident fell early in the morning before breakfast, and a dietary staff and housekeeper picked the resident up off the floor. Following the fall, the resident was pushed in the wheelchair back to the dining room table; -Staff should have waited to transfer the resident to the wheelchair after the nurse assessed the resident for injuries; -The resident ate some breakfast that morning and attempted to feed himself/herself. He/She remained at the table all morning. Staff did not toilet or change the resident all morning and did not transfer the resident out of the wheelchair all morning; -The resident was not complaining or anything unusual, he/she did not move around from the table all morning; -Just before lunch time LPN A went to check the resident's blood sugar and noticed there was blood on the table, a skin tear between the resident's left fingers and a big knot on the underside of the resident's left arm and puncture wound on the outside of the arm; -The resident went to the hospital by ambulance. During interview on 12/6/22 at 3:30 P.M. Certified Medication Technician (CMT) C said the following: -He/She worked on 11/19/22 and took over passing medications at about 7:45 A.M. after Resident #1 fell . Later in the morning he/she administered the resident's morning medications crushed and mixed in applesauce. The resident sat at the dining room table with his/her hands in his/her lap; -At about 11:00 A.M. staff noticed the resident had blood on his/her pants and complained of pain with movement of the left arm. The resident yelled out and cussed when his/her left arm was touched. Puncture holes were noted in the skin just above the wrist area and on the upper forearm when the resident's shirt sleeve was pulled up. EMS was called and the resident sent to the hospital. During interview on 12/6/22 at 1:10 P.M. Licensed Practical Nurse (LPN) A said the following: -On 11/19/22 he/she worked the day shift. At about 11:00 A.M. he/she attempted to check the resident's blood sugar (obtaining blood from the finger to determine glucose level), picked up the resident's left hand and the resident cussed and yelled out in pain. Blood was noted on the table and the resident's pants; -He/She pulled the resident's long sleeves up and noted a puncture wound to the left forearm about two to three inches above the wrist and a knot to the outer part of the forearm, skin tears to the left hand and obvious fractures of the left forearm; -The puncture wound and knot were not visible until he/she pulled up the resident's long sleeve; -He/She immobilized the arm while staff called the ambulance. The resident was sent to the hospital. During interview on 12/6/22 at 12:10 P.M. the DON said the following: -She was the charge nurse on 11/19/22. At about 7:00 A.M. she was down the hall passing medications when staff yelled and said the resident fell . Dietary and housekeeping staff lifted the resident off the floor and into the wheelchair as the DON arrived. She checked the resident and found a skin tear to the right hand near the little finger. She did not remove the resident's clothing or complete a full head to toe assessment. She checked the resident's vital signs, cleansed and secured the right hand skin tear, and pushed the resident's wheelchair to the dining room table near the nurses' desk; -She should have checked the resident's vital signs and completed neurological checks per the facility policy starting with every 15 minutes for one hour and then every 30 minutes for one hour. She only checked the resident's vital signs and attempted a neurological check initially at the time of the fall. She did not assess the resident again after the fall and was not aware the resident had a compound fracture (displaced break in the bones with puncture of the skin) of both bones in the left forearm. She should have assessed and monitored the resident closely after the unwitnessed fall; -Following a fall, staff should assess the resident immediately for injuries before transferring the resident off the floor. Staff should not have gotten the resident off the floor before the resident was assessed. During interview on 12/14/22 at 9:50 A.M. the administrator said staff should provide a thorough assessment following a fall for injury and implement the fall policy including neurological checks. Staff should not get the resident up from the floor without an assessment completed and should not lift the resident under the arms. The fractured arm might have been noticed earlier if staff had completed a thorough assessment after the fall and followed the fall protocol. Staff should have toileted the resident and provided care after breakfast. The injury might have been noticed earlier. Staff should not have left the resident at the table from the time of the fall (approximately 7:15 A.M.) until lunch time with no assessment or toileting for approximately four hours. During interview on 12/9/22 at 9:35 A.M. the resident's physician said the resident fell and sustained a compound fracture of both bones in the left forearm. Staff should provide a complete assessment of every resident following a fall, assessing for injuries. Force was required to make a compound fracture. Staff should have assessed the resident, called the physician requesting an x-ray of the injury if the resident showed signs of pain at the time of the fall or immediate transfer to the hospital. Staff should follow the fall protocol and complete assessments ongoing. The injury could have been identified earlier with appropriate staff assessments. The resident had Alzheimer's disease and was unable to verbalize his/her condition. MO#210361 MO#210506

Based on observation, interview, and record review, the facility failed to ensure two residents were free from neglect. On 11/20/21, Registered Nurse (RN) D failed to administer scheduled medications and check blood sugar levels as ordered by the physician for two residents (Resident #8 and #12). Resident #12 had a diagnoses of high blood pressure and diabetes and did not receive his/her scheduled blood pressure medications, oral diabetic medication, and sliding scale insulin. Resident #12 required emergent treatment in the hospital that included intravenous insulin for extremely elevated blood sugar, as well as treatment for extremely elevated blood pressure. Resident #8 had a fractured right arm and a diagnosis of congestive heart failure and did not receive his/her scheduled blood pressure medication. Resident #8 reported to staff that he/she was in pain in the morning which was not addressed until after 4:00 P.M. A sample of 18 residents was selected for review. The facility census was 46. The administrator was notified on 11/22/21 at 4:33 P.M., of the Immediate Jeopardy (IJ) which began on 11/20/21. The IJ was removed on 11/23/21, as confirmed by the surveyor onsite verification. Record review of the facility's Abuse, Prevention and Prohibition Policy, revised November 2018 showed the following: -Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress; -This facility prohibits mistreatment, neglect or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain or mental anguish. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect; -The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The facility Administrator will designate as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing; - Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process; -Implement steps to prevent further potential abuse. (See section on Protection: Resident to Resident Altercation, Employee Allegations or Other Potential Perpetrators) initiate investigation including initial notifications of all listed on the Notification form, documenting on the form. This includes the State Agency and Law Enforcement if there is reasonable suspicion of a crime; -Utilize Resident Abuse Investigation Forms for completing investigation; -Complete a Report of Alleged Resident Abuse within required timelines (Administrator will see that the report is completed, reviewed and sent) -A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted. -Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format -Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated; -Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has a special rapport participate if possible. If the resident is not interviewable, question the roommate and any family or friends who visit frequently with completion of a questionnaire; -The facility will immediately remove any alleged perpetrator from any further contact with any resident; -When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee. The Administrator and/or the Director of Nursing will relay this suspension. At that time, the alleged staff member will be advised of the allegation and encouraged to assist in completing a statement relevant to the facts. The employee shall be instructed that the suspension is without pay and will be in effect as long as the investigation is ongoing. The investigation and due process rights of the alleged perpetrator/s will be observed. If the allegation is found unsubstantiated, the employee will be reinstated with retroactive pay for any days missed that the employee was originally scheduled to work. If the allegation is substantiated, the employee will be terminated. 1. Record review of Resident #12's face sheet showed the following: -admitted [DATE]; -Diagnoses included pneumonia, chronic kidney disease, congestive heart failure, high blood pressure, and type 1 diabetes (insulin dependent diabetes in which the pancreas produces little or no insulin, the hormone needed to allow sugar to enter the cells to produce energy). Review of the resident's care plan, dated 10/25/21, showed the following: -The resident was dependent on staff for activities, cognitive stimulation, and social interaction. Converse with the resident while providing care; -The resident had diabetes mellitus. Educate the resident/family/caregivers on the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations; -The resident had a seizure disorder. Administer medications as ordered; -The resident required limited assistance from staff with personal hygiene, toileting, and transfers; -The resident had limited physical mobility and was able to walk with the assistance of one staff member. Record review of the resident's nurse's notes showed the following: -On 10/31/21 the resident had three episodes of vomiting and his/her morning blood sugar level was 588 (the normal blood sugar level range for an adult who hasn't eaten is between 90 and 110). The physician was notified and orders received to send the resident to the emergency room . The nurse called the hospital at 2:42 P.M. and was told the resident was in diabetic ketoacidosis (DKA, a serious complication of diabetes that can be life threatening. It develops when the body does not have enough insulin to allow blood sugar into the cells for use as energy); -On 11/11/21 the resident was readmitted to the facility from the hospital. Record review of the resident's physician order sheet (POS) for November 2021 showed the following: -Metalozone 2.5 milligrams (mg) by mouth once daily for 30 days (a water pill (diuretic) that increases urine production and lowers blood pressure); -Torsemide 100 mg by mouth daily for 30 days (a powerful diuretic used to treat heart failure and kidney disease); -Hydralazine 75 mg by mouth three times daily for 30 days (relaxes blood vessels to treat high blood pressure); -Lispro Insulin (short acting insulin) per sliding scale before meals subcutaneous (SQ). For blood sugar of 70-139 give 0 units, 140-175 give 2 units, 176-200 give 3 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 9 units, over 400 give 12 units; -Metoclopramide 7.5 mg by mouth three times a day before meals (used to treat heart burn); -Carvedilol 12.6 mg by mouth twice a day with meals (slows the heart rate and makes it easier for the heart to pump blood to the rest of the body, used to treat heart failure and high blood pressure); -Citalopram 10 mg by mouth once daily (antidepressant); -Clonidine 0.2 mg by mouth twice a day (used to treat high blood pressure); -Cyclobenzaprine 10 mg by mouth three times a day (muscle relaxant); -Levetiracetam 750 mg by mouth twice a day (anticonvulsant used to treat seizure disorders). Record review of the resident's Medication Administration Record (MAR) for 11/20/21 showed the following: -The 8:00 A.M. sliding scale lispro insulin was circled (indicating it was not administered) and there was no documented blood sugar reading; -The A.M. (6:00 A.M. to 10:00 A.M.) dose of citalopram 10 mg once daily was circled as not administered; -The 7:00 A.M. dose of metoclopramide 7.5 mg (before meals) was blank; -The A.M. dose of clonidine 0.2 mg was circled as not administered; -The A.M. dose of cyclobenzaprine 10 mg was circled as not administered; -The A.M. dose of Levetiracetam 750 mg was circled as not administered; -The A.M. dose of metalozone 2.5 mg was circles as not administered; -The A.M. dose of torsemide 100 mg was circled as not administered; -The A.M. dose of hydralazine 75 mg was circled as not administered; -The A.M. dose of carvedilol 12.5 mg was circled as not administered; -The 11:00 A.M. dose of metoclopramide 7.5 mg (before meals) was blank; -The 12:00 P.M. sliding scale lipsro insulin was circled as not administered. There was no documented blood sugar reading; -The evening dose (3:00 P.M. to 7:00 P.M.) dose of cyclobenzaprine 10 mg was circled as not administered; -The evening dose of hydralazine 75 mg was circled as not administered; -The evening dose of carvedilol 12.5 mg was circled as not administered; -There was no documentation showing the reason the medication was not given. Record review of the resident's nurse's notes showed the following: -On 11/20/21 at 4:30 P.M. the south charge nurse called the on call nurse to report the resident's family called upset related to medications and insulin. The nurse (on call) had the charge nurse monitor the resident's blood sugar due to the family's concern. The resident's blood sugar was 543 and the resident had started to vomit. The charge nurse was instructed to call the physician related to this. The physician instructed the nurse to send the resident to the emergency room for evaluation. Record review of the resident's nurse's notes showed the following: -On 11/20/21 at 4:45 P.M. medications, insulin accucheck (blood sugar check) not done. This nurse was not given report on this client (resident) behind the curtain (on the observation unit). Medications and narcotics were behind the curtain. The resident's blood sugar result was 543 at 4:00 P.M. when the nurse found out the client was here. The resident was sent to the hospital. The physician and Director of Nursing (DON) are aware. Record review of the resident's Emergency Medical Services (EMS) documentation, dated 11/20/21, showed the following: -Primary impression: Diabetic hyperglycemia (elevated blood sugar); -Secondary impression: Hypertensive crisis (extremely high blood pressure); -Chief complaint: Elevated blood sugar; -Secondary Complaint: Vomiting; -At 4:00 P.M. the resident was alert. The resident's blood sugar was 512. The resident's blood pressure was 213/109 (normal blood pressure is less than 120/80); -At 4:03 P.M. EMS placed an intravenous (IV) line; -At 4:06 P.M. the resident was alert. The resident's blood pressure was 224/105; -At 4:07 P.M. the resident was transported to the hospital and report was given to emergency room staff. Record review of the resident's emergency department's nurse's note, dated 11/20/21 at 4:15 P.M. showed the following: -The resident presented to the emergency room with complaints of high blood sugar and high blood pressure; -The resident stated he/she did not receive any medications today; -The resident said he/she ate all of his/her meals like normal; -The resident said the nurse at the facility did not bring him/her any medications today; -The resident was alert and oriented; -The resident's blood sugar was 512. The resident was placed on a cardiac monitor and an electrocardiogram (EKG, records the electrical signal from the heart). Record review of the resident's emergency department physician note, dated 11/20/21 at 9:51 P.M. showed the following: -The resident presented to the emergency department from the facility. The resident was a longstanding diabetic with a previous history of multiple episodes of diabetic ketoacidosis (DKA); -Since admission to the facility the resident had one other episode of DKA and dehydration that required hospitalization which occurred three weeks ago; -The resident had been exposed to COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus that is spread person to person through respiratory droplets) and was moved to a different bed in the facility; however in doing so, the resident did not receive his/her medications; -The resident was noted to have an elevated blood sugar and one episode of nausea and vomiting; -Medications administered were 100 units of regular insulin with 100 milliliters (ml) of sodium chloride (the chemical name for salt, used to treat or prevent sodium loss from dehydration, excessive sweating, or other causes) intravenously (IV), clonidine 0.2 mg by mouth, carvedilol 12.5 mg by mouth, 10 units of regular insulin by IV push, and 1000 ml of normal saline IV for hydration; -The resident's blood pressure was 185/87; -The resident was transferred to another hospital at 9:36 P.M. Record review of the resident's nurse's notes showed the following: -On 11/21/21 at 11:45 A.M. the facility called the hospital for a follow up on the resident's emergency room visit and was informed the resident was transferred to another hospital due to unstable blood pressure and to monitor his/her blood sugars. The resident's primary physician was made aware of the transfer. Record review of the resident's hospital history and physical, dated 11/21/21, showed the following: -The resident was a Type 1 diabetic with chronic heart failure, and chronic kidney disease; -The resident states he/she did not receive his/her medications or insulin yesterday because of issues at the facility; -The resident had chronic weakness and has been at a nursing home for therapy; -High blood pressure and high blood sugar are his/her biggest issues; -The resident has variable (not consistent) blood sugars that need to be watched closely; -The resident was discharged back to the facility on [DATE]. Observation on 11/22/21 at 9:40 A.M. showed Resident #12's room was located on the observation unit which was behind a plastic divider with a zipper. The unit had it's own medication cart and medication book. During an interview on 11/24/21 at 9:34 A.M., Resident #12 said on 11/20/21 he/she did not get any medications or insulin and did not have his/her blood sugar checked. The resident asked the aide that brought in the breakfast tray about it and the aide said something to the effect that he/she wasn't going to cross the nurse. It seemed as though the aide was scared of the nurse. Another aide delivered the resident's noon meal tray and the resident again asked about his/her medications and insulin. The aide started writing things down and said he/she would look into it. The resident started throwing up and called his/her family member and let him/her know what was going on. The family member called the facility and spoke to the other nurse, Licensed Practical Nurse (LPN) G. LPN G came to the resident's room and said he/she couldn't get into the medication cart because he/she did not have the keys. LPN G checked the resident's blood sugar which was over 500. LPN G then called and had the resident transported to the emergency room . The resident received IV medications and an insulin drip and was transported to another hospital. The resident's blood pressure was very high, 200 and something over 100 and something. The resident said this was because he/she had not received any medications all day. The resident felt terrible and was very ill and really needed to have his/her medicine. The resident said he/she did ask the first aide that came in that morning to speak to his/her nurse, but the nurse never came in the resident's room. The resident never saw any nurse that day until LPN G came in the room after the resident's family spoke with him/her and let LPN G know what was going on. During an interview on 11/22/21 at 2:45 P.M., the resident's family member said on 11/20/21 he/she got a call from the resident in the early afternoon. The resident said he/she had not received any medication or insulin so far that day and was feeling sick. The family member was fearful the resident would go into DKA because he/she had done so in the past. The resident was admitted to the facility on [DATE]. On 10/31/21 the resident started vomiting and ended up admitted to the hospital for 12 days for DKA. Upon readmission to the facility, the resident was placed on the observation unit. The family member called the facility at approximately 3:00 P.M. and spoke to LPN G and explained what the resident had said. LPN G told the family member he/she did not have keys to the medication cart to give the resident his/her insulin because the nurse assigned to the resident, Registered Nurse (RN) D, had left the faciity on a lunch break. LPN G called the DON to make him/her aware of the situation. LPN G checked the resident's blood sugar and it was very high. The resident had already started vomiting. LPN G contacted the physician who gave orders to send the resident to the emergency room . During an interview on 11/22/21 at 2:11 P.M., Certified Nurse Aide (CNA) F said he/she worked as one of two aides on 11/20/21 from 6:00 A.M. to 6:00 P.M. on the resident's side of the facility. Resident #12 complained of not feeling well around 2:00 P.M. or 3:00 P.M. CNA A told LPN G, who worked on the other side of the facility, that the resident wasn't feeling well because RN D was not in the facility at that time. Earlier that morning, CNA A had to remind RN D to go and check another resident's blood sugar because he/she had complained it hadn't been done yet and he/she wanted to eat breakfast. CNA F never saw RN D go onto the observation unit the entire shift or go into either resident's room who resided on the observation unit. 2. Record review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included multiple myeloma (a type of bone marrow cancer), altered mental status, sleep apnea, and muscle weakness. