Every finding on record at Baptist Homes of Shelbina

Based on interview and record review, the facility failed to ensure staff treated four residents (Residents #4, #2, #6, and #3), in a review of 10 sampled residents, with dignity and respect when Certified Medication Assistant (CMT) A spoke to the residents with a harsh and demeaning tone and with aggressive actions that resulted in the residents feeling they were being scolded and/or treated like children. The facility census was 61. Review of the facility policy, Dignity, dated 2001, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -The facility culture supports dignity and respect for residents by honoring goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; -Residents' private space and property are respected at all times. Staff do not handle or move a resident's personal belongings without the resident's permission. Review of the facility policy, Resident Rights, dated 2001, showed the following: -Employees shall treat all residents with kindness, respect, and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be treated with respect, kindness, and dignity. 1. Review of Resident #4's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 05/14/26, showed the following: -Cognitively intact; -Diagnosis of cerebral palsy (a group of disorders affecting a person's ability to move and maintain balance and posture). Review of the resident's progress note, dated 06/02/26 at 1:39 P.M., the Administrator documented staff called him/her into the business office director's office to address a complaint from the resident. The resident said the CMT on duty (CMT A) handled him/her roughly by pulling up his/her pants too quickly after toileting and peri-care activities. The Administrator brought the CMT in to hear the allegations and it was decided the CMT should not provide toileting and peri-care to avoid any further issues. During an interview on 06/07/26 at 2:35 P.M., Certified Nurse Assistant (CNA) C said the following: -Today at the lunch table, CMT A took a fork out of the resident's hand without asking when the resident was trying to cut up his/her food; -The resident said, I'll do it!-CMT A said fine, he/she would just tell the charge nurse the resident refused help. CMT A put the fork down and left; -CMT A's voice was somewhat loud, and it was like CMT A scolded the resident; -He/She did not tell anyone about this but probably should have. During an interview on 06/08/26 at 10:40 A.M., the resident said the following: -CMT A took his/her fork out of his/her hand today and tried to cut up his/her food; -He/She became angry because CMT A did that: -One day, CMT A came into his/her bathroom, stood him/her up, and pulled up his/her pants too fast and too rough; -CMT A always worked fast and did not take time with him/her, and he/she did not like it; -CMT A argued with him/her when he/she told CMT A he/she was going too fast; -It made him/her mad when CMT A argued with him/her. During an interview on 06/07/26 at 5:15 P.M., CMT A said the following: -He/She denied any previous conflicts with the resident; -The resident could be challenging to care for, so he/she tried to avoid providing care for the resident, but passed medications to the resident; -The resident struggled to cut his/her food today at lunch. He/She asked if the resident needed help. The resident said no and slammed his/her fist on the table so he/she left. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 06/07/26 at 11:30 A.M., the resident said the following: -About one week ago, he/she placed his/her blanket on the chair next to the empty spare bed in his/her room; -CMT A did not knock on his/her open door or speak, entered his/her room, grabbed the blanket off the chair and tossed it onto his/her bed; -CMT A told him/her to keep his/her things on his/her own bed, because the other side of the room had to be kept clean and not cluttered, and ready for the possibility of a new resident, then left the room; -He/She could tell CMT A was angry when he/she tossed the blanket and spoke by the tone of CMT A's voice; it was harsh and aggressive, and the way CMT A forcibly tossed the blanket onto his/her bed; -CMT A spoke to him/her several times before with a harsh and aggressive tone, like CMT A thought he/she was the boss; -CMT A's tone of voice and how he/she spoke was disrespectful and felt degrading;-He/She told Licensed Practical Nurse (LPN) H about this, but was not sure anything had been done; -CMT A does not usually speak to him/her now when CMT A comes into his/her room. During an interview on 06/08/26 at 12:50 P.M., the resident's family member said the following: -CMT A talked down to the resident last week when the resident was on the phone with him/her; -He/She heard CMT A's voice; it was abrupt and short with the resident. The resident identified the staff member was CMT A; -It was not so much the words CMT A said, but the tone of his/her voice, like CMT A had no patience, was irritated, and wanted to make the resident feel small;-The resident told him/her CMT A made him/her feel like a child. During an interview on 06/07/26 at 03:45 P.M., LPN H said the following: -About one week ago, the resident told him/her CMT A was a little cross with him/her; -CMT A told the resident he/she needed to keep his/her belongings on his/her side of the room, in the event of a new admission; -The resident said it was the tone of voice CMT A used, like CMT A was scolding him/her, that made him/her mad; -He/She did not tell anyone about this because the resident said CMT A did not raise his/her voice. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 06/07/26 at 12:05 P.M., the resident said the following: -About one month ago, CMT A was rude and hateful to him/her at the nurses' station when he/she stopped CMT A and asked for assistance. He/She could not recall what he/she needed at that time; -CMT A spoke to him/her in a harsh tone and said he/she did not have time to help him/her right then; -He/She refused to let CMT A speak to him/her that way, and told CMT A that; -Since then, CMT A did not speak much, if any, to him/her; -CMT A talked down to people, like they were beneath him/her;-He/She reported this to the previous administrator and for a while, CMT A seemed better, but now it was occurring again. 4. Review of Resident #3's comprehensive MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 06/07/26 at 12:40 P.M., the resident said the following: -CMT A came into his/her room this morning, did not knock or speak, pulled up his/her shirt, placed a pain patch on his/her upper back, did not pull his/her shirt back down, and left the room without saying anything; -A couple of months ago, he/she asked CMT A to call his/her physician to see if his/her medications could be spread throughout the day. CMT A said, You can't do that! in a harsh and mean tone; -The resident asked another nurse to call his/her physician. The other nurse called his/her physician and now his/her medications were scheduled at different times through the day;-CMT A seemed angry because he/she asked another nurse to do this, and his/her medications were changed. CMT A had been worse since then, like he/she was mad he/she asked someone else to do it. Sometimes, CMT A did not speak to the him/her at all. If CMT A did speak to him/her, it was with a short, fast, and angry tone of voice; -One day, he/she was in the dining room and tried to help another resident open a carton of milk. CMT A grabbed the milk carton out of his/her hand and said, I'll do that, you go back to your room; -About one month ago, he/she tried to help another resident put on a clothing protector. CMT A took the clothing protector out of his/her hand and said, I'll do that and told him/her to go to his/her room; -It made him/her angry and he/she felt like a child who was being scolded when CMT A spoke to him/her in a harsh or angry tone of voice and when CMT A stopped him/her from helping others;-He/She told the previous administrator about what had occurred, but he/she was not sure anyone said anything to CMT A to address it. 5. During an interview on 06/07/26 at 5:15 P.M., CMT A said the following: -His/Her relationship with all of the residents was pretty good. He/She got along with all the residents; -He/She was not aware of any time he/she spoke to a resident in a rude, loud, or demeaning way; -He/She was not aware of any time he/she told a resident they could not do something for themselves or made a resident feel like a child; -He/She was not aware of any residents who complained about the care he/she provided. During an interview on 06/08/26 at 3:45 P.M., the Director of Nursing (DON) said the following: -A couple of weeks ago, some staff said CMT A spoke to some of the residents in a mean and hateful way, and was short-tempered with the residents; -She could not recall who told her this or who the residents were; -She spoke with CMT A. CMT A said he/she had been under a lot of stress lately, so she recommended some mental health counseling for CMT A; -She spoke with some residents about their general care but could not recall who she spoke with or what specific questions she asked. No resident complained at that time about CMT A; -She did not document this or report it to the Administrator; -It was not respectful to speak to a resident with a harsh or short-tempered tone; -Staff should treat all residents with dignity and respect. During interviews on 06/07/26 at 5:42 P.M. and 06/08/26 at 3:25 P.M., the Administrator said the following: -Last week Resident #4 said CMT A was rushed when he/she provided care and the resident did not like it. The resident said CMT A was too fast when he/she assisted the resident off the toilet and when CMT A pulled up the resident's pants;-He told CMT A to allow the other CNAs to provide personal care to Resident #4, for CMT A just to pass medications; -Resident #4 seemed agreeable to this plan; -He was not aware of any other residents who had complained about how CMT A spoke to them; -No staff reported any concerns with how CMT A interacted with the residents; -He expected staff to immediately report if any employee spoke to a resident in a mean, harsh, or derogatory way; -All residents should be treated with dignity and respect. Complaints #3035853 and #3035861