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff), dated 10/7/21, showed the following: -Cognition was intact; -Required limited physical assistance of one staff for transfers; -Balance when moving from a seated to a standing position was not steady and required human assistance to stabilize. Record review of the resident's care plan, dated 11/2/21, showed the following: -Self-care performance deficit; -Required one to two staff participation with transfers; -The resident was at risk for falls. Record review of the resident's nurse's note, dated 11/9/21 at 5:40 P.M. showed the following: -The resident left the facility by ambulance for a right arm deformity; -The resident complained of pain and was assessed by the nurse who saw a deformity; -911 was called and the family was notified. Record review of the resident's care plan, updated 11/10/21, showed the following: -The resident had pain; -Monitor, record, and report to the nurse any signs or symptoms of non-verbal pain; -Anticipate the resident's need for pain relief and respond immediately to any complaints of pain; -The resident had a mood problem and would remain free from adverse reactions related to anti-anxiety therapy; -Administer medications as ordered. Monitor and document for side effects and effectiveness. Record review of the resident's nurse's note, dated 11/12/21 at 6:01 P.M. showed the resident had readmitted to the facility with a diagnosis of right arm fracture which was non-surgical and had a splint and sling in place. The resident used a wheelchair for mobility and required assistance of two staff for transfers and activities of daily living. Record review of the resident's Physician Order Sheet (POS) for November 2021 showed the following: -Acyclovir 400 mg by mouth every eight hours (antiviral medication that stops the spread of the herpes virus in the body); -Calcium 500 mg plus Vitamin D by mouth twice a day (supplement to treat low blood calcium levels); -Vitamin B12 50 micrograms (mcg) by mouth daily (helps keep blood and nerve cells healthy and prevent low red blood cell counts); -Folic acid 1 mg by mouth daily (a B vitamin that helps the body make healthy new cells); -Lasix 40 mg by mouth daily (a diuretic that treats fluid retention and swelling caused by congestive heart failure); -Magnesium Oxide 400 mg by mouth twice a day (a supplement used to treat constipation, indigestion, and headaches); -Methimazole 2.5 mg by mouth daily (used to treat hyperthyroidism, a condition that occurs when the thyroid gland produces too much thyroid hormone); -Metoprolol 50 mg by mouth daily (affects the blood flow in arteries and veins to treat high blood pressure); -Oxybutynin 5 mg by mouth twice a day (reduces muscle spasms of the bladder and urinary tract and treats symptoms of overactive bladder); -Miralax 17 grams by mouth daily (laxative); -Potassium Chloride 40 milliequivalents (meq) by mouth twice a day (used to treat or prevent low levels of potassium that is needed for several functions of the body, including the beating of the heart); -Prednisone 40 mg by mouth daily (a corticosteroid that prevents the release of substances in the body that cause inflammation); -Acetaminophen 650 mg by mouth as needed every four hours for pain (non-narcotic pain reliever); -Norco 5 mg/325 mg by mouth every four hours as needed for pain (narcotic pain reliever); -Tramadol 50 mg by mouth every four hours as needed for pain (narcotic pain reliever). Record review of the resident's MAR for 11/20/21 showed the following: -The 6:00 A.M. dose of acyclovir 400 mg was circled (indicating the medication was not administered); -The A.M. dose (6:00 A.M. to 10:00 A.M.) of Calcium 500 mg plus Vitamin D was circled as not administered; -The A.M. dose of Vitamin B12 50 mcg was circled as not administered; -The A.M. dose of folic acid 1 mg was circled as not administered; -The A.M. dose of Lasix 40 mg was circled as not administered; -The A.M. dose of magnesium oxide 400 mg was circled as not administered; -The A.M. dose of methimazole 2.5 mg was circled as not administered; -The A.M. dose of metoprolol 50 mg was circled as not administered; -The A.M. dose of oxybutynin 5 mg was circled as not administered; -The A.M. dose of miralax 17 grams was circled as not administered; -The A.M. dose of potassium chloride 40 meq was circled as not administered; -The A.M. dose of prednisone 40 mg was circled as not administered; -No documentation showing the reason the medication was not given. There were no pain medications documented on the MAR as administered for the resident on 11/20/20. Record review of the resident's nurse's note, dated 11/20/21 at 4:45 P.M. showed the following: -The resident was assessed and his/her right arm was extremely swollen and the resident had difficulty moving his/her fingers; -The resident complained of severe pain and discomfort, 8-9 out of 10 on the pain scale (pain scale with 1 being least amount of pain and 10 being the most severe pain); -The physician was notified and gave orders for an ice pack, on 20 minutes, off 20 minutes, alternating as needed; -RN B was instructed to give the resident pain medication at that time. Observation on 11/22/21 at 11:35 A.M. showed the resident's room was behind a zippered plastic divider curtain on the observation unit. Observation of the resident showed his/her right arm and hand were in a sling. The right hand was swollen. During an interview on 11/22/21 at 11:36 A.M., the resident said his/her right arm was fractured a couple of weeks prior. On 11/20/21 he/she did not receive any of his/her medications and the nurse never came in his/her room. The aides did come in and assist him/her and the resident received meals in his/her room. The resident had pain in his/her right arm and had told the aide he/she was hurting, but the nurse never came to his/her room and the resident did not receive any treatment for the a pain until the late afternoon when the DON came in and checked on him/her. The DON got the resident an ice pack and the resident said his/her pain improved. The resident was not certain if he/she received any pain medication on 11/20/21 or not. During an interview on 11/22/21 at 2:11 P.M., CNA F said he/she worked as one of two aides on 11/20/21 from 6:00 A.M. to 6:00 P.M. on the resident's side of the facility. Resident #8 told CNA F he/she was having pain between 7:00 A.M. and 10:00 A.M. that morning. CNA F reported to RN D that the resident was in pain and RN D said okay and asked which resident he/she was. CNA F told RN D Resident #8 was one of the residents behind the plastic curtain. RN D again said, okay. CNA F never saw RN D go into Resident #8 or Resident #12's rooms on the observation unit the entire shift. During an interview on 11/22/21 at 3:15 P.M., LPN I said he/she gave report to RN D for the north side of the facility on the morning of 11/20/21. RN D arrived at the facility at 6:15 A.M. LPN I went through the report sheet and gave RN D a heads up on what was going on and who liked their medications crushed or not and other things. LPN I did tell RN D there were two residents behind the plastic curtain and explained they did not have COVID-19 but were on observation. LPN I said he/she and RN D physically walked onto the observation unit and counted the narcotics on the observation unit medication cart, which was a separate cart, and left on the observation unit. There were two narcotic cards for Resident #8 that LPN I and LPN D counted together. LPN I explained to RN D that Resident #8 took his/her medications crushed. LPN I explained to RN D that Resident #12 was diabetic and his/her blood sugars could get very high. LPN I told RN D Resident #12's birthday was the day before (11/19/21) and told him/her the resident's age. RN D said, wow, that's really young to be in a nursing home. LPN I said Resident #8 had requested a pain pill through the night, which LPN I administered and it was effective. Resident #12 asked for ice cream the night before because it was his/her birthday. LPN I gave the resident the ice cream. The resident's blood sugar was around 200 at that time. Neither resident had any other complaints or request through the night. During an interview on 11/22/21 at 12:33 P.M. LPN G said on 11/20/21 he/she was the charge nurse for the south side of the facility and RN D was the charge nurse for the north side of the facility. Around 2:30 P.M. RN D left the faciity on a break and did not give LPN G his/her keys to the medication carts. LPN G got a call from the family member of Resident #12, sometime after RN D had left the facility. Resident #12's family member said the resident had not received any medications or insulin all day. LPN G called the DON who said they could administer any medications that were once daily and that's when LPN G realized he/she did not have the keys to the north side medication carts. Resident #12's family member called back and said the resident was now vomiting and he/she was very upset. LPN G went to Resident #12's room and the resident was sitting up in the wheelchair and had vomited twice. LPN G checked the resident's blood sugar which was 548. LPN G called the on call physician who gave orders to send the resident to the emergency room . LPN G called Emergency Medical Services (EMS) who arrived 10 minutes later and transported the resident out. RN D returned to the facility around 3:50 P.M. LPN G showed RN D the fall binder with the protocols so he/she could complete the documentation for another resident who had fallen. The DON arrived at the facility who contacted the agency staffing administrator who said RN D needed to stay until his/her work was completed. RN D claimed he/she didn't know there were residents on the observation unit, but RN D would have received this information in report. LPN G said RN D did not seem concerned at all that two residents had not received their medications and one had to be transferred out to the emergency room . LPN G was an agency staff member and did receive training when he/she first started at the facility on policies and procedures and was given a tour of the facility and instructed how to document in the electronic health record. During an interview on 11/22/12 at 10:30 A.M. the DON said he/she got a call at home on Saturday, 11/20/21 in the afternoon about 3:30 P.M. from LPN G who said he/she had received a call from the family member of Resident #12 who told LPN G the resident had not received any medications or insulin. The family member said the resident didn't feel well and his/her blood sugar had not been checked. The DON directed LPN G to go check the resident's blood sugar and to call the physician and inform him/her the resident had not received any medications. Resident #12 was a brittle diabetic. The resident's blood sugar was very high and the physician gave orders to send the resident to the emergency room . RN D was the charge nurse for the north side of the facility, which included the observation unit where Resident #8 and Resident #12 were located. RN D had left the facility with the keys to the medication cart and LPN G could not access the medications from that medication cart. RN D did sign out all other residents' medications except for Resident #8 and Resident #12. RN D did not clock out for his/her break and left the facility around 2:30 P.M. and returned to the facility around 3:50 P.M. Staff can leave the campus for their breaks but they must leave any keys and give report to the other nurse before leaving. When RN D returned to the facility the DON asked him/her to document what happened and to notify the physicians on the missed medications. The DON instructed RN D to initial and circle the missed medications on the MAR's. Another resident had fallen while RN D was gone and the DON asked RN D to assist with the paperwork and assessments for this resident. RN D did finish his/her shift which ended at 6:30 P.M. RN D did not seem concerned at all or apologetic that he/she had overlooked two residents completely. There was a binder at the nurse's station for agency staff to read and sign acknowledging they have read and understood the policies and procedures. During an interview on 11/23/21 at 8:53 A.M., RN D said he/she was not aware there were two reside

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #9) was free from abuse. On 9/2/21, Resident #9 reported that on 9/1/21, Certified Nurse Aide (CNA) A (agency staff) slapped him/her on the face and told him/her to shut up. Resident #9 said it hurt and he/she was afraid of CNA A. A sample of 18 residents was selected for review. The facility census was 46. On 11/18/21 at 7:18 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 9/1/21. On 9/2/21, the administrator identified CNA A had physically and verbally abused Resident #9. Upon discovery, staff contacted the police, conducted an investigation, and notified appropriate parties. The employee was arrested upon his/her return to facility premises. Facility staff reviewed their abuse and neglect policies and inserviced staff on abuse and neglect. The IJ was removed and corrected on 9/2/21. Record review of the facility's Abuse, Prevention and Prohibition Policy, revised November 2018 showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish; -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. -This facility prohibits mistreatment, neglect or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain or mental anguish. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect; -The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The facility Administrator will designate as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing; -Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process; -Implement steps to prevent further potential abuse. (See section on Protection: Resident to Resident Altercation, Employee Allegations or Other Potential Perpetrators) initiate investigation including initial notifications of all listed on the Notification form, documenting on the form. This includes the State Agency and Law Enforcement if there is reasonable suspicion of a crime; -Utilize Resident Abuse Investigation Forms for completing investigation; -Complete a Report of Alleged Resident Abuse within required timelines (Administrator will see that the report is completed, reviewed and sent); -A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted; -If sexual assault has been alleged, the physician will be contacted for an order to transfer to the emergency room for examination; -Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format; -Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated; -Interview the resident if they are cognitively able to answer questions in a private setting free from any intimidating factors. Request that a staff member who has a special rapport participate if possible. If the resident is not interviewable, question the roommate and any family or friends who visit frequently with completion of a questionnaire; - The facility will immediately remove any alleged perpetrator from any further contact with any resident; -When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee. The Administrator and/or the Director of Nursing will relay this suspension. At that time, the alleged staff member will be advised of the allegation and encouraged to assist in completing a statement relevant to the facts. The employee shall be instructed that the suspension is without pay and will be in effect as long as the investigation is ongoing. The investigation and due process rights of the alleged perpetrator/s will be observed. If the allegation is found unsubstantiated, the employee will be reinstated with retroactive pay for any days missed that the employee was originally scheduled to work. If the allegation is substantiated, the employee will be terminated. 1. Record review of Resident #9's care plan, dated 4/20/21, showed the following: -The resident had impaired cognition or impaired thought processes; -Break tasks into small sub tasks to support short term memory deficits; -The resident required assistance of one staff for dressing and hygiene; -The resident required assistance of one or two staff for transfers; -The resident was dependent on staff for toilet use; -The resident was able to make his/her needs known to staff; -The resident had limited physical mobility related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident had a behavior problem. Administer antipsychotic and anti-anxiety medication as ordered. Monitor behavior episodes and attempt to determine the underlying cause. Record review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/17/21, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was severely impaired; -No behaviors, delusions, or hallucinations; -Required limited assistance of one staff for bed mobility, transfers, walking, and toilet use; -The resident was dependent on one staff for dressing and hygiene. Record review of the statement from Resident #9, dated 9/2/21 at 10:25 A.M., transcribed by the DON, showed the following: -CNA A slapped the resident with his/her hands several times. The resident pointed to his/her left cheek; -There were no visible marks; -CNA A stated he/she did not want to be here but had to work; -CNA A was known by residents as little devil; -CNA A helped the resident to bed and was rough; -CNA A had previously thrown the resident in his/her recliner chair; -The resident told CNA A if he/she didn't stop the resident would spit on him/her but the resident didn't. During an interview on 11/10/21 at 2:05 P.M., Resident #9 said CNA A slapped his/her cheek several times, put his/her hand over the resident's mouth, and told the resident to shut up. The resident said this hurt and the resident was scared of CNA A. Record review of Resident #10's (Resident #9's roommate) Quarterly MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was intact. Record review of the statement from Resident #10, dated 9/2/21 at 10:30 A.M., transcribed by the DON, showed the following: -Resident #10 heard CNA A tell Resident #9 to shut up; -CNA A gets mad at people, several, all the time and tells them all the same thing; -Resident #10 did not see any physical contact between Resident #9 and CNA A. Record review of the written statement dated 9/2/21, obtained by the facility from CNA E, showed the following: -CNA E assisted Resident #9 out of bed for breakfast that morning and the resident said CNA A, who had worked the day before, was mean to him/her; -The resident said CNA A smacked him/her in the face; -CNA E took the resident to breakfast and then went back to the room to wake up Resident #10; -Resident #10 told CNA E that Resident #9 was up late the night before, upset because CNA A was mean to him/her; -Resident #10 said every time CNA A was in their room he/she was mean to Resident #9 and yelled at him/her and told him/her to shut up and go to sleep. During a telephone interview on 11/16/21 at 8:54 A.M., CNA E said Resident #9 did get confused at times and would say some things that didn't make sense, but the resident was more alert and oriented back in September. CNA E said Resident #9 told him/her that CNA A was mean and told him/her to shut up and smacked the resident's face. The resident was very upset about the situation. Resident #10, who was alert and oriented, said he/she heard CNA A tell Resident #9 to shut up. Record review of the undated written statement from Certified Medication Technician (CMT) B showed the following: -On 9/2/21 CMT B administered medications to Resident #9 who told CMT B that he/she was upset; -The resident said he/she didn't like CNA A; -The resident said CNA A was mean to him/her and was the devil; -CMT B informed the DON. During a telephone interview on 11/11/21 at 10:50 A.M., CMT B said Resident #9 told him/her CNA A was the devil and was mean. CMT B did not ask the resident to elaborate on what he/she meant by mean. Resident #9 was confused at times but was pretty good at remembering names. Resident #9 was upset about what happened. CMT B reported what the resident told him/her to the DON. During a telephone interview on 11/17/21 at 11:27 A.M. the DON said Resident #9 was adamant that CNA A slapped his/her left cheek several times and told him/her to shut up when the DON spoke with him/her about it on 9/2/21. The resident was upset, tearful, and hard to console. Resident #9 had no history of delusions or making false allegations and at the time of the incident the resident was very with it. Resident #9 said he/she did not want CNA A back in his/her room. CNA A was assigned to Resident #9's hall on 9/1/21 and would have been his/her caretaker. There was a previous allegation made by Resident #11 that CNA A had told him/her to shut up prior to the incident with Resident #9, but the facility could not substantiate that allegation. The DON interviewed other residents on 9/2/21 and they reported CNA A as being mean, unkind, and spiteful and reported his/her behavior to be verbally abusive. These residents had not reported this prior to 9/2/21. CNA A was terminated because of the allegation and the DON believed the allegation made by resident #9 regarding verbal and physical abuse to be true. The facility did notify the police about the incident and CNA A was arrested and the DON believed there were criminal charges filed against him/her. Record review of the police report, dated 9/10/21, showed the following: -Type of incident: Elder abuse-3rd degree; -On 9/2/21 at approximately 1:11 P.M. the police department received a call about possible elder abuse at the facility; -The responding officer arrived and met with the DON who said he/she had met with Resident #9 who said CNA A slapped him/her in the face several times during the bedtime routine and had also thrown him/her into the recliner chair in the past few days; -The DON said residents described CNA A as the devil and several residents stated CNA A was verbally abusive to residents; -The DON said he/she spoke with Resident #10 who stated he/she heard CNA A tell Resident #9 to be still and shut up. Resident #10 said CNA A was verbally abusive to people and gets mad and yells at other residents; -The DON said a resident said CNA A had refused to let him/her use the bedpan and would place the emergency call light button on the other side of the room so the resident could not call for assistance; -The DON said several residents complained about CNA A in the past but none of the residents felt safe enough to push the issue until Resident #9 was assaulted. The DON said he/she had reported CNA A to the hiring agency about previous allegations. 