Based on observation, interview and record review, the facility failed to provide protective oversight to ensure one additional resident (Resident #33), followed facility policies regarding smoking. Resident #33, who utilized oxygen, was assessed by the facility to be a safe smoker and could smoke independently. Observation on 06/24/25 at 12:30 P.M., showed the resident outside smoking a cigarette. His/Her portable oxygen concentrator (a device that delivers oxygen) was turned on and running at three liters per minute. The resident had removed his/her oxygen tubing from his/her nose and laid the tubing across the right armrest of his/her wheeled walker. The resident held a lit cigarette in his/her right hand, approximately six inches from the oxygen tubing connected to the portable oxygen concentrator located under the seat of the wheeled walker. Another resident, Resident #52, sat in a metal chair next to Resident #33 with a lit cigarette. Facility staff failed to follow facility policy when two residents (Resident #33 and #15) kept their smoking supplies in their possession rather than turning them in to facility staff in a review of 16 sampled residents. The facility census was 56. The administrator was notified of the Immediate Jeopardy (IJ) on 06/25/25 at 4:56 P.M. which began on 06/24/25. The IJ was removed on 06/26/25 as confirmed by surveyor onsite verification. Review of the facility policy, Smoking Policy/Oxygen-Residents, dated August 2022, showed residents must make sure oxygen is turned off prior to lighting a cigarette and that residents would be educated to leave portable oxygen in their room or in the facility in an area close to the smoking area. Residents with independent smoking privileges were permitted to keep smoking supplies in their possession. Review of the facility's Resident Smoking Policy, dated 02/01/2025, showed smoking materials and lighters must be kept at the nurses' station when not in use and staff and/or residents will return smoking materials to the nurses station to be secured. 1. Observation of the B Hall nursing desk, showed a sign dated 06/05/25, which read as follows:-Smoking:-We are going to move all smokers to the courtyard (off community room/door near activity office);-A Wing: Keep Resident #15's and Resident #52's cigarettes at the desk;-B Wing: Keep Resident #33's cigarettes at the desk. 2. Review of Resident #33's smoking assessment, dated 02/28/24, showed the following:-The resident was not careless with smoking materials (dropping cigarette butts or matches on the floor, furniture, self or others, does not burn fingertips or smoke near oxygen);-The resident had no problem with general awareness and orientation (including ability to understand the facility safe smoking policy);-The resident had no problem with the capability to follow facility safe smoking policy;-The resident was evaluated to be a safe smoker. Review of the resident's care plan, initiated on 04/22/25, showed the following:-The resident wore continuous oxygen and liked to smoke;-He/She would follow the smoking policy and will let the nurse know when he/she was going out to smoke and when he/she returned;-He/She was to turn in his/her cigarettes and lighter to the nurse. Review of the resident's smoking assessment, dated 04/25/25, showed no documentation regarding the resident utilizing oxygen, education provided related to leaving his/her portable oxygen in his/her room or in the building close to the smoking area or where smoking supplies were to be kept. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 04/26/25, showed the following:-Cognition was intact;-Received oxygen therapy;-Independent with activities of daily living (ADLs), mobility including walking 150 feet, and wheeling in a wheelchair 150 feet. Review of the resident's physician order sheet (POS) dated June 2025 showed the following:-Diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease caused by damage to the lungs, making it difficult to breath), chronic respiratory failure with hypoxia (a chronic condition where the lungs can't maintain sufficient oxygen levels in the blood over a prolonged period), and dependence on supplemental oxygen;-Three liters of continuous oxygen via nasal canula (progs placed in the nostrils to deliver oxygen from an oxygen source). Observations on 06/23/25 at 2:30 P.M. and 06/24/25 at 9:35 A.M., showed a pack of cigarettes and a lighter in the storage compartment of the resident's seated walker. Observation on 06/24/25 at 12:30 P.M., showed the following:-Resident #33 sat on the seat of his/her wheeled walker in the smoking area smoking a cigarette;-His/Her portable oxygen concentrator was turned on and running at