2. Record review of Resident #11's Quarterly MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was moderately impaired; -No behaviors, delusions, or hallucinations; -Independent with transfers, dressing, and walking; -Required limited assistance of one staff for toilet use and hygiene. Record review of Resident #11's care plan, revised 7/21/21, showed the following: -The resident had impaired cognitive function or impaired though processed related to Alzheimer's and dementia; -Break tasks into small sub tasks to support short term memory deficits; -Use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. The resident understood consistent, simple, directive sentences; -Provide the resident with necessary cues. Stop and return if the resident was agitated; -The resident enjoyed conversation; -Provide the resident with a homelike environment; -The resident preferred consistency with his/her daily routine; -The resident was slightly hard of hearing. Ensure you are facing the resident and provide direct instructions the resident can understand; -Ensure the resident's call light is in reach. Record review of Resident #17's (Resident #11's roommate on 8/23/21), Significant Change in Status MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was intact. Record review of the facility's investigation, dated 8/23/21, showed the following: -The resident reported to the activity aide and the administrator that CNA A told him/her to shut up and was being mean to him/her and to the resident's roommate (Resident #17); -The Assistant Director of Nursing (ADON) was called to the administrator's office as well as the south side charge nurse, and the administrator had the resident re-state what was said to him/her; -The resident stated CNA A told him/her and his/her roommate to shut up. CNA A was just mad at him/her; -The ADON then spoke with Resident #17 and he/she stated CNA A told him/her to be quiet and not talk to him/her. CNA A was mad. Resident #17 said this made him/her feel very small; The ADON spoke with CNA A in the administrator's office and explained it had been reported he/she told a resident to shut up and was being mean; -CNA A provided a written statement and he/she was suspended pending the investigation. Record review of the undated, written statement by CNA A, obtained by the facility, showed the following: -On 8/23/21, CNA A was answering lights after breakfast and making beds and putting bags in trash cans; -One resident kept putting on his/her call light but when CNA asked him/her what he/she needed, the resident would say he/she didn't need anything; -The resident did this like five times; -CNA A told the resident to stop hitting the call light for no reason. If he/she really needed anything that was fine but not if he/she doesn't; -The resident said CNA A was mean; -CNA A told the resident he/she was not mean, he/she was busy; -CNA A left the resident's room to do his/her work. During an interview on 11/23/21 at 8:25 A.M., Resident #11 said he/she did remember a staff member who matched the physical description of CNA A who told him/her to shut up. The resident could not remember exactly when this occurred but said it happened a while ago. The resident said CNA A was mad at him/her and was mad at everything. The resident did not remember why CNA A told him/her to shut up. It made the resident feel bad and the resident said he/she was scared of CNA A because the resident wasn't sure what else CNA A was going to do. The resident said he/she did not like being told to shut up and it made him/her feel like he/she wasn't supposed to ask for anything. During a telephone interview on 11/10/21 at 4:28 P.M., CNA A said he/she had two accusations made against him/her at this facility. The first accusation was when a resident (CNA A could not recall the resident's name) said he/she told him/her to shut up and to not use the call light unless the resident needed something. The resident kept putting on the call light when he/she didn't need anything. 3. Record review of Resident #18's Quarterly MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was intact; -No Hallucinations or delusions; -Verbal behaviors directed towards others four to six days out of seven. Record review of a typed statement transcribed by the DON and signed by Resident #18, dated 9/3/21, showed the following: -The resident stated CNA A was always on the phone, avoided allowing the resident to use the bedpan or give the resident any care; -CNA A had moved the resident's bedside table with the call light on it out of reach so the resident could not call for help and so CNA A did not have to assist the resident. During an interview on 11/10/21 at 3:10 P.M., the administrator said the following: -The administrator would consider CNA A's actions to Resident #9 abusive; -The administrator expected staff to treat residents with dignity and respect and for residents to be free from any kind of abuse. MO 2 MO 1 MO 0

Based on interview and record review, the facility staff failed to use a gait belt during a transfer for two residents (Resident #5 and Resident #8). Resident #8 sustained a fractured right arm as a result of the improper transfer. Resident #5 sustained injury during the transfer. A sample of 18 residents was selected for review. The facility census was 46. Record review of the facility's gait belt policy revised on 1/30/2014 showed the following: -All employees are given a gait belt at time of employment. If you do not have a gait belt at the start of your shift, you must notify your charge nurse and she will obtain one for you. If you lose your gait belt, you may purchase another one for $10.00 through payroll deduction; -All new employees will be in-serviced during their orientation on the proper use of a gait belt. -Gait belts must be with you at all times; -Any resident requiring assistance with ambulation and/or transfers will have a gait belt applied before assistance is provided. -At no time may a resident be assisted any way (to stand, sit, pull up, etc.) by placing your arms under theirs; -Any employee found transferring or ambulating a resident that requires assistance without using a gait belt is subject to immediate termination. 1. Record review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included [CONDITION(S)] (a type of bone marrow cancer), altered mental status, sleep apnea and muscle weakness. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff), dated 10/7/21 showed the following: -Cognition was intact; -Required limited physical assistance of one staff for transfers; -Balance when moving from a seated to a standing position was not steady and required human assistance to stabilize. Record review of the resident's care plan, dated 11/2/21 showed the following: -Self-care performance deficit; -Required one to two staff participation with transfers; -The resident was at risk for falls. Record review of the resident's nurse's note, dated 11/9/21 at 5:40 P.M. showed the following: -The resident left the facility by ambulance for a right arm deformity due to a two person transfer; -A transfer was attempted at 4:00 P.M. on 11/9/21 but was unsuccessful; -The resident complained of pain and was assessed by the nurse who saw a deformity; -911 was called and the family was notified. During an interview on 11/16/21 at 1:05 P.M., Resident #8 said he/she was sitting in the wheelchair and wanted to get in bed. Two aides came in the room (CNA (Certified Nurse Aide) J and CNA K). They did not put a gait belt on him/her. CNA J grabbed the resident by the right arm and lifted. CNA K stood by the resident's bed and told the resident to help himself/herself and to do what he/she could. The resident heard a loud pop. CNA J quit lifting the resident. The aides went and got the nurse who looked at his/her arm and then they took the resident out of the facility on a gurney to the hospital. The resident said his/her right arm was broken because of the incident. It was very painful and swollen and the resident was taking medication to control the pain. Record review of a facility acquired written statement, dated 11/9/21 showed Certified Nurses Aide (CNA) K wrote the following: -On 9/2/21 at 4:00 P.M. Resident #8 wanted to transfer to the bed from the wheelchair; -There was no gait belt on the resident. Record review of a facility acquired written statement, dated 11/9/21 showed CNA J wrote the following: -On 11/9/21 at 4:00 P.M., he/she went to transfer (the resident) to bed from the wheelchair by pivot transfer and assist of two (staff); -CNA J was on the right side and CNA K was on the left side; -The resident refused to let go of the wheelchair when they tried to stand him/her and they immediately sat the resident back down in the wheelchair; -There was no gait belt on the resident. During an interview on 11/10/21 at 3:20 P.M., CNA K said on 11/9/21 a little after 4:00 P.M. Resident #8 wanted to go to bed. CNA K stood in front of the resident who was seated in a wheelchair. CNA J stood on the right side of the resident. The resident was holding onto the arms of the wheelchair with his/her hands. There was no gait belt on the resident. CNA K stepped away from the resident and told CNA J to leave the resident in the wheelchair. CNA J said let me try and grabbed the resident by the right arm and started lifting. CNA K heard a loud pop. CNA K went to tell the nurse what happened. The nurse assessed the resident and went to get the Director of Nursing (DON). CNA K does use a gait belt for residents who need assistance to transfer. CNA K had not transferred Resident #8 before. CNA K told CNA J to leave the resident in the wheelchair and CNA J was the one who pulled on the resident's arm. During an interview on 11/16/21 at 12:50 P.M. the DON said the charge nurse came and got him/her on 11/9/21 and made him/her aware of the situation with Resident #8. The DON assessed the resident who was still sitting in his/her wheelchair. It was obvious the resident's arm was broken just by looking at the arm. The DON separated CNA K and CNA J and removed them from the floor. The DON instructed the nurse to call 911 for transport of the resident to the emergency room . Resident #8 told the DON he/she wanted to transfer from the chair to the bed. CNA J lifted him/her by the right arm and there was a loud pop. The DON said the resident was very tiny and the aide probably felt he/she could transfer the resident without the gait belt. It was the DON's expectation that staff use a gait belt appropriately any time a resident required physical assistance with repositioning or transfers. Staff should never lift a resident by their arms. During an interview on 11/10/21 at 1:15 P.M., the administrator said she received a call from the facility on 11/9/21 that the resident was injured during a two person transfer. CNA J and CNA K attempted to transfer the resident without a gait belt. The administrator found out on 11/10/21 the resident had a fractured arm. During an interview on 12/1/21 at 10:45 A.M., the resident's physician said the resident had [CONDITION(S)] (cancer of plasma cells) and his/her bones were weak. The resident's arm was most likely fractured by a staff member grabbing and lifting the resident by the arm. The physician expected staff to transfer residents per the facility's policy. 2. Record review of Resident #5's revised care plan dated 2/4/21 showed the resident required moderate assistance of one staff member to transfer. Record review of the resident's quarterly Admission (MDS), dated [DATE] showed the following: -The resident had severe cognitive impairment; -His/Her diagnoses included non-traumatic [CONDITION(S)] (injuries to the brain that are not caused by an external physical force to the head), dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), Alzheimer's disease (common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), and [CONDITION(S)] (occurs when the protective cartilage that cushions the ends of the bones wears down over time); -He/She required extensive assistance of one staff member to transfer, toilet, dress and bathe; -The resident rarely understood others and rarely made self understood. Record review of the resident's nurse's notes dated 10/14/21 at 6:40 P.M. showed the following: -The resident's roommate came to the dining room and reported that aide threw Resident #5 into his/her chair; -Resident #5 was seated at his/her dining room table; -Staff completed a skin assessment and found two skin tears to the resident's right lower leg; -The superior (higher up) skin tear measured 2.8 centimeters (cm) length (L) x 2.4 cm width (W); -The inferior (lower) skin tear measured 2.6cmL x 2.2cmW; -A blue bruise above the superior skin tear measured 3cmL x 3.2cmW. During an interview on 10/28/21 at 10: 00 A.M. Certified Medication Technician (CMT) B said the following: -Resident #1 said CNA C threw Resident #5 into his/her wheelchair; -Resident #5 sat at a dining room table; -The resident was not upset or crying and had no change in his/her demeanor; -He/She notified the administrator (acting as charge nurse). During an interview on 10/28/21 at 10:28 A.M. Resident #1, (Resident #5's roommate) said the following: -Resident #5 was in his/her bed; -CNA C put his/her hands under Resident #1's arms and put him/her in the wheelchair. During an interview on 10/29/21 at 9:56 A.M. CNA C said the following: -Resident #5 was the last resident to get up for dinner; -He/She assisted the resident to sit on the side of the bed; -He/She placed the wheelchair next to the foot of the bed; -He/She stood the resident to pivot the resident to the wheelchair; -The resident started to resist and started to push him/her away/back; -His/Her hands were at the resident's hips and he/she guided the resident to the wheelchair; -The transfer was not graceful and said, an object in motion was going to go down; -The resident sat squarely in the wheelchair; -He/She did not see the resident's leg hit the wheelchair, but it was possible his/her leg hit the hinge on the wheelchair; -The resident did not cry or flinch and had no appearance of an injury; -He/She did not use a gait belt during the transfer because the resident required assistance of one staff member to transfer. Observation on 10/28/21 at 10:39 A.M. showed the following: -Resident #5 had two adhesive dressing to the lateral (side) of the front of his/her right calf; -The resident's wheelchair had no leg rest; -There were two hinges for the leg rest on the right front of the lower part of the wheelchair approximately at the same distance/placement of the adhesive dressings on the resident's right leg. During an interview on 10/28/21 at 10:10 A.M., the administrator said the following: -CNA C said he/she had a difficult time with the transfer to the resident's wheelchair as the resident did not want to stand; -The resident had two fresh skin tears to his/her right leg; -He/She was not sure if the skin tears came from the transfer; -The resident had fresh blood and partially dried blood on his/her leg; -The resident can be combative during care and had kicked at staff; -Resident #5 did not respond or answer questions of what happened. During an interview on 11/17/21 at 12:36 P.M., the administrator said she expected staff to use a gait belt for any type of transfer for all residents that require assistance at all times. CNA C should have used a gait belt to transfer Resident #5. MO 7 MO 9 MO 6

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) with a history of elopement of 15 sampled residents. The facility failed to put effective interventions in place resulting in the resident eloping from the facility twice. The resident left the facility without staff knowledge in sub-zero temperatures on 2/14/21. The resident left the facility again without staff knowledge on 2/22/21 after dark, and walked into the street. Another facility resident observed Resident #1 walking into traffic. The facility census was 38. The administrator was notified on 2/23/21 at 7:30 P.M. of an Immediate Jeopardy (IJ) which began on 2/14/21. The IJ was removed on 2/24/21 as confirmed by surveyor onsite. Record review of the facility policy Elopement, dated December 2007 showed the following: -It is the facility policy that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans; -Responsibility: All staff is responsible; -Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility; -Door alarms on facility exits and/or; -A personal safety device that will alert facility staff when the resident has left the building without supervision (i.e.: code alert or wander guard bracelet/anklet system or personal chair/bed alarm) and/or staff supervision, either by visual contact or by video camera; As a part of the facility's preventative maintenance program, all door alarms will be checked for proper function on a weekly basis; -At no time shall a personal safety or door alarm be turned off without continual supervision of the exit, the person responsible for turning off the personal safety alarm or door alarm shall be responsible for resetting the alarm and ensuring it is in working condition. Record review of the facility's procedure, Routine Procedures for Prevention of Missing Residents and Elopements, last revised January 2017 showed the following: -Using the Minimum Data Set (MDS) resident assessment schedule residents shall be reviewed for safety concerns and pre¿cautions. Residents at risk for elopement shall be identified and documented in the individual plan of care; -Unless otherwise identified in a plan of care, residents who are at risk for possible elopement shall be accompanied when leaving the facility grounds. The resident representative shall sign the resident out of the ¿facility on the resident sign-out sheet; -Residents at risk for elopement shall be identified on a Resident Watch list as well as in the clinical record. This list shall be updated whenever new resident safety issues are identified and shall be located at nursing stations and the reception area; When a door alarm sounds, staff shall immediately respond to and determine the cause of the alarm; -The staff person responding to the alarm will check the outside of the building to determine if a resident has exited the building; -If, upon investigation, no reason can be found for the sounding of that alarm, the Charge Nurse shall initiate an accounting of all residents at risk for elopement. If, after all at-risk residents are accounted for, the cause of the alarm is still undetermined, a complete head count of all residents will be conducted; -Procedures for missing residents and/or Elopements: -Even when all precautions are taken, a resident may walk away from the facility. In such instances, the following checklist shall be put into action immediately; -Notify the Administrator and Director of Nursing (DON) Immediately; -Designate someone to record the sequence of events as they occur and the specific lime of notification of each person/agency in this procedure; -Do a complete search of the building interior. Look in every room and bathroom including closets and offices; During the initial 15-30 minutes, cover a radius of one mile from the facility. This should include both searches by car and by foot. Interview staff and determine who last saw the resident and what they were wearing, etc.; -Validate all residents are accounted for by conducting a 100% head count. Document the head count results. -Documentation can occur on the resident census report or on the elopement worksheet; -Notify local and/or county law enforcement to assist with the search. Give a complete description of the res¿ident including height, weight, hair color, eye color, and what they were wearing and provide photo; -Contact the resident's representative. Ask representative about familiar loca¿tions resident may want to return to; -Should a resident attempt an elopement, a review of their individualized care plan shall be triggered for possible changes in care practices or safety precautions for that resident; -Should an elopement occur, the facility's QAPI (Quality Assurance Process Improvement) Committee shall review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement. 1. Record review of Resident #1's face sheet showed admitted [DATE]. Record review of the resident's 7/8/20 elopement risk assessment showed: -The resident had a desire to leave the facility; -The resident was exit seeking with a purpose; -The resident had active mental illness, anger related to placement in the facility; -Intervention: Wanderguard (personal alarm); -Frequent visual monitoring; -Provide distracting activity; -One on one during periods of anxiety; -The resident is an elopement risk; -Goal: The resident will not leave the facility unattended; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of the resident's annual Minimum Data Set (MDS), a federally required assessment completed by facility staff, dated 1/5/21, showed the following: -Severe cognitive impairment; -Usually understood and understands others; -Inattention and disorganized thinking, behavior fluctuates, comes and goes and changes in severity; -No rejection of care exhibited; -Wandering not exhibited; -Independent with bed mobility, transfers, locomotion on and off the unit, dressing eating, toilet use and personal hygiene; -Uses a walker; -Diagnoses included dementia, [CONDITION(S)], anxiety and depression. Record review of the resident's 1/5/21 elopement assessment showed: -The resident wanders; -The resident is an elopement risk; -Interventions: Wanderguard; -Goal: The resident will not leave the facility unattended; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of the resident's nursing note dated 1/31/21 at 12:10 A.M., completed by Licensed Practical Nurse (LPN) E showed the following: -The resident has been up during the evening ambulating with his/her walker in the hallway and going into other resident rooms occasionally; -Staff redirected the resident; -The resident was tearful at times and was talking about going home several times; -Resident went to the exit doors occasionally and opened the exit door; -Staff redirected the resident; -The resident asked several times if he/she could go out the exit doors; -Staff encouraged the resident to go to bed and rest; -The nurse walked the resident to his/her room at this time and the resident went to bed. Record review of the resident's care plan, revised 2/4/21, showed the following: -Elopement risk related to wandering and cognition (initiated on 5/16/19); -Resident will not leave facility unattended through the review date; -Resident wears a Wanderguard (personal alarm); -Charge nurse to check placement and function every shift; -Provide structured activities, toileting, scheduled activities, snacks and naps between meals; -Staff to observe and monitor the resident when he/she was up ambulating throughout the facility; -Antipsychotic (medication used to treat psychotic disorders such as [CONDITION(S)]) and antianxiety medication; -Monitor/record target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document. Record review of the nurse's note dated 2/14/21 at 4:23 P.M., completed by LPN A showed the following: -LPN A observed the resident going outside into the parking lot from the west door; -LPN A and the medication technician immediately went outside and assisted the resident back inside of the building; -Exit door checked and was not working; -The Director of Nursing (DON) and administrator notified. Record review of the resident's elopement report completed by the DON on 2/18/21 (for the 2/14/21 elopement) showed the following: -Incident description/Nursing description: Charge nurse and certified medication technician (CMT) informed that Resident #1 was outside in an employee's family member's car; -Immediate action taken: Brought inside and placed in common area, Wanderguard checked to assure working; -Maintenance called to fix door; -Maintenance arrived and fixed the door; -Injury type: No injuries observed at time of incident; -Mental status: Alert to person; -Predisposing Environmental Factors: None; -Incident location: Outside; -Predisposing physiological factors: Behaviors, confused, gait imbalance, impaired memory and incontinent; -Predisposing Situation Factors: Ambulating with assist and using walker; -Witnesses: No witnesses found; -The resident did not give a reason as to why he/she went outside, he/she was upset that staff brought him/her back inside, physician and family notified today. During an interview on 2/23/21 at 3:15 P.M., Resident #16 (Resident #1's roommate) said the following: -On 2/14/21 around 4:00 P.M., while waiting for supper, Resident #1 and Resident #2 were sitting together in the dining room by a window; -Resident #1 went out the side door; -Resident #16 didn't hear an alarm sounding; -He/She told the nurses the resident was outside; -He/She saw Resident #1 walk by the window while outside. During an interview on 2/24/21 at 9:22 A.M., Visitor G said the following: -On 2/14/21, around 4:30 P.M. to 5:00 P.M., he/she was out in the parking lot waiting to pick up an employee at the end of their shift; -He/She observed a resident (Resident #1) come out the west side door of the facility where the parking lot was located; -He/She thought the resident was coming outside to smoke at first; -The resident had his/her walker and disappeared briefly around the corner of the building; -The resident was walking at a fast pace; -He/She hollered for the resident to get in his/her car as it was very cold outside; -The resident said he/she was thrown out of the building; -The resident was getting into his/her car when staff came out and assisted the resident back into the building; -He/She thought the resident was outside about five minutes. During an interview on 2/23/21 at 4:00 P.M., LPN A said the following: -On 2/14/21, he/she was working the 6:00 A.M.-6:00 P.M. shift; -He/She recalled the resident asking him/her to call his/her family member close to 5:00 P.M.; -After that LPN A checked a resident's blood sugar and was walking back through the dining room when Resident #16 said the resident had gone outside; -LPN A looked out the window and observed Resident #1 getting into a vehicle; -LPN A was not sure how long the resident had been outside, but thought it was around ten minutes; -The resident was wearing a long sleeved shirt, pants, shoes and had his/her walker with him/her; -The Wanderguard alarm had not sounded when the resident exited the building; -The resident did not want to come back in the facility and swatted at LPN A, but LPN A assisted the resident back into the building; -LPN A checked the resident's Wanderguard to see if it was functioning. The door would not alarm when the Wanderguard was close to the door like it was supposed to; -He/She called the DON and reported the elopement, the DON said to call the administrator as the door would need to be repaired; -LPN A had not been involved in a resident elopement before and wasn't sure what to do; -He/She phoned the administrator (administrator employed at that time) and he said to be vague when completing the note on the elopement, and to document that the resident was observed exiting the facility; -He/She told the administrator that he/she did not feel comfortable doing that; -He/She did not complete an assessment of the resident because the resident was very upset at the time; -He/She thought someone called the physician a few days later; -He/She was not aware calling the physician needed to be done as he/she did not receive any specific direction on what to do after the elopement. During an interview on 2/23/21 at 2:05 P.M., the maintenance supervisor said the following: -On 2/14/21 the previous administrator attempted to call him/her on Sunday 2/14/21 when he/she was at home around 5:30 P.M.; -He/She missed the call so the administrator texted him/her and said the Wanderguard at the exit door to the smoking area of the facility needed to be looked as a nurse reported it wasn't working; -A screw had broken on the door and the sensitivity was turned down and the door would not alarm when a resident with a Wanderguard attempted to open the door; -The nurses scan each of the resident's Wanderguards each day to assure functioning, but no one checked the sensitivity of the alarm. Record review of Weather Underground weather history of surrounding townships for 2/14/21 showed at approximately 4:00 P.M. the temperature was negative 3 degrees Fahrenheit outside. Record review of the resident's Elopement assessment dated [DATE] showed the following: -The resident was cognitively impaired and independently mobile (with or without a device); -The resident has a history of elopement; -The resident was at risk for elopement; -Interventions put in place to prevent the resident from eloping included application of electronic monitoring bracelet, frequent visual monitoring and provide with distracting activity; -Elopement needs included the resident is an elopement risk, distract the resident from wandering by offering pleasant diversions, structured activities food conversation, television and books. Record review of the resident's care plan, revised 2/18/21, showed the following: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book; -Wanderguard in place on my wrist, check to make sure that it is functioning properly every shift. Record review showed no documentation the facility updated the resident's care plan with new interventions to address the resident's exit seeking behaviors. Record review of the resident's care plan, revised 2/19/21, showed the following: -When the resident gets mad about something he/she will verbalize wanting to leave, but he/she rarely goes to the doors; -If unable to correct the issue for the resident, distract the resident from exiting by offering pleasant diversions, structured activities, food conversation, television and book. Record review showed no documentation the facility updated the resident's care plan with new interventions to address the resident's exit seeking behaviors. Record review of the resident's nurse's note, completed by the Social Service Director dated 2/22/21 at 4:23 P.M., showed the following: -The resident tried to open the door and go outside office on 2/21/21 at 7:30 P.M. (exit door the door by the office); -A certified nursing assistant (CNA) walked the resident back to the North hall. During an interview on 3/11/21 at 1:00 P.M., the Social Service Director said the following: -On 2/21/21, he/she was working late in his/her office, located in the front of the facility; -Resident #1 wandered up to the front of the facility and tried to open a side exit door (which was located directly beside his/her office) of the facility and go outside; -He/She heard the door alarm sounding and stopped the resident from exiting the facility; -He/She called the nurse's station and sat with the resident until a CNA came to assist the resident back to his/her room; -All of the staff at the time were working on the resident halls (opposite side of the building) and there was no staff in that area of the facility except for the Social Service Director; -She mentioned the incident to the DON. During an interview on 2/23/21 at 2:50 P.M., the DON said the following: -Interventions were not put in place after the first elopement (on 2/14/21); -She thought staff observed the resident exiting the facility on 2/14/21 and immediately brought the resident back inside; -Three days later she found out that a visitor in the parking lot observed the resident exit the building; -On 2/19/21 she instructed staff to start 15 minute checks on Resident #1; -Staff misunderstood her instructions and the 15 minute checks were not started until 2/22/21. Record review showed no documentation the facility updated the resident's care plan to include 15 minute monitoring checks. Record review of an untitled form dated 2/22/21 with time and location for 15 minute checks for the resident showed the following: -At 7:15 P.M., the resident was at the bird cage; -At 7:30 P.M. CNA found the resident outside. Record review of the resident's progress note, dated 2/22/21 at 9:00 P.M., (hand written and unsigned by LPN F verified by the DON) showed the following: -The resident was anxious; -It was reported by a CNA after being redirected by CNA to a chair near other sociable residents, Resident #1 appeared to be consoled and calm; -Door alarm heard by CNA shortly after; -CNA went to the door immediately after it alarmed, and resident was found off the premises; -The resident was assisted back in the building, the DON and charge nurse was notified; -The resident was very anxious and was not easily redirected at this time. Record review of the resident's Elopement Report, from the elopement on 2/22/21 at 7:15 P.M., completed on 2/23/21 by the DON showed the following: -Predisposing Physiological factors: Behaviors and impaired memory; -Predisposing situation factors: Ambulating with assist, using walker; -DON received phone call from CNA C that the resident got out the front door. CNA C said the alarm was going off, CNA said they just completed 15 minute check and went in to care for another resident and when they came out they heard front door alarm going and Resident #1 was down the street in front of the apartments; -Immediate action taken: Resident was brought back to the facility, placed at the birdcage with staff. DON was called and staff was informed that the resident was to be 1:1 while out of bed for the rest of the night; -No injuries observed at time of the incident; -Incident location: Outside; -Witnesses: No witnesses found; -Notes: 2/23/21 DON was notified that resident was out of building and off premises, staff was informed to place the resident 1:1 while out of bed; -Resident was last seen by CNA at 7:15 P.M.; -At 7:30 P.M., the CNAs heard the alarm going off; -CNAs went outside and saw the resident down the street; -CNAs went and directed the resident back to the building and brought back to North hall behind double doors next to staff. During an interview on 3/3/21 at 8:20 A.M., Resident #2 said the following: -He/She was sitting beside the birdcage (around the beginning of last week) after supper so it was around 7:00 P.M.; -Resident #1 ran from the hall (where Resident #1's room was located), and pushed open the double doors (which led to the front of the facility) with his/her shoulder; -Resident #3, who was the only resident with a walker, and could move quickly went after the resident; -Resident #2 did not hear an alarm sound, but later heard the resident got out the front door of the facility. During an interview on 2/23/21 at 6:15 P.M. and 3/3/21 at 9:00 A.M., Resident #3 said the following: -On 2/22/21 at approximately 7:30 P.M., he/she was waiting for his/her medications by the birdcage; -Resident #1 was very upset and kept walking back and forth (pacing); -Resident #1 pushed the double doors open that led to front of the facility (where the facility dining room was located); -Resident #3 took off running after the resident; -Resident #1 pushed the front door open (he/she had to push it for a few seconds); -The alarm sounded, but it was very faint; Resident #3 propped his/her walker between the facility doors, so it would not shut with him/her outside (as he/she went after Resident #1); -Resident #3 was in his/her sock feet and walked out into the parking lot in the dark (following after Resident #1); -Resident #3 yelled at Resident #1, You're in traffic!; -The resident became tearful during the conversation, and said he/she was so upset the resident was going to be hit by a car; -Two or three cars drove past the resident and he/she could see them hit their brakes; -It was foggy that night; -He/She was so scared for the resident; -Resident #1 has tried to get out of the facility before; -The aides aren't watching the resident; -Resident #3 tried to keep an eye on Resident #1. During an interview on 2/23/21 at 4:00 P.M., CNA B said the following: -Resident #1 had been on a locked unit prior to COVID (Coronavirus Disease 2019 - COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2) due to wandering and trying doors; -Since COVID the doors to the unit had been opened and the resident was free to walk about the building; -It was much more difficult to contain the resident to a specific area and for staff to visually monitor the resident at all times; -The resident has always paced, wandered and had anxious behaviors, but in the last two weeks it had been much worse; -The resident would go to the front door, try to open doors and staff would have to redirect him/her back to the hall; -CNA B worked the 2:00 P.M.-10:00 P.M. shift on 2/22/21; -The resident had been very anxious and had gone door to door trying to open them; -After supper he/she was putting residents to bed and came out of another resident's room and heard the door alarm sounding; -Resident #2 said the resident got out; -Resident #3 said he/she had tried to stop the resident from getting out of the facility, but couldn't; -CNA B said it was completely dark outside and he/she could see nothing; -He/She used the flashlight on his/her phone and observed the resident walking with his/her walker at a very fast pace in the street, heading west away from the facility; -He/She went after the resident; -The resident was very resistive and did not want to come back inside. During an interview on 2/23/21 at 3:15 P.M., CNA C said the following: -The resident had been on the facility's locked unit, as the resident was an exit seeker, the facility closed down the unit and now the residents were free to move about the facility; -He/She was not sure which residents were considered an elopement risk; -It was very concerning as it was difficult to monitor those residents who had previously been on the unit when staff was in a room assisting another resident with cares; -He/She worried about it, staff closed the double doors at night that divided the front of the facility from the resident rooms on the north side of the facility, to deter the residents from going to the front of the building where they couldn't monitor them closely; -If a resident went through the double doors, opened the front door to the facility, and staff were not aware, they would not be able to hear the door alarm from where the resident rooms were located in the facility; -He/She worked 2:00-10:00 P.M. shift on 2/22/21; -The resident had been wandering a lot more than normal, up and down halls, in and out of resident rooms and the resident was very paranoid; -He/She had been assisting a resident with cares and around 7:30 P.M., when he/she came out of a resident room he/she observed CNA B bringing Resident #1 back in the front entrance of the facility; -Registered Nurse (RN) F who was the charge nurse working, did not know what to do after the resident eloped from the building; -The resident was very upset and tearful. During an interview on 2/23/21 at 4:45 P.M., LPN A said the following: -He/She was working 6:00 A.M. to 6:00 P.M. on 2/22/21; -When he/she left the facility close to 7:00 P.M., Resident #1 was at the front door trying to open it; -A CNA was with the resident; -He/She was very worried as the charge nurse working was an agency staff nurse who was not familiar with the resident; -He/She called LPN F (agency staff) and said to keep a close eye on Resident #1 as he/she was at risk for elopement; -LPN F said okay; -The last few weeks Resident #1 had been much more anxious and pacing more, he/she thought everyone was aware of the ongoing behaviors; -The resident was on a locked unit before COVID around March 2020; -It was very hard to keep an eye on the resident, and there was too much room for the resident to move around in and to be supervised when staff were caring for other residents in the facility; -He/She had actually questioned recently why the unit was not locked because of his/her concern with resident elopements. Record review of Weather Underground weather history of surrounding townships for 2/22/21 showed at approximately 7:00 P.M. the temperature at approximately 7:30 P.M. was 42 degrees Fahrenheit outside. Observation and interview on 2/23/21 at 4:40 P.M., showed the following: -Just outside the facility front door was a covered/paved driveway (the facility faced south); -The employee/visitor parking lot was located on the west side of the building; -Cars were observed in the parking lot; -The parking lot had holes and crumbling asphalt; -A paved street ran in front of the facility from east to west; -A house was located on the opposite side of the street and just west of it was an apartment building; -CNA B said the resident was observed walking on the street headed west just before the apartment building facing oncoming traffic, in the dark; -Distance approximately 250 ft. away from the facility. Record review of the resident's nursing note, dated 2/23/21 at 1:30 P.M., showed the following: -The resident attempted to get out the door by the time clock; -A CNA stopped the resident from exiting the building; -Resident was cursing and threatening staff; -Staff was able to redirect the resident away from the door; -Resident was tearful after and said he/she was tired. Assisted the resident to bed. During an interview on 2/24/21 at 3:39 P.M., the resident's representative said the following: -Approximately a week ago the facility called and said the resident was found outside in the parking lot, it was very cold that day, and the wrist alarm didn't go off when the resident went outside; -Before COVID he/she went to see the resident every day; -A few days ago the facility called again and said the resident pushed against an exit door until it opened and the resident was found outside again; -He/She worried about the resident a lot, the resident called him/her daily asking to come home, he/she did not live too far from the facility. During an interview on 3/3/21 at 12:55 P.M., LPN E said the following: -The resident would go to the door in the evenings when the resident was more emotional and wanted to see his/her family; -The resident knew his/her home (prior to being admitted to the facility), was just a few blocks away from the facility; -At one time the resident was on a locked unit at the facility, the locked unit was closed so residents moved about the facility; -The resident needed to be monitored more closely, but there was not enough staff to do that; -If LPN E had not been there (working at the time and monitoring the resident closely) on more than one occasion the resident would have eloped from the building; -He/she often tried to keep the resident close to him/her when working at the facility; -Resident #1 was not the only resident that was an elopement risk; -For Resident #1's safety, he/she should be on a locked unit, the facility had a lot of agency staff that were not familiar with Resident #1 and were not aware of the resident's risk for elopement; -On the night shift the staff would shut the double doors that divided the front of the facility (where offices and the dining room were located) from the north side of the facility where the nurse's station and resident rooms were located; -Staff would also turn off the lights in the front part of the facility to deter residents that wandered from going to the front of the facility. During an interview on 3/3/21 at 9:45 A.M. and 1:15 P.M., the Assistant Director of Nursing said the following: -She was not aware the resident had attempted to elope or was exit seeking prior to 2/14/21; -She was in the process of completing training to be the care plan coordinator so was not very familiar with updating the care plan; -If staff would have notified her that the resident was exit seeking, she would have put another intervention into place; -The facility did not increase resident supervision after the 2/14/21 elopement; -Initially she thought the resident did not actually get out of the building and that LPN A stopped the resident from exiting, LPN A came forward later on 2/18/21 and said it was not witnessed. During an interview on 2/23/21 at 2:50 P.M., DON said the following: -She was not sure when the facility had a locked unit for residents who were at risk for elopement and she was not aware what residents were located on the unit; -The unit had not been a locked unit since he/she had been the DON (toward the end of 2020); -The resident had been identified as an elopement risk as he/she had a Wanderguard in place; -She was not aware if there was an intervention in place to monitor Resident #1 when he/she was up and about; -She was not aware that the resident had been exit seeking prior to the elopements on 2/14/21 and 2/22/21; -She would have expected staff to report exit seeking behaviors to her; -On 2/22/21 around 7:30 P.M. (while on 15 minute checks), the resident eloped a second time; -CNA C called her and reported the elopement; -The charge nurse working did not report the elopement to the family, physician or complete an assessment of the resident at the time, so it was completed the next day. During an interview on 2/23/21 at 2:00 P.M. and 3/3/21 at 2:27 P.M., the administrator said the following: -He was the corporate interim administrator and started working in that role in the facility on 2/23/21; -If any resident was observed exit seeking they should immediately be placed 1:1 and the nursing staff should report the exit seeking behaviors to the DON and administrator for specific guidance and follow the facility policy; -He would expect the facility to immediately start staff in-servicing to assure all of the staff were aware of the elopement and the resident's exit seeking behaviors; -He would expect resident specific interventions to be put in place at that time and the care plan updated; -He would expect a kardex to be kept at the nurse's station and it should be updated with the resident's elopement risk;<BR

Based on interview and record review, the facility failed to identify one resident's (Resident #1's) individual risks and vulnerabilities when staff provided the cognitively impaired and dependent resident with orders for a pureed diet, a peanut butter sandwich for a snack. Staff assisted the resident to eat the sandwich and the resident immediately presented with symptoms of distress after ingesting a portion of the sandwich. As a result, the resident expired with cause of death noted as choking. The census was 56. The administrator was notified on [DATE] at 3:20 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility policy, Therapeutic Diets, revised ,[DATE], showed therapeutic diets shall be prescribed by the attending physician. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated, [DATE], showed the following: -Resident's Brief Interview for Mental Status (BIMS) score three, indicating severe cognitive impairment; -Has disorganized thinking and inattention; -Required extensive assistance of two staff for bed mobility and transfer; -Did not walk; -Required supervision and set up assistance to eat; -Holds food in mouth/cheeks or residual food in mouth after meals; -Mechanically altered diet; -Therapeutic diet. Review of the resident's care plan dated [DATE], showed the following; -Activities of daily living self care performance deficit related to confusion; -Sleep patterns vary; -Requires extensive assistance of two with bed mobility; -Needs supervision and set up help with meals. (MONTH) need verbal cues. On a pureed no added salt diet; -Alert and oriented to self only; -Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the resident's physician orders dated [DATE] through [DATE], showed the following: -[DIAGNOSES REDACTED]. -Pureed no added salt diet. Review of the resident's CNA Charting Record for (MONTH) 2019, showed the following: -First charting item noted as appetite with the word Diet noted and space to note type of diet left blank, (no diet identified); -Resident condition noted as good during the night shift for [DATE]. Review of the resident's nurse's notes dated [DATE] -[DATE] for the 10:00 P.M. to 6:00 [NAME]M. shift, 3:10 [NAME]M. showed the following: -At approximately 2:00 [NAME]M., went from north hall to south nurse's station. Heard nurse aide coming down hall loudly calling nurse's name. Nurse aide reports resident choking. Upon entering room noted resident bluish in color. Noted Certified Nurse Aide (CNA) had arms around resident from the back and nurse aide went around and had arms around resident from the back to do the [MEDICATION NAME] maneuver. This nurse instructed nurse aide to let the nurse do the [MEDICATION NAME]. Staff reported resident wanted a snack and they gave him/her a bite of a peanut butter sandwich and the resident choked. This nurse had resident sitting on bed with back toward side of bed and feet/legs toward other side of bed. [MEDICATION NAME] maneuver performed. Instructed nurse aide to call 911 and bring resident's chart to verify if a full code or DNR. Nurse aide called 911 on portable phone and brought portable phone to room. Informed 911 of resident choking and requesting assist. At 2:04 [NAME]M., Assistant Director of Nurses (ADON) also called and informed of incident. Two ambulance staff arrived. Resident took an occasional breath, not responding to verbal or tactile stimuli. Respiration stopped. Ambulance staff assessed resident with an EKG and reported the resident had expired. Noted time on print out of EKG was 02:08:13. Resident's passing also confirmed, no blood pressure, pupils fixed and dilated, no heart or breath sounds on auscultation and no carotid pulses. Review of the resident's ambulance trip ticket dated [DATE] at 02:00 (2:00 [NAME]M.), showed the following: -Primary assessment resident unconscious with cyanotic skin; -Responded to a patient choking, resident sitting upright in bed with three staff around him/her; -Staff believe the resident was choking, but is breathing now; -Resident is having agonal (gasping respiration) respirations, placed on pulse ox (a test used to measure the oxygen level (oxygen saturation) of the blood), no reading; -Resident is pulseless and takes final breath, confirmed with EKG (electrocardiogram-test that measures the electrical activity of the heartbeat.) Review of the resident's Notification of Death dated [DATE], showed the resident choked with evidence to support someone hastened the resident's death. Review of the resident's Certificate of Death dated [DATE], showed the resident's immediate cause of death as choking. Review of facility acquired interview notes with Nurse Aide (NA) A, dated [DATE], showed NA A said the following: -He/She heard the resident's bed alarm sounding and responded. He/She changed the resident as the resident was soiled and the resident said he/she was hungry; -He/She went to get the Certified Nurse Aide (CNA) A working with him/her to ask his/her opinion on a snack. Both NA A and the CNA A were in the resident's room. NA A said he/she broke the sandwich in half and the handed the sandwich to CNA [NAME] CNA A gave the sandwich to the resident; -He/She noticed the resident's lips appeared blue and ran to get the nurse, he/she saw CNA A swipe the resident's mouth to remove the sandwich; -The resident was not gasping for air, but was attempting to swallow. He/She felt the resident was not okay and went to get the nurse; -When they gave the resident the sandwich the resident's head of bed was raised all of the way up; -He/She attempted the [MEDICATION NAME] maneuver, but did not know if anything came out; -He/She ran to get the nurse and ran back to the room. Upon returning to the room was when he/she attempted the [MEDICATION NAME] maneuver; -The resident did take a drink of water after taking a bite of the sandwich, the resident did not swallow the water and it came back out of his/her mouth; -He/She said the resident was choking because he/she did not think the resident was moving any air; -He/She said the resident's care plan was not checked prior to giving the resident the sandwich to review the resident's diet orders. During an interview on [DATE] at 11:35 [NAME]M., NA A said the following: -He/She started working at the facility [DATE] and was certified as a nurse aide in a different state; -The past three weeks he/she has worked the night shift and worked with CNA B at the time of the incident; -On [DATE], in the early morning he/she heard the resident's bed alarm go off and immediately responded. The resident was on the side of the bed. He/She transferred the resident back into bed and changed him/her. The resident thanked him/her and said he/she was hungry; -There was a snack cart on the hall each night supplied with peanut butter and jelly sandwiches, cookies, milk and juice; -He/She brought the snack cart down to the resident's room, he/she had gotten CNA A and asked him/her what to give. The resident did not want cookies. He/She tore a portion of a peanut butter sandwich from the whole sandwich and the resident took one bite and said good and then wanted to know if the aides wanted some. The resident was sitting up in the bed trying to swallow. The resident looked like he/she was choking, the resident did not make noises and he/she could not tell if the resident was gasping or gagging. The resident's lips turned blue. CNA A sat the resident further up to reach the resident's back and hit the resident on the back, he/she did not remember how many times. NA A said he/she went around the bed and grabbed the resident up and did the [MEDICATION NAME]. LPN A came in and asked if anything was coming out. CNA A had done a sweep of the resident's mouth and got quite a bit of the sandwich out. NA A said when LPN A came in he/she said to call 911. NA A got the phone, dialed 911 and ran back to the room; -He/She was familiar with the resident and had assisted the resident at meals. The resident received a pureed diet; -He/She did not know how to get snacks for someone on a pureed diet. The kitchen was closed and locked. Somehow the nurse was able to get into the kitchen to get thickened liquids. To get an appropriate snack for a pureed diet one would need to use a food processor. Review of a facility acquired written statement dated [DATE], showed CNA A said the following: -On [DATE] at 2:00 [NAME]M., he/she was in the shower room and was told by staff the resident was hungry; -Offered the resident a snack, PB and J (peanut butter and jelly sandwich). Resident took a bite, they thought he/she was choking; -Staff went to the nurse, did the [MEDICATION NAME] and swept the resident's mouth; -Realized resident was not choking anymore and called 911; -CNA A said he/she had handed the resident a cookie, the resident did not want the cookie so he/she held up the sandwich and the resident took a bite of the sandwich. Review of facility acquired interview notes with CNA A dated [DATE] at 4:30 [NAME]M., showed the following: -CNA A said he/she did not know where the residents' diets were located, he/she works the night shift and usually does not feed residents; -Peanut butter and cookies are left out to feed residents, no other snacks are provided; -NA A came into the shower room and said the resident wanted a snack. CNA A said NA A gets assistance with everything and was always asking for guidance; -He/She did not check with the nurse prior to giving the snack. He/She offered the resident cookies and the resident declined. He/She then offered a peanut butter sandwich. He/She held the sandwich out and the resident leaned in to take a bite. The resident's head of the bed was raised all of the way up to a sitting position when he/she fed the resident; -CNA A said the resident then began breathing funny. He/She felt uncomfortable and realized something wasn't right and sent the other aide to get the nurse. CNA B noted the sandwich still in the resident' mouth and removed what was visible while waiting for the nurse to arrive; -He/She gave the resident a drink of water during the incident. He/She did not remember if he/she gave it prior to the bite of sandwich or after; -CNA A said it was not like a normal choking scenario, describing it as a change in breathing and not a total obstruction. Review of facility acquired interview notes with Licensed Practical Nurse (LPN) A dated [DATE] at 7:20 [NAME]M., showed the following: -He/She came to the south side hall to give a 2:00 [NAME]M. treatment and heard NA A screaming; -NA A said the resident was choking; -LPN A entered the resident's room and CNA A had his/her arms around the resident attempting the [MEDICATION NAME]; -NA A was then attempting the [MEDICATION NAME]; -LPN A instructed NA A to quit the [MEDICATION NAME] and he/she would take over. He/She instructed NA A to call 911 and get the resident's chart; -LPN A said the resident was blue when he/she entered the room and took over the situation. CNA A attempted to remove food from the resident's mouth and he/she instructed CNA A to stop; -It was 2:00 [NAME]M., when he/she was walking down the hall to give the treatment and 2:04 [NAME]M. when EMS arrived. During interview on [DATE] at 6:45 P.M., LPN A said the following: -At approximately 2:00 [NAME]M., he/she went to the south hall and heard NA A screaming down the hall saying the resident was choking. He/She immediately entered the resident's room, the resident's face was very blue; -CNA A had his/her arms around the resident and NA A went around the bed to the the [MEDICATION NAME] and LPN A said he/she did the [MEDICATION NAME]; -The resident did not make any sounds, CNA A did a mouth sweep when LPN A went in, the aides said the resident was hungry and they gave her/him a peanut butter sandwich, one bite reportedly; -NA A called 911, chart showed code status was DNR; -The resident was on a pureed diet; -Snacks are brought out on a cart after supper, which included peanut butter and jelly sandwiches, cookies and applesauce; -The applesauce was also use for medication passes, the resident's medications were crushed and given in applesauce; -The aides gave no response for why the resident gave the resident a peanut butter and jelly sandwich while the resident was in bed other than the resident said he/she was hungry and wanted a snack. Review of facility acquired interview notes dated [DATE] at 6:16 [NAME]M., showed the following: -CNA B said he/she heard screams and went to the south hall to assist as needed. He/She walked in and saw LPN A attempting to do the [MEDICATION NAME]. CNA helped get charts for the nurse. He/She noted the CNAs offered multiple snacks to the resident evidenced by snacks laying in the resident's bed. He/She helped LPN A sit the resident up while the nurse tried to clear the resident's airway. He/She was not present for the entire incident. Review of the facility's Summary of investigation as of 1:00 P.M. on [DATE], showed the following: -At approximately 2:00 [NAME]M., the resident was awake and sounded his/her bed alarm; -The NA responded and found the resident attempting get out of bed. The NA noted the resident had been incontinent and assisted in cleaning the resident up; -The NA said the resident said he/she was hungry or said snack, she couldn't remember which; -The NA left the resident's room and entered the shower room where CNA A was cleaning and told CNA A the resident wanted something to eat; -Both CNA A and NA A went to give the resident a snack. CNA A reports she offered the resident a cookie, but the resident declined. CNA A then offered a peanut butter sandwich, the resident wanted the sandwich; -At that time the sandwich was given to the resident; -CNA A and NA A then noted the resident was choking; -NA A left the room to go get the nurse while CNA A stayed to assist the resident; -They attempted to clear the airway and when the nurse arrived he/she took over; -The nurse instructed the aide to quit doing the [MEDICATION NAME] and the nurse started the [MEDICATION NAME]. The nurse instructed NA A to get the resident's chart and call 911; -EMS was at the facility at 2:04 [NAME]M.; -EMS pronounced the resident expired at 2:08 [NAME]M. on [DATE]. During interview on [DATE] at 2:15 P.M., the Assistant Director of Nurses (ADON) said the following: -NA A was doing what CNA A told him/her to do; -Staff gave the resident food that was not approved for his/her ordered diet, the resident did not get the correct snack; -Staff fed the resident a peanut butter sandwich while the resident sat in the bed, the resident should not have been eating in bed. During interview on [DATE] at 3:20 P.M., the Regional Director of Operations for the facility said he knew staff giving a resident on a pureed diet a peanut butter sandwich as a snack was an immediate issue and expected staff to provide resident food in the form that was ordered for their individual needs. The facility identified the failure and responded with an investigation and started a plan to address the situation. MO 2 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to follow interventions as indicated on one resident's (Resident #10) care plan in a sample of nine residents, to address prevention of falls. Resident #10 fell , sustaining a [MEDICAL CONDITION] and a laceration above his/her eyebrow. The facility census was 56. 1. During interview on 8/7/19 at 11:40 A.M., the Administrator said he was not sure if the facility had a policy regarding falls. Record review of Resident #10's care plan, updated 6/21/19, showed the following: -The resident was a high risk for falls related to psychoactive drug use, weakness, confusion and incontinence; -Staff was to ensure the resident's call light was within reach and encourage him/her to use it for assistance; -Ensure the resident is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in a wheelchair; -The resident had a fall; -Interventions put in place showed staff was to assist the resident to be in an area where he/she would be in eyesight if he/she was restless; -Staff is to assist the resident to the bathroom when he/she is restless. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/24/19 showed the following: -Date of admission was 1/14/19; -[DIAGNOSES REDACTED].>-The resident's cognition was impaired; -The resident's short and long term memory were impaired; -The resident required extensive assistance of one staff with transfers; -The resident's balance was not steady and he/she was not steady with ambulation; -The resident used a wheelchair for mobility; -The resident had two or more falls with no injuries since admission; -There were no skin conditions documented. Record review of the resident's care plan, updated 7/27/19, showed the following: -The resident used a chair alarm; -Staff was to provide the resident with activities that minimized the potential for falls while providing diversion and distraction such as reading, watching TV or watching the birds; -The resident was to be kept within eyesight with periods of confusion and restlessness. Record review of the resident's care plan, updated 7/31/19, showed the following: -The resident had a fall in his/her room; -The resident broke his/her hip and got a laceration to his/her head. Record review of the resident's nursing notes showed staff documented the following: -On 7/31/19 at 9:30 A.M., staff reported the resident with increased confusion; no documentation of interventions; -On 7/31/19 at 12:10 P.M., the resident was pleasantly confused; no documentation of interventions; -On 7/31/19 at 1:55 P.M., staff heard the resident's chair alarm sounding, upon arrival to resident's room, resident was found on the floor, lying on his/her left side, small laceration to his/her left forehead and under eye, pressure applied to stop bleeding, 911 was called and the resident transferred to the hospital; -On 7/31/19 at 6:30 P.M., condition report from the hospital was that the resident sustained [REDACTED]. Review of the resident's x-ray report, dated 7/31/19 showed the impression was that of a minimally displaced left subcapital [MEDICAL CONDITION] (a [MEDICAL CONDITION] (thigh bone) head and neck junction). During an interview on 8/6/19 at 4:53 P.M., the resident's family member said the following: -He/She had received a call from the facility around lunch time and was told the resident was having increased confusion and restlessness; -He/She thought the staff was to be closer to the resident when he/she was like that to try and prevent falls; -He/She would have expected staff to follow the resident's care plan as they had discussed for the resident's safety; -As a result of the fall, the resident had broken his/her hip and had a black eye and cut on his/her forehead; -The resident did not seem him/herself after the fall. During interview on 8/6/19 at 5:20 P.M. Licensed Practical Nurse (LPN) A said the following: -He/She had been the nurse on duty on 7/31/19; -He/She knew the resident had been having increased confusion and restlessness; -He/She had called the resident's family to make them aware of the resident's confusion; -The resident was a fall risk and had many falls; -When the resident was confused or restless, he/she gave the resident his/her Bible to read, asked him/her to pray for the staff or sometimes took the resident on a wheelchair ride; -He/She thought he/she gave the resident his/her Bible to read in his/her room on 7/31/19 when he/she was confused and restless before he/she fell ; -He/She was not aware the resident's care plan documented interventions included keeping the resident within eyesight when he/she was confused or restless; -The resident had a decline since his/her fall and was no longer getting up in his/her wheelchair and seemed to be talking less. During an interview on 8/7/19 at 11:15 A.M., the Director of Nurses (DON) said the following: -Staff was to follow interventions put in place on resident care plans; -Keeping a resident within eyesight meant frequent checks or having the resident there with staff, keeping their eyes on the resident, ensuring their safety. During an interview on 8/7/19 at 11:30 A.M., the Administrator said the following: -He expected staff to follow the resident's care plan; -If the care plan intervention was to keep a resident within eyesight, that would mean frequent checks or placing the resident where he/she could be seen all of the time. MO 0

Based on interview and record review, the facility failed to follow interventions as indicated on one resident's (Resident #10) care plan in a sample of nine residents, to address prevention of falls. Resident #10 fell , sustaining a [MEDICAL CONDITION] and a laceration above his/her eyebrow. The facility census was 56. 1. During interview on 8/7/19 at 11:40 [NAME]M., the Administrator said he was not sure if the facility had a policy regarding falls. Record review of Resident #10's care plan, updated 6/21/19, showed the following: -The resident was a high risk for falls related to psychoactive drug use, weakness, confusion and incontinence; -Staff was to ensure the resident's call light was within reach and encourage him/her to use it for assistance; -Ensure the resident is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in a wheelchair; -The resident had a fall; -Interventions put in place showed staff was to assist the resident to be in an area where he/she would be in eyesight if he/she was restless; -Staff is to assist the resident to the bathroom when he/she is restless. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/24/19 showed the following: -Date of admission was 1/14/19; -[DIAGNOSES REDACTED].>-The resident's cognition was impaired; -The resident's short and long term memory were impaired; -The resident required extensive assistance of one staff with transfers; -The resident's balance was not steady and he/she was not steady with ambulation; -The resident used a wheelchair for mobility; -The resident had two or more falls with no injuries since admission; -There were no skin conditions documented. Record review of the resident's care plan, updated 7/27/19, showed the following: -The resident used a chair alarm; -Staff was to provide the resident with activities that minimized the potential for falls while providing diversion and distraction such as reading, watching TV or watching the birds; -The resident was to be kept within eyesight with periods of confusion and restlessness. Record review of the resident's care plan, updated 7/31/19, showed the following: -The resident had a fall in his/her room; -The resident broke his/her hip and got a laceration to his/her head. Record review of the resident's nursing notes showed staff documented the following: -On 7/31/19 at 9:30 [NAME]M., staff reported the resident with increased confusion; no documentation of interventions; -On 7/31/19 at 12:10 P.M., the resident was pleasantly confused; no documentation of interventions; -On 7/31/19 at 1:55 P.M., staff heard the resident's chair alarm sounding, upon arrival to resident's room, resident was found on the floor, lying on his/her left side, small laceration to his/her left forehead and under eye, pressure applied to stop bleeding, 911 was called and the resident transferred to the hospital; -On 7/31/19 at 6:30 P.M., condition report from the hospital was that the resident sustained [REDACTED]. Review of the resident's x-ray report, dated 7/31/19 showed the impression was that of a minimally displaced left subcapital [MEDICAL CONDITION] (a [MEDICAL CONDITION] (thigh bone) head and neck junction). During an interview on 8/6/19 at 4:53 P.M., the resident's family member said the following: -He/She had received a call from the facility around lunch time and was told the resident was having increased confusion and restlessness; -He/She thought the staff was to be closer to the resident when he/she was like that to try and prevent falls; -He/She would have expected staff to follow the resident's care plan as they had discussed for the resident's safety; -As a result of the fall, the resident had broken his/her hip and had a black eye and cut on his/her forehead; -The resident did not seem him/herself after the fall. During interview on 8/6/19 at 5:20 P.M. Licensed Practical Nurse (LPN) A said the following: -He/She had been the nurse on duty on 7/31/19; -He/She knew the resident had been having increased confusion and restlessness; -He/She had called the resident's family to make them aware of the resident's confusion; -The resident was a fall risk and had many falls; -When the resident was confused or restless, he/she gave the resident his/her Bible to read, asked him/her to pray for the staff or sometimes took the resident on a wheelchair ride; -He/She thought he/she gave the resident his/her Bible to read in his/her room on 7/31/19 when he/she was confused and restless before he/she fell ; -He/She was not aware the resident's care plan documented interventions included keeping the resident within eyesight when he/she was confused or restless; -The resident had a decline since his/her fall and was no longer getting up in his/her wheelchair and seemed to be talking less. During an interview on 8/7/19 at 11:15 [NAME]M., the Director of Nurses (DON) said the following: -Staff was to follow interventions put in place on resident care plans; -Keeping a resident within eyesight meant frequent checks or having the resident there with staff, keeping their eyes on the resident, ensuring their safety. During an interview on 8/7/19 at 11:30 [NAME]M., the Administrator said the following: -He expected staff to follow the resident's care plan; -If the care plan intervention was to keep a resident within eyesight, that would mean frequent checks or placing the resident where he/she could be seen all of the time. MO 0

Based on interview and record review the facility failed to ensure a system to accurately reflect one resident's (Resident #14) and one additional resident's (Resident #28) wishes in regards to provision of cardiopulmonary resuscitation (CPR) of 14 sampled residents. Resident #14's Durable Power of Attorney (DPOA) specified on admission the resident wished to have CPR efforts and activation of the emergency medical system (EMS) in the event of a [MEDICAL CONDITION]. Resident #14's and Resident #28's documentation to this request was never communicated to the nursing staff or the physician and the residents' wishes were not accurately reflected in the resident's record. Resident #14 was found on [DATE] without a pulse or respirations. Facility staff failed to initiate CPR or activate EMS, the resident expired. The facility also failed to ensure staff were trained, certified and available to provide CPR on all shifts for residents who requested full code status. Facility staffing reports showed three days in November (28th, 29th, and 30th) where there was not a CPR certified staff on the night shift. The facility census was 55. 1. Review of the facility's CPR policy and procedure, dated [DATE] showed the following: -It is the policy of this facility to provide life-saving measures in accordance with current standards of practice while maintaining the resident's dignity and right to choose individualized care in determining their personalized choice by developing and following their advance directive; -Any resident who chooses not to formulate an advanced directive will be considered Full Code unless otherwise stated. It is this facility's policy to provide necessary treatment to revive and resuscitate any individual who shows signs of [MEDICAL CONDITION], choking, or other ceasing of life sustaining activity; -CPR will be initiated by certified personnel if the following criteria are present: 1) a valid DNR order or Advanced Directive is NOT in place; 2) Obvious signs of clinical death are not present i.e.: rigor mortis, dependent lividity, decapitation, transection, or decomposition; 3) initiating CPR would cause injury or peril to the rescuer; -All licensed personnel should be CPR certified and renewed in a timely manner to maintain the certification. Copies of the certification should be maintained in the personnel file and a tracking record showing license renewal and CPR certification renewal should be maintained by the Director of Nursing (DON); -Should the need for CPR be identified, CPR will be initiated and 911 will be notified immediately. CPR will continue until First Responder or EMS arrives and assumes the Code; -It is imperative that Advanced Directives and DNR policies be discussed and implemented upon admission with all residents regardless of age. 2. Review of Resident #14's Admission Nursing Evaluation dated [DATE] showed the following: -Cognitive: alert and oriented to person, place and time; -The resident has the closest relationship with DPOA; -Anticipated discharge to home. Review of the resident's Consent for: Do Not Resuscitate form dated [DATE], showed the following: -I understand that until I inform the facility of my Advance Directives relating to my health care needs, CPR and emergency transfer to the hospital will be implemented should I suffer [MEDICAL CONDITION]; -CPR consists of two basic actions: Rescue Breathing and Chest Compressions. The objective of CPR is to force blood with oxygen into the heart and brain. Air exhaled from a rescuer's lungs during rescue breathing contains enough oxygen to sustain life in a person who has stopped breathing. Chest compressions mean that the rescuer applies external pressure to the victim's chest so that blood is pushed from the heart through the body's blood vessels; -The space beside, I do wish Cardiopulmonary Resuscitation efforts, I understand that the Emergency Medical System (EMS) will automatically be activated (ambulance transfer to the hospital), checked; -Signed by the resident's DPOA and the Social Service Designee (SSD); -Physician signature blank. Review of the resident's physician's orders [REDACTED]. -Code Status: Do Not Resuscitate; -Rehab potential: fair; -admitted [DATE]. Review of the resident's admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted from another nursing home or swing bed; -Makes self understood; -Able to understand others; -Intact cognition; -Extensive assist of one for bed mobility, transfer, walk in room/corridor, locomotion on/off unit, dressing, toilet use and bathing; -Independent with eating and personal hygiene; -[DIAGNOSES REDACTED]. Review of the resident's care plan dated [DATE] showed the care plan did not address the resident's advanced directives/code status. Review of the resident's nurses' notes dated [DATE], shift showed the following: -Resident continues to work with therapy; -Ambulated with wheeled walker, walk to dine, and also uses wheelchair. -Resident alert and oriented times three; -Able to make needs known; -Rings call light for assistance. Review of the resident's nurses' notes dated [DATE] (no time) showed the following: -Resident working with physical therapy (PT), occupational therapy (OT), and speech therapy (ST); -Resident's discharge plan is to remain in facility. Review of the resident's nurses' notes dated [DATE] 6:00 P.M. to 6:00 A.M. shift showed the following: -Resident alert and oriented times three; -Limited assist of one with ADLs; -Steady with all tasks. Review of the resident's nurses' notes dated [DATE] 6:00 P.M. to 6:00 A.M. shift showed the following: -Resident continues to work with therapy; -Ambulates with wheeled walker. Review of the resident's nurses' notes dated [DATE] at 5:25 A.M. showed the following: -Physician called; -Condition report given and orders received; -May have ER evaluation if family wants, though he/she would encourage comfort measures. Review of the resident's nurses' notes dated [DATE] at 8:05 A.M. showed the following: -Resident continues to pull oxygen off face; -Oxygen saturation 74% upon entering room; -Oxygen mask applied and oxygen saturation 98% with 4 liters per minute per nasal cannula; -Resident barely opens eyes and does not answer questions; -Resident not speaking; -DPOA notified of condition; -DPOA understands that resident is staying in facility for comfort measures. Review of the resident's [DATE] physician's orders [REDACTED].>Review of the resident's nurses' notes dated [DATE] at 6:00 P.M., showed the following: -Resident found by staff member in recliner not breathing at 5:50 P.M.; -This nurse and the Assistant Director of Nursing (ADON) checked all vital signs; -No signs of life noted; -Resident last seen alive at 5:30 P.M.; -Family, coroner, funeral home, and primary care provider notified; -Telephone order given to release body and remove oxygen. During an interview on [DATE] at 1:45 P.M. and [DATE] at 9:35 A.M., the SSD said the following: -She gets the Consent for: Do Not Resuscitate form signed on admission and gives it to the charge nurse; -The charge nurse is responsible for getting the physician's signature on the form and the order for DNR or Full Code; -The resident asked to have his/her DPOA sign his/her admission paperwork; -The resident's DPOA was activated; -The DPOA and SSD talked to the resident and the resident said he/she wanted CPR; -The DPOA signed the Consent for: Do Not Resuscitate form requesting CPR; -She is not sure which charge nurse she gave the resident's Consent for: Do Not Resuscitate form to. During an interview on [DATE] at 2:38 P.M. and [DATE] at 9:42 A.M., the resident's DPOA said the following: -He/she doesn't remember exactly what form he/she signed; -He/she signed admission paperwork with the SSD; -The resident said he/she wanted everything done to keep him/her alive; -He/she was sure the resident wanted CPR; -He/she worked for the resident for [AGE] years and the resident always said he/she wanted CPR if he/she could be saved; -The resident wanted staff to attempt resuscitation if able. During an interview on [DATE] at 2:05 P.M., LPN H said the following: -He/she was the admitting nurse for this resident; -The resident was a DNR; -He/she knew the resident was a DNR from the paperwork received from the previous facility; -He/she does not have anything to do with the Consent for: Do Not Resuscitate form; -He/she does not know what is done with the Consent for: Do Not Resuscitate form, maybe it is something the SSD fills out on admission; -He/she identifies a resident's code status by opening the chart and checking the physician's orders [REDACTED].>-If unsure of the resident's code status, he/she would do CPR. During an interview on [DATE] at 1:30 P.M., Nurse Assistant (NA) J said the following: -He/she checked on the resident on [DATE] around 6:00 P.M.; -The resident was sitting up in his/her recliner; -The resident was still, ashen and his/her hand was cold to touch; -He/she called for the nearest nurse; -The resident wasn't breathing; -He/she did not check for a pulse; -He/she had seen the resident approximately 15 minutes earlier and the resident was breathing at that time; -When he/she yelled for help the MDS Coordinator came right away; -He/she doesn't know if anyone attempted resuscitation; -He/she did not check the resident's chart for code status; -The resident was fairly pliable during postmortem care. During an interview on [DATE] at 9:37 A.M., LPN O said the following: -The resident expired before 6:00 P.M. on [DATE]; -The resident was having respiratory issues that day; -The resident had declined and was no longer coherent; -He/she was called into the resident's room by one of the aides; -The resident was in his/her recliner with his/her feet up; -The resident wasn't blue; -The resident's skin wasn't warm; -He/she thought the resident had expired approximately 15 to 20 minutes prior; -There was no rigidity; -He/she checked for breathing and a pulse; -The resident did not have a heartbeat or respirations; -He/she did not attempt resuscitation; -His/her CPR certification is expired, but he/she knows how to do it; -He/she was pretty sure the resident had a no resuscitation sticker on his/her chart; -If the resident's chart said Full Code he/she would have started CPR immediately and called 911. During an interview on [DATE] at 8:13 A.M., the Minimum Data Set (MDS) Coordinator said the following: -On [DATE] NA J yelled at her and LPN O; -NA J said he/she thought the resident passed away; -She told the aide to go get a stethoscope; -Both she and LPN O checked for a pulse, the resident had no pulse; -The resident was not breathing; -LPN O listened for a heartbeat, the resident had no heartbeat; -A staff member did go to the resident's chart to check the code status, but she doesn't remember which staff member; -She lifted the resident's arm to check his/her pulse; -The resident was not stiff; -The resident was cool to touch and pale; -Staff had trouble that day keeping the resident's oxygen saturation up; -The physician saw the resident that day and knew he/she was declining; -Staff did not attempt resuscitation; -The SSD and the admitting nurse address code status; -There are stickers on the chart to indicate code status; -The Consent for: Do Not Resuscitate sheet and the physician's orders [REDACTED]. -If the resident's chart had said Full Code she would have initiated CPR; -She completes the MDS and care plans; -She doesn't address code status in the resident's care plans; -She is CPR certified. During an interview on [DATE] at 7:45 A.M., the Assistant Director of Nursing (ADON) said the following: -She did not verify the resident's death with LPN O; -She followed LPN O and the MDS Coordinator into the resident's room; -The resident was in his/her recliner and looked like he/she normally does; -The resident's fingertips were dusky, but the resident has a history of issues with poor oxygenation. During an interview on [DATE] at 4:00 P.M. and [DATE] at 9:59 A.M. the Director of Nursing (DON) said the following: -Addressing resident code status is initiated by Social Services on admission; -Social Services have the resident or family sign the Consent for: Do Not Resuscitate form; -Social Services should give the Consent for Do Not Resuscitate form to the charge nurse to obtain the physician's signature; -Every resident should have a Consent for: Do Not Resuscitate form signed on admission; -When facility staff got report on the resident from the previous facility the resident was a DNR; -She knew the resident wanted to be a DNR, because when she received report from the transferring facility she was told the resident was a DNR; -The resident was hard of hearing, but alert and oriented; -There was a miscommunication between social services and nursing; -The Consent for: Do Not Resuscitate form should be signed by the physician; -Two to three weeks ago she noticed the Consent for: Do Not Resuscitate forms were not being signed by the physician and were just being placed in the residents' charts and they have been working on their system. During an interview on [DATE] at 3:11 P.M., and [DATE] at 2:09 P.M. the Administrator said the following: -It was Social Services responsibility to address code status on admission; -Staff should verify code status with the chart, either the Consent for: Do Not Resuscitate form or the Advanced Directive; -If there is no Consent for: Do Not Resuscitate form staff should check the physician's orders [REDACTED].>-Staff only get an order for [REDACTED].>-The resident's physician told the charge nurse staff were not going to do CPR on this resident during his last visit to the facility; -The resident's physician told the charge nurse no heroic measures; -Staff had not had time to get a DNR order; -The charge nurse talked to the resident's DPOA who just wanted the resident kept comfortable; -Two nurses can verify death and notify the physician; -Not all licensed personnel are CPR certified; -Currently there are CPR certified staff on all shifts. During an interview on [DATE] at 4:56 P.M., the resident's physician said the following: -He saw the resident on the day he/she died and he/she was mentating (mental activity) very well; -The resident was end stage [MEDICAL CONDITION] and [MEDICAL CONDITIONS] but doing better; -The resident told the physician I think I'm doing fine; -The facility normally contacts him for orders regarding code status, but usually not immediately; -He was not aware the resident's DPOA requested for the resident to be a Full Code; -The DPOA did not understand what was involved in resuscitation; -He would expect staff to attempt resuscitation if the resident was Full Code and the arrest was witnessed. 3. Review of Resident 28's Physician order [REDACTED]. -admission date of [DATE]; -Code status CPR per policy; -Rehab potential fair; -Orders for physical therapy, occupational therapy, and speech therapy; -[DIAGNOSES REDACTED]. Review of the resident's Consent for: Do Not Resuscitate form dated [DATE], showed the following: -The space beside I do wish Cardiopulmonary Resuscitation efforts, I understand that the EMS will automatically be activated (ambulance transfer to the hospital) checked; -Signed by the resident's spouse and the SSD; -Physician signature blank. During an interview on [DATE] at 2:17 P.M., the SSD said: -The resident wasn't feeling well and asked his/her spouse to fill out paperwork; -He/she couldn't write very well due to a stroke. Review of the resident's admission MDS, dated [DATE] showed the following: -Brief Interview for Mental Status (BIMS) score of 12 indicating cognition moderately impaired; -Hearing adequate; -He/she was usually understood; -Understood others. Review of the resident's Physician order [REDACTED]. Review of the resident's medical record showed no documentation to change the resident's code status to DNR. During an interview on [DATE] at 6:45 P.M., the administrator said: -The code status sheet and the physician orders [REDACTED]. -She doesn't know why the code status was changed to DNR on the January physician orders; -She would expect staff to do CPR if the resident coded; -The resident is alert and oriented to person, place and time and is competent; -She doesn't know why the spouse signed the code status sheet instead of the resident; -At this time she would expect staff to go ask the resident what his/her wishes are and call the physician and get the correct order in the chart. 4. Record review on [DATE] at 5:00 P.M. showed seven resident charts at the South Nurses' Station without code status stickers. During an interview on [DATE] at 5:00 P.M. Licensed Practical Nurse (LPN) O said the following: -A green dot on the resident's chart means Full Code; -A red or pink dot on the resident's chart means DNR. During an interview on [DATE] at 4:55 P.M., Certified Nursing Assistant (CNA) G said the following: -He/she identifies resident code status by the sticker on the chart; -A pink sticker means DNR and a green sticker means Full Code; -If no sticker on the chart he/she would ask the charge nurse; -He/she is CPR certified; -He/she has had no inservices prior to today on CPR/code status. During an interview on [DATE] at 10:00 A.M. and 11:03 A.M., the DON said the following: -She would have to check and see if she had a report that would show how many full code residents are in the facility; -If she didn't have one she would have pharmacy print a report and fax it to her. -She could not find a report listing full code residents in the facility; -She asked the ADON to call the pharmacy and send the facility a code status report. 5. Review of the resident list provided by the facility on [DATE], showed the census of 55 residents and 25 residents requested to be full codes. Review of the CPR certified staff list provided by the facility, showed there was no CPR certified staff working 10:00 P.M. to 6:00 A.M. on [DATE], [DATE], and [DATE]. Review of the facility staffing sheets provided by the DON showed the following: -On [DATE] there was no CPR certified staff working on the 10:00 P.M. to 6:00 A.M. shift, the census was 55 residents; -On [DATE] there was no CPR certified staff working on the 10:00 P.M. to 6:00 A.M. shift, the census was 55 residents; -On [DATE] there was no CPR certified staff working on the 10:00 P.M. to 6:00 A.M. shift, the census was 56 residents. During an interview on [DATE] at 1:30 P.M., NA J said the following: -He/she has worked as a NA since [DATE]; -He/she hasn't had any inservices regarding code status since hired; -He/she is not CPR certified, but has been in the past. During an interview on [DATE] at 3:01 P.M., the DON said she did not know how many facility residents were full codes on [DATE], [DATE], and [DATE], she would have to go back and count charts. During an interview on [DATE] at 3:40 P.M., LPN S said: -He/she was the charge nurse on [DATE], [DATE] and [DATE] on the 10:00 P.M. to 6:00 A.M. shift; -His/her CPR certification is expired; -He/she would not feel comfortable performing CPR on a resident; -He/she did not know if anyone else working on those nights was CPR certified; -He/she did not know how many residents are full codes in the facility; -If a resident coded, he/she would call 911 and find a staff member that was CPR certified to perform CPR for the resident; -If no staff working were CPR certified, the staff would have to wait for 911 to get to the facility. During an interview on [DATE] at 10:10 A.M., the DON said: -She does the schedule for licensed staff; -Not all licensed staff are CPR certified; -She hasn't been making sure a CPR certified staff is scheduled on every shift. During an interview on [DATE] at 9:50 A.M., and [DATE] at 11:00 A.M., the Administrator said: -The DON was responsible for ensuring the nurses are CPR certified; -She would expect CPR trained staff to be scheduled to cover all shifts. -She does the schedule for the CNAs and CMTs; -Not all CNAs and CMTs are CPR certified; -She tries to make sure there is a CPR certified staff on every shift; -There could be shifts without a CPR certified staff working due to availability of CPR certified staff. * At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J . Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility audited each resident's medical record and confirmed/clarified all resident's code status. Code status forms will be placed in the front of each resident's charts and staff placed a red dot (indicating DNR) or Green dot (indicating full code status) on the resident's charts, depending on code status. Red or Green dots will also be placed on the headboards of each resident's bed, indicating code status. In the future the charge nurse will be responsible for obtaining resident's code status, signatures and physician's orders [REDACTED]. It will also be the charge nurses' responsibility to maintain the dot system on the charts and resident's beds to reflect changes in status and to ensure accuracy. The facility educated all staff present and will review the code status system with all employees prior to the beginning of their scheduled shift until all staff have been educated . 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 violations.

Based on interview and record review the facility staff failed to notify the physician according to their policy when one additional resident (Resident #27) in a review of 14 residents did not have a bowel movement for three days (72 hours) and did not have a physician's order for a laxative. Staff documented the resident did not have a bowel movement for three days, 1/18/17, 1/19/17, and 1/20/17 and the resident complained to the charge nurse on 1/20/17 about having trouble having a bowel movement. Staff obtained a physician's order for a laxative on 1/21/17, four days after the resident's last bowel movement. Staff failed to monitor and assess the resident who had an episode of diarrhea after they administered the laxative. The resident was transferred to the local emergency room with a [DIAGNOSES REDACTED]. The facility staff also failed to administer ordered vitamin supplement for ten days and failed to follow up with the resident's physician after laboratory findings indicated the resident had a very high TSH ([MEDICAL CONDITION] stimulating hormone) level. The facility census was 55. Review of the facility's policy Bowel Movement Protocol, dated January 2015, showed the following: 1. The facility will ensure that the resident's normal bowel function is maintained and will prevent the occurrence of constipation and fecal impaction; 2. The Certified Medication Technician (CMT) will monitor the bowel movements of each resident and intervene to prevent constipation and fecal impaction as needed;3. The nursing assistants will: a. Write down each resident's bowel movement on the resident bowel movement record each shift; b. Notify the CMT immediately when a resident has not had a bowel movement in the last 72 hours; 4. The CMT will follow the protocol below unless ordered differently by the physician; a. If the resident has not had a bowel movement for 72 hours, administer a laxative if ordered. If the resident does not have an order for [REDACTED]. b. If the resident has not had a bowel movement by the next morning, administer the laxative again;c. Iff the resident has not had a bowel movement by the next morning, the CMT will notify the charge nurse and he/she will check for fecal impaction and remove it if present. The charge nurse will notify the physician of the presence or absence of fecal impaction and ask the physician to review the resident's bowel management program; d. Notify the Minimum Data Set (MDS, a federally mandated assessment instrument) Coordinator for a reevaluation of the resident's bowel care plan by the care plan team; e. Notify the Director of Nursing (DON); f. The charge nurse will notify the resident and responsible party of any new orders and document in the chart; g. Only a licensed nurse is authorized to remove an impaction. Review of the facility's policy Following Physician's Orders, revised April 2010, showed the following: Purpose: -The facility is committed to providing an environment conducive to the delivery of appropriate care and health-related services. This includes ensuring the availability of a supervising physician to assist the facility of the overall program of medical care offered in the facility and ensuring that physician orders are carried out properly; Policy: -The administrator, DON and staff will collaborate with the Medical Director and the attending physicians to create an environment conducive to the delivery of appropriate medical practice and health related services; -Nursing staff will following this policy and the Nurse Practice act in receiving, recording, and following physician orders, as well as delegating, communicating and care planning orders; Procedure: Following Physicians Orders: 1. Medication and treatment administration records are derived from the physician orders and document the delivery of ordered services; 2. The administration of medications and treatment must be signed by the nurse when completed. Review of the facility's policy Condition Change (Observing, Recording and Reporting), undated, showed the following: Responsibility: Licensed Nurse; Purpose: -To observe, record and report any condition change to the attending physician so proper treatment will be implemented; Procedure: 1. After all resident falls, injuries or condition changes, monitor the following: a. Observe for alterations in consciousness; b. Observe for incontinence; c. Take vital signs and include temperature; d. Observe for abdominal spasm or pain. 1. Review of Resident #27's admission MDS, dated [DATE], showed staff assessed the resident as: -Entry date 12/12/16; -admitted from the community; -Cognitively intact; -Required extensive staff assistance with transfers, toileting and dressing; -Always continent of bladder and bowel; -[DIAGNOSES REDACTED]. -No pain. Review of the resident's December 2016 Physician's Orders Sheet (POS), showed the following: -Multivitamin (supplement) 9 milligrams (mg) iron/15 milliliters (ml) oral liquid (original order start date 12/12/16); Give 155ml by mouth daily. -No orders for scheduled or as needed laxative; -No order for [MEDICAL CONDITION] medication. Review of the physician's summary report, dated 12/12/16, showed a past medical history of [REDACTED]. Review of the resident's laboratory results on 12/13/16 showed the following: -[MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and slow the heart rate) level 2.3 (high); -[MEDICAL CONDITION] Stimulating Hormone (TSH) (blood test used to check for [MEDICAL CONDITION] problems) level of 120.400 (high), Normal range 0.270-4.200 uIU/ml (one millionth of an International unit per milliliter); -Interpretive guidelines: According to the American Association of Clinical Endocrinologists a persistent TSH level greater than 3.000 uIU/ml but within the reference range increases the likelihood of sub-clinical [MEDICAL CONDITION]; -Vitamin B12 (a vitamin important for the normal formation of red blood cells and the health of nerve tissues) level 127 (low); Normal range 211.0-946.0; -Folate level greater than 20.0; -Initialed by the physician. Review of the resident's telephone orders, dated 12/17/16, showed the following: -Hold [MEDICATION NAME] for two nights then decrease to 0.125 micrograms (mcg) daily, recheck level in one week; -Vitamin B12 one milliliter (ml) weekly time three then one ml monthly; -No new orders concerning the elevated TSH level. Review of the resident's care plan, dated 1/4/17, showed the following: -I have impaired thought processes related to dementia; -Administer medications as ordered; -I am alert and oriented times three most of the time; -I have periods of confusion; -I have an Activities of Daily Living (ADL) self care performance deficit related to dementia, shortness of breath and poor self care maintenance; -I am extensive assist of one with transfers; -I am an extensive assist of one with toileting; -I am continent of bowel and bladder; -Nursing staff to assist me with toileting every two hours and as needed; -The care plan did not address monitoring bowel movements/risks for constipation. During an interview on 1/24/17 at 4:15 P.M., the resident's primary physician said the following: -She last saw the resident in December 2016; -The resident had been [MEDICAL CONDITION] for a long time; -The TSH level of 120.400 was abnormal; -She completely missed the elevated TSH. Review of the resident's medical record showed no evidence facility staff attempted to clarify the resident's physician not addressing the resident's elevated TSH level when he/she addressed all other abnormal values on the report. During an interview on 1/24/17 at 5:45 P.M., the DON said the following: -She would expect staff to review all labs and call the physician if abnormal labs were not addressed; -She would expect staff to notify the physician to obtain orders regarding abnormal labs. Review of the Mayo Clinic website showed the following signs and symptoms of [MEDICAL CONDITION]: -Fatigue; -Constipation; -Impaired memory. Review of the resident's December 2016 MARs showed on December 13, 14, 15, 16 and 17th staff circled the resident's ordered multivitamin indicating they did not administer the medication. Review of the back of the resident's December 2016 MARs showed facility staff documented the liquid multivitamin as unavailable on 12/13, 12/14, 12/15 and 12/16. Review of the resident's medical record showed no documentation the physician was notified the multivitamin was unavailable in December 2016. Review of the resident's January 2017 MARs showed on January 6, 7, 8, 9 and 10 staff circled the ordered multivitamin indicating they did not administer the medication. The MAR indicated [REDACTED]. Review of the resident's medical record showed no documentation the physician was notified the multivitamin was unavailable in January 2017. During an interview on 1/24/17 at 5:15 P.M., the DON said the following: -She would expect staff to notify the physician if ordered medication was not available; -Staff need to call the pharmacy to find out why the medication is not available; -A resident should not go more than 24 hours without a prescribed medication; -Going three or four days without a prescribed medication was unacceptable. Review of the resident's POS, dated January 2017, showed no physician's order for scheduled or as needed (prn) laxatives. Review of the resident's bowel movement/laxative record, dated 1/17/17 - 1/20/17, showed the following: -On 1/17/17 6:00 A.M. to 2:00 P.M. shift: small bowel movement times two; -On 1/17/17 2:00 P.M. to 10:00 P.M. shift: medium bowel movement; -On 1/18/17 no bowel movement; -On 1/19/17 no bowel movement; -On 1/2017 no bowel movement. During an interview on 1/24/17 at 3:20 P.M., Licensed Practical Nurse (LPN) U said the following: -He/she is a night shift charge nurse; -Thursday night (1/19/17) the resident said he/she was having trouble having a bowel movement; -He/she checked the resident rectally; -The resident had stool there, little pebbles of stool; -The resident probably needed to have an order for [REDACTED].>-He/she told the day shift nurse in report that the resident needed a laxative; -On Saturday night (1/21/17) he/she assumed the resident's bowels had moved; -The resident was tired Saturday night. Review of the resident's nurses' notes showed no documentation the resident complained of having trouble having a bowel movement or that LPN U checked the resident rectally on 1/19/17. Review of the resident's nurses' notes showed no documentation that the CNAs reported the resident complained of not having a bowel movement on 1/20/17. Review of the resident's medical record also showed no evidence staff assessed the resident's abdomen or bowel sounds. Review of the resident's nurses' notes, dated 1/21/17 at 12:30 P.M., showed the following: -Resident complains of not having a bowel movement for three days; -Abdomen firm and distended; -Not eating; -Stayed in room for breakfast and lunch. Review of the resident's medical record showed no evidence staff assessed the resident's bowel sounds. Review of the resident's nurses' notes, dated 1/21/17 at 12:40 P.M., showed the following: -Call made to on-call physician for further orders; -Order for one cap of [MEDICATION NAME] (laxative) one time and if no bowel movement in four hours give [MEDICATION NAME] suppository (laxative). Review of the physician's order sheet, dated January 2017, showed no documentation of the physician's order for [MEDICATION NAME] one time and give [MEDICATION NAME] if no bowel movement in four hours. Review of the resident's nurses' notes, dated 1/21/17 at 1:10 P.M., showed [MEDICATION NAME] given dissolved in eight ounces of water. Review of the resident's nurses' notes, dated 1/21/17, showed the following: -At 5:00 P.M., the resident resting in room in the recliner, appears to be comfortable; -Awakened to check if he/she has urge to defecate; -Resident stated I want to try to sit on the pot to try and go; -CNA notified to room to assist with restroom; -At 6:00 P.M., the CNA reported the resident had/having diarrhea. Review of the facility's 24 hour Report/Change of Condition report, dated 1/21/17, showed the following: -Resident complained of abdominal discomfort; -Checked rectally-large amount of stool; -Laxative given. During an interview on 1/24/17 at 3:42 P.M., LPN B said the following: -He/she is a day shift charge nurse; -The resident was alert and oriented; -The resident did not have a history of constipation; -Normally the resident would call for help; -The resident required staff assist of one for ADLs; -He/she was notified in report on Saturday (1/21/17) that the resident was checked rectally and needed a laxative; -It was reported to him/her on Friday and Saturday by the CNAs that the resident complained about not having a bowel movement; -He/she called the physician for orders on Saturday (1/21/17); -He/she gave the resident [MEDICATION NAME] (a laxative) on Saturday evening; -The resident had diarrhea Saturday evening; -Sunday morning he/she noticed the resident was getting up; -He/she assisted the CNA to get the resident up out of the recliner; -He/she noticed dried blood on the floor; -The resident had diarrhea in his/her pants, almost down to his/her knees; -The resident did not respond; -He/she called the ambulance; -The resident jerked when he/she pressed on his/her abdomen; -The resident had abdominal pain; -When he/she pushed on the resident's abdomen on Saturday the resident did not complain of pain; -He/she did not check for bowel sounds on Saturday or Sunday or take vital signs. Review of the resident's nurses' notes, dated 1/22/17 at 6:55 A.M., showed the following: -To resident's room, appeared to be resting; -CNA tried to awaken resident; -Resident alert and oriented times one; -Resident not wanting to talk which is unlike him/her; -Recliner footrest put down; -Blood on floor; -Diarrhea in pants; -CNAs cleaned resident up; -Resident stood on demand/asked became shaky while standing; -CNAs noted greater amount of blood than diarrhea; -Ambulance/911 called for transfer to local emergency room (ER); -Report given to ambulance crew; -Transfer for further evaluation. Review of the nurses' notes showed no evidence staff monitored or assessed the resident after he/she had diarrhea at 6:00 P.M. on 1/21/17, until staff tried to awaken him/her on 1/22/17 at 6:55 A.M. and found blood on the floor and diarrhea and blood in his/her pants. Review of the resident's undated Nursing Home to Hospital Transfer form, page 1 of 2, completed by facility staff showed the following: -Reason for transfer: Possible bowel obstruction; -Vital signs-blank; -Pain location: Abdomen. During an interview on 2/1/17 at 2:01 P.M. the DON said LPN B did not complete the second page of the resident's Nursing Home to Hospital Transfer Form, when the resident was transferred to the hospital. Review of a blank page 2 of 2 of the facility's Nursing Home to Hospital Transfer Form showed it addressed bowel and bladder continence and asked for the date of the patient's last bowel movement (BM). Review of the resident's ER Triage report, dated 1/22/17, showed the following: -Chief complaint: Blood in stool. Blood visibly running down thigh this morning; -Resident Narrative: Resident had abdominal cramping yesterday. This morning when sat in recliner CNA saw blood running down his/her thigh. Abdomen distended since last night; -Pain Assessment: Score: 5/10; -Character: cramping; -Duration: acute; -Non-verbal signs: facial grimaces and winces; -Intensified by: touch; -Relieved by: nothing. Review of the resident's ER History and Physical, dated 1/22/17, showed the following: -Complaint: rectal bleeding; -Onset: days; -Duration: days; -Timing: still present; -Associated symptoms: rectal bleeding, blood mixed in stool, abdominal pain; -Unable to obtain history from resident due to unresponsiveness/nonverbal; -Gastrointestinal: abdominal distention and pain; -Abdomen: distension, tenderness, abnormal decreased bowel sounds; -Rectal: gross blood present; -Progress: Spoke with resident's family member and he/she reports that a couple days ago the resident was talking/oriented; -Disposition: Stable, serious. Transfer to regional hospital for evaluation by [MEDICATION NAME]. Review of the resident's CT of abdomen and pelvis, dated 1/22/17, showed the following: History: generalized abdominal pain, blood per rectum; Bowel: mild colonic fecal retention; Impression: Findings are non-specific and could represent partial small bowel obstruction in setting of adhesions or internal hernia, infections or [MEDICAL CONDITION] enteritis, or other possible more aggressive etiology. Correlate clinically and recommend follow-up. Review of the facility's resident's nurses' notes, dated 1/22/17 at 1:50 P.M., showed the following: -Resident remains at (local) ER awaiting transfer to (regional) hospital to be further evaluated by surgeon due to bowel obstruction; -Resident has increased lactic acid and increased white blood cell count (WBCs) (cells the body makes to help fight infections). Review of the admitting (regional) hospital's History and Physical, dated 1/22/17, showed the following: Current problems: 1. Septic shock (serious medical condition that occurs [MEDICAL CONDITION], which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism); 2. Acute hypoxemic [MEDICAL CONDITION] (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon [MEDICATION NAME] or both cannot be kept at normal levels. A drop in the oxygen carried in blood is known as hypoxemia); 3. Lactic acidosis (occurs when there is too much lactic acid in the body); 4. [MEDICAL CONDITION]; History of present illness: -The resident is nonverbal; -The resident presented at the local ER having bright red blood per rectum and blood on his/her thigh; -CT of the abdomen was done which showed possibility of having small-bowel obstruction; -Called STAT around 7:30 P.M. that the resident had arrived to the Intensive Care Unit (ICU); -Examination: Abdomen: Soft but distended. No bowel sounds heard. Review of the surgeon's consult note (regional hospital), dated 1/22/17 at 8:59 P.M., showed the following: -Per rectal exam, a couple of skin tags consistent with old external hemorrhoids; -He/she had a large brick red colored liquid stool with odor of old blood in the stool, like melena (dark sticky stool containing partially digested blood); -On digital exam has multiple small pieces of formed stool in rectal vault; -Difficult to tell if there is actually blood within the stool or this is all coming around it; Impression: [MEDICAL CONDITION] and lower [MEDICAL CONDITION]. During an interview on 1/24/17 at 4:15 P.M., the resident's primary physician said the following: -She last saw the resident in December 2016; -Normally the resident is alert and oriented. -She expected staff to notify her if a resident goes more than 48 hours without a bowel movement unless the resident complains of pain and she would want to be notified earlier; -It's okay for staff to call her in the middle of the night if a resident is having problems with constipation; -She would have expected staff to notify her when the resident was checked rectally and found to have small pebbles of stool; -She does not remember any call from facility staff about this resident's complaints of constipation. During an interview on 1/26/17 at 12:12 P.M., the local ER physician said the following: -The resident had blood coming out of his/her rectum when he/she arrived at the ER; -The resident's admitting [DIAGNOSES REDACTED].>-He was not aware the resident had not had a bowel movement for three days; -The resident was transferred to another hospital because the local hospital does not have a [MEDICATION NAME]; -The resident was diagnosed with [REDACTED]. During an interview on 1/25/17 at 12:14 P.M., the admitting physician (from the regional hospital) said the following: -The resident arrived in the ICU around 7:30 P.M. on 1/22/17; -The resident was in lactic acidosis from ischemic bowel; -The resident was severely [MEDICAL CONDITION] and was not receiving any medication for it. During an interview on 1/24/17 at 5:45 P.M., the DON said the following: -She would expect staff to notify the physician with any condition change; -She would expect staff to notify the physician for no longer than three days without a bowel movement; -The charge nurse should monitor the bowel movement book; -She would expect staff to notify the physician if a resident complains of constipation and is checked rectally for stool because the resident may be really constipated or impacted; -She would expect staff to document and follow-up after a resident receives a laxative and is having diarrhea; -She would expect staff to do a good abdominal assessment including taking vital signs, listening to bowel sounds, palpating the abdomen, and checking the bowel movement sheet if a resident is complaining of not having a bowel movement.

Based on interview and record review, the facility failed to follow physician's orders to monitor [MEDICATION NAME] (an anticoagulant/blood thinner) every two weeks after one resident (Resident #1) of nine sampled residents, was discharged back to the facility from the hospital on [DATE]. The facility failed to obtain a PTT or PT/INR between 6/9/10 (when the hospital discharged Resident #1 and 6/28/10 when the facility transferred Resident #1 to the hospital for a large hematoma), despite orders to obtain these lab results every two weeks. The lab should have been drawn on 6/23/10. The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The facility census was 60. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/6/10 showed: -Short term and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Rarely/never understands; -Rarely/never understood; -Totally dependent upon two persons' physical assistance for bed mobility, transfers, toilet use and hygiene; -Totally dependent upon one person's physical assistance for locomotion on and off the unit, eating and dressing; -Not able to attempt to maintain balance while standing without physical help; -Limited range of motion of a hand and leg; -Partial loss of voluntary movement on one side of a hand and leg; -Disease [DIAGNOSES REDACTED]. -fell in past 30 days; -Abrasions/bruises present; -Medications included an antipsychotic, antidepressant, a diuretic and a hypnotic. Record review of the resident's medication reconciliation form from the hospital, signed by the resident's physician on 6/8/10, showed orders for [MEDICATION NAME] 500 mg one tablet daily for three days, Chem 7 (a laboratory panel which measures electrolytes and glucose), CBC (complete blood count), outpatient on Friday at the facility, UA (urinalysis) on Friday, discharge to the facility. The form did not specify orders for the facility to change or complete a new PT/INR lab. Review of the resident's physician's order sheets (POS) dated 6/9/10-6/30/10, following return from the hospital showed [DIAGNOSES REDACTED]. -[MEDICAL CONDITION]; -Stasis [MEDICAL CONDITION] with stasis [MEDICAL CONDITION]; -Generalized muscle weakness; -Senile dementia with verbal outburst; -[MEDICAL CONDITION]; -[MEDICAL CONDITION]; -History of falls; -Fracture left wrist; -Orders included staff administer [MEDICATION NAME] 4 milligrams (mg) (initially started 3/30/10), take one tablet by mouth (PO) every other day. Alternate with 3 mg. The reason listed for this medication was [MEDICAL CONDITIONS]; -[MEDICATION NAME] 3 mg (initially started 3/30/10), take one tablet PO every other day. Alternate with 4 mg. The reason listed for this medication was [MEDICAL CONDITIONS]; -PT/INR ([MEDICATION NAME]/international normalized ratio) every two weeks; -TED hose (compression stockings) on in the morning and off at bedtime. - [MEDICATION NAME] (an antibiotic) 500 mg, one tablet PO daily for three days for urinary tract infection. Review of the resident's [MEDICATION NAME] time/international normalized ratio (PT/INR) on 6/9/10, the day the resident was discharged from the hospital back to the facility, showed an INR of 2.03. This result was faxed to the resident's physician with a note which said, "readmitted from PCMH 6/9/10. Is on [MEDICATION NAME] 4 mg every other day alternating with [MEDICATION NAME] 3mg has orders for PT/INR every two weeks. Any new orders? " The physician indicated " YES, " . Review showed no new orders were noted on the lab sheet, in the nurses' notes, POS or telephone orders. Review of telephone orders following the 6/9/10 lab results showed orders for speech therapy five times per week for 30 days and occupational therapy five times per week for two weeks on 6/10/10, [MEDICATION NAME] (an antifungal medication) swish and swallow and [MEDICATION NAME] (an antifungal) on 6/11/10, add house supplement twice a day on 6/16/10, may straight cath to obtain urinalysis on 6/21/10. Review of lab results dated 6/11/10 and 6/15/10 showed the facility had labs drawn to obtain a complete blood count and basic metabolic panel, but no PT/INR. The facility faxed the results to the physician who noted NNO (no new orders) on 6/19/10. A urinalysis (UA) was obtained on 6/11/10 which showed a small amount of leukoesterase, 6-15 RBC/hpf (red blood cells per high power field) (0-5 hpf is normal), moderate [MEDICATION NAME] cells (none is normal), moderate bacteria (none is normal) and yeast present (none is normal). The physician noted orders for [MEDICATION NAME] (an antifungal medication) 100 milligrams (mg), two tablets by mouth on Day #1 and one tablet by mouth on days #2 through #7 and repeat the UA 24 hours later. Record review of the resident's plan of care updated 6/16/10, showed direction for staff to complete the following interventions: -Monitor for signs and symptoms of dehydration; -Monitor labs as ordered, report abnormals to physician; -Administer medications as ordered; -The plan of care did not have any specific interventions related to the resident's [MEDICATION NAME] use or his/her history of [MEDICAL CONDITION] for monitoring. Review of the resident's nurses notes dated 6/27/10 through 6/28/10 showed: - On 6/27/10 at 11:30 P.M. - vital signs, blood pressure 116/72 (normal 120/80), 96.5 degree Fahrenheit temperature (normal 98.7 degrees Fahrenheit); pulse 83 (normal 70-100), respirations 20 (normal is 12-20), 94% oxygen saturation (normal is 100%) with oxygen on at three liters per minute per nasal canula. No signs or symptoms of pain or discomfort. Alert and oriented times one; -On 6/28/10 at 3:00 A.M. - Resting quietly. Has been cooperative with staff with care with no inappropriate behavior noted; -On 6/28/10 at 6:30 A.M. - Certified Nursing Aides (CNA) reported resident had a large raised area to left inner thigh. Nursing assessment showed a large, raised, hard knot to left inner thigh. Area warm to touch. Bruising noted to center of area. CNA's stated area had grown in size since 6:00 A.M.; -On 6/28/10 at 6:45 A.M. - Notified physician and received an order to send to the hospital emergency department for evaluation and treatment to rule out [MEDICAL CONDITION]; -On 6/28/10 at 6:50 A.M. - Placed call to the hospital emergency department and requested ambulance; -On 6/28/10 at 7:00 A.M. - Ambulance arrived to transport. Skin assessment showed bruising to both upper extremities and large reddish-colored bruise to the resident ' s left hand; -6/28/10 at 7:20 A.M. - Family notified of transfer to hospital; -6/28/10 at 7:25 A.M. - Director of Nursing (DON) notified of transfer to the hospital; -6/28/10 at 5:50 A.M. - (not noted as a late entry, this note is the next in sequence) - Vital signs 124/82 blood pressure, 68 pulse, 16 respirations. CNA reports raised area to left thigh. Area approximately 8X14 centimeters (cm) at widest area and raised slight (illegible word) to inner aspect. Will monitor and report to oncoming nurse. Note was signed by Licensed Practical Nurse (LPN) E. Review of the resident's nurses' notes from 6/3/10-6/29/10 showed nursing staff did not address any new orders related to changes in the PT/INR order in the documentation. Review of hospital records for the resident showed: -admitted on [DATE] at 7:25 A.M. to the emergency room ; -Chief complaint was pain in medial left thigh per nursing facility staff; -On 6/28/10 at 7:45 A.M. - INR 8.74 (normal for a patient who receives treatment for [REDACTED]. -Admitting [DIAGNOSES REDACTED]. During an interview on 4/7/11 at 1:00 P.M., LPN B said he/she had worked at the facility for around four years. When he/she received a new order for a resident, the procedure was to note the order in nurses' notes, transcribe to the physician orders sheet (POS), making sure to note whether the order came in as a faxed order, a telephone order or a verbal order, fill out a telephone order sheet for the physician to sign later. He/she also noted why the order was received, e.g., if a PT/INR lab, [MEDICATION NAME] therapy would be noted. He/she notified the resident if they are their own responsible party or the family if they were. He/she would then note on the calendar at the nurses' desk when the next scheduled lab draw was due if the order received was for a lab and also note it on the report sheet to hand-off to the on-coming shift nurse. If a lab was ordered and it was to be a repetitive lab, he/she would also note it under LABS on the physician orders sheet. There had not been any changes in this procedure for over a year. During an interview on 4/7/11 at 3:35 P.M., Registered Nurse (RN) A, Nurse Manager, said the facility did not have any policies and procedures related to obtaining labs or orders for labs. The resident's discharge orders did not include orders for obtaining a PT/INR and the nurse that received the resident back from the hospital noted the previous order for the PT/INR as every two weeks. The expectation would have been for the nurse to contact the physician to request an order for [REDACTED]. The expectation would have been that the frequency of labs would not be interrupted and drawn two weeks from 6/9/10 and the physician would have been contacted soon after the lab being faxed in case any dose changes were required. The physician circled " YES " in the note on the 6/9/10 lab results which indicated he/she had new or changed orders for the resident, however nursing did not note any order changes on the physicians' order sheet, Medication Administration Record, [REDACTED]. During an interview on 3/30/11 at 2:00 P.M., the resident's physician said he/she usually monitored PT/INR's every two weeks when a dose had been established. The resident had a history of [REDACTED]. PT/INR could be affected by the general state of health and the resident had multiple co-morbidities. The resident's dose of [MEDICATION NAME] was 3 mg every other day, alternating with 4 mg every other day. The last lab in the resident's medical record at the physician's office showed an INR drawn on 6/9/10 and results of 2.03. Facility staff noted the dosing of [MEDICATION NAME] as 3 mg and 4 mg alternating days and the resident had an order for [REDACTED]. The resident was on a regimen of antibiotic therapy, [MEDICATION NAME], and that could have interfered with the [MEDICATION NAME] and clotting time. He/she did not recall being contacted by the facility regarding the bruise the resident had at the time of transfer. He/she did not recall them reporting the bruise prior to the request to send the resident to the hospital for evaluation and treatment. The resident was in a much debilitated state. Review of the Nursing 2009 Drug Handbook showed [MEDICATION NAME]'s indications included [MEDICAL CONDITION] embolism, deep vein [MEDICAL CONDITIONS] infarction ([MEDICAL CONDITION]), rheumatic [MEDICAL CONDITION] with heart valve damage, prosthetic heart valves and chronic [MEDICAL CONDITION]. Draw blood to establish baseline coagulation parameters before therapy. PT/INR determinations are essential for proper control. Adverse reactions included hemorrhage, enhanced uric acid excretion, hematuria (blood in urine) and [MEDICAL CONDITION]. Nursing considerations included regularly inspecting patients for bleeding gums, bruises on arms or legs, petechiae (tiny broken blood vessels that present as blue or purple specks on the skin), nosebleeds, melena (black, tarry stools), hematuria and hematemesis (blood in emesis). Elderly patients and patients with renal or hepatic failure are especially sensitive to the drug's effect. MO 159