three liters per minute;-The resident's oxygen tubing lay across the right armrest of his/her wheeled walker;-He/She held a lit cigarette in his/her right hand, approximately six inches from the oxygen tubing connected to the portable oxygen concentrator stored in the compartment under the seat of the seated walker;-Another resident, Resident #52, sat in a metal chair next to Resident #33, with a lit cigarette;-The resident finished his/her cigarette in about ten minutes;-No staff checked on residents while they smoked. Observation on 06/25/25 at 8:45 A.M., showed a pack of cigarettes and a lighter in the storage portion of the resident's seated walker. Observation on 06/25/25 at 9:45 A.M., showed the following:-The resident sat outside in the smoking area alone, in a chair;-The resident's portable oxygen was turned on at 3 liters per minute and the nasal cannula prongs were in the resident's nostrils;-There was a pack of cigarettes and a lighter was in the storage portion of the resident's seated walker. During an interview on 06/25/25 at 9:45 A.M., the resident said the following:-He/She had just finished smoking a cigarette;-The staff have not told her not to take her oxygen outside;-There wasn't anywhere to place the portable oxygen concentrator inside the facility before he/she goes outside;-He/She had been told to take his/her oxygen off and move it with the walker a few feet away from where he/she was smoking, but has not been doing this;-He/She thought as long as he/she was not wearing the oxygen and breathing it in, the concentrator would not put out any oxygen. During an interview on 06/25/25 at 10:40 A.M. and 2:00 P.M., Registered Nurse (RN) A said the following:-The resident was supposed to leave the oxygen in his/her room when he/she goes outside to smoke;-The resident was supposed to bring his/her cigarettes and lighter to the nurses' desk after each smoke break;-He/She was not aware the resident had them in her possession;-He/She had notified the Director of Nursing (DON) and Administrator about the resident taking his/her oxygen outside when he/she went to smoke, but could not recall when. During an interview on 06/25/25 at 10:45 A.M. and 1:45 P.M., Certified Medication Technician (CMT) B said the following:-The resident was supposed to leave his/her cigarettes and lighter at the nurses desk; -He/She did not realize they were not at the nurses desk;-The resident was not supposed to take his/her oxygen outside while smoking;-The resident's portable oxygen was always stored in the storage area of his/her seated walker;-The resident told CMT B that he/she could take the oxygen outside, but had to move it away from where they are smoking and shut it off. 3. Review of Resident #15's Smoking Assessment, dated 07/30/24, showed the following:-No problem with general awareness and orientation-including ability to understand the facility safe smoking policy;-No problem with capability to follow facility safe smoking policy;-Evaluation: safe smoker;-Continue current plan of care. Review of the resident's Quarterly MDS, dated [DATE] showed the following:-Cognitively intact;-Current tobacco use left blank. Review of the resident's Care Plan, revised 04/12/25 showed the following:-Cognitively intact;-Staff assist the resident in and out of the building when he/she smokes. Observation on 06/24/25 at 2:00 P.M. showed the following:-The resident propelled him/herself independently in his/her electric wheelchair to the resident smoking area outside the community room;-The resident's cigarettes sat on the table in the smoking area. During an interview on 06/24/25 at 2:05 P.M., the resident said the following:-He/She must have left his/her cigarettes in the resident smoking area the last time he/she smoked;-He/She kept his/her lighter with him/her, because the lighter was too expensive to give to staff. 3. During an interview on 06/25/25 at 4:00 P.M., the Social Service Designee (SSD) said the following:-Nursing was responsible for completing the smoking assessment and reviewing the smoking policy with residents if the resident was able to smoke safely. During interviews on 06/30/25 at 9:00 A.M., 07/01/25 at 3:27 P.M., and 07/07/25 at 2:39 P.M., the Director of Nurses (DON) said the following:-Residents who smoke should turn in their cigarettes and lighters after each smoke break;-Residents should not have an oxygen source flowing or with them while outside smoking;-Residents should remove oxygen before smoking outside;-He/She was unaware Resident #33 was smoking with the oxygen source flowing and outside with him/her. During an interview on 06/25/25 at 3:40 P.M. and 07/07/25 at 2:39 P.M., the Administrator said the following:-She would expect residents who smoke to turn in their smoking supplies (lighter and cigarettes) into staff when not smoking;-The facility policy was for residents who smoked to turn their smoking supplies into the nurses' station when not smoking; -It would not be safe for Resident #33 to smoke with his/her oxygen nearby;-Staff had not reported to her until today (06/25/25) that Resident #33 was taking his/her portable oxygen with him/her to the smoking area while he/she smoked; -Nursing staff and the SSD have talked to Resident #33 before about leaving his/her oxygen inside the facility before going outside to smoke; Resident #33 had been educated many times about this;-Resident #33 was an independent smoker and did not require staff supervision when he/she smoked;-Use of oxygen and smoking should be included on the resident's care plan. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to maintain one ice machine to be free of an accumulation of debris and failed to ensure the ice machine was equipped with an air gap. The facility also failed to ensure food items were labeled, dated, covered and discarded when expired. The facility census was 56. 1.Observation on 6/23/25 at 9:12 A.M. of the ice machine located in the facility kitchen showed pink-colored debris inside the unit on the white plastic shield over the accumulated ice below. The ice machine drain was not equipped with an appropriate air gap below the unit. During an interview on 6/23/25 at 3:05 P.M., the Dietary Manager said dietary staff was responsible for wiping down the outside of the ice machine daily. The unit was deep cleaned by maintenance staff monthly. The ice machine was new and the facility just got the unit last month. During an interview on 6/23/25 at 3:47 P.M., the Maintenance Director said the ice machine in the kitchen had been replaced approximately one month ago. The vendor was contracted to clean and descale the unit quarterly. He did not remember there being any pink debris inside the unit when it was installed. The vendor installed the pipe in the floor drain when the unit was brought into the facility, and he had installed the actual floor drain. He was unaware the ice machine needed an air gap. 2. Observation on 6/23/25 at 9:20 A.M. of the upright reach-in refrigerator in the kitchen showed a bowl of pimento cheese spread was covered with plastic wrap and was not dated. 3. Observation on 6/23/25 at 9:51 A.M. of the black refrigerator/freezer unit inside the dining room showed the following:-In the refrigerator, a tan pitcher with a white lid contained tomato juice and was not dated;-In the refrigerator, a 46-ounce container of thickened orange juice was dated with a black marker 4/25 and had a manufacturer's best if used by date of 4/30/25 and had not been discarded;-In the refrigerator, a clear squeeze bottle with a brown lid contained what appeared to be chocolate sauce and was not labeled or dated;-In the refrigerator, a 46-ounce container of thickened orange juice was dated with a black marker 2/21 and had manufacturer's best if used by date of 6/21/25;-In the freezer, a clear plastic cup contained a frozen brown substance labeled with a resident's name and was not labeled or dated.Observation on 6/23/25 at 10:01 A.M. of the black refrigerator/freezer unit in the sunroom portion of the dining rooms showed the following:-In the refrigerator, a 16-ounce bottle of creamy French dressing was labeled with a resident's name and had a manufacturer's expiration date of 4/2/25;-In the refrigerator, a 3-ounce package of real bacon bits was labeled with a resident's name and had a manufacturer's expiration date of 8/3/24;-In the refrigerator, a 16-ounce container of potato salad was labeled with a resident's name and was dated with a black marker 5/24 and had a manufacturer's use by date of 6/4/25;-In the freezer, two packages of beef and bean burritos was open to air and not sealed or dated. 4. Observation on 6/23/25 at 10:35 A.M. of the refrigerator/freezer unit in the Special Care Unit (SCU) showed the following:-In the refrigerator, a bowl of chopped peaches was not covered or dated;-In the refrigerator, a package of bulk American cheese slices was open to air and was not sealed and was dated 3/13/25;-In the refrigerator, two separate partial one-pound sticks of butter (stored in separate areas of the unit) were both open to air and not sealed. Observation on 6/23/25 at 10:45 A.M. above the upper cabinets in the SCU kitchen area showed a two-pound package of dry cereal (cinnamon toast crunch) sat on top of the cabinet and was open to air and not sealed. 5. During an interview on 6/23/25 at 3:05 P.M., the Dietary Manager said food items should be dated with they are placed into the refrigerator/freezer. Leftover food items should be discarded after three days. All food items should be covered. The refrigerators should be checked weekly by dietary staff to look for expired items. He was unsure who was responsible for checking the SCU refrigerator/freezer food items.

Based on observation, interview, and record review, the facility failed to develop specific control parameters for addressing Legionella (a bacterium that can cause a serious type of pneumonia in persons at risk), based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards. The facility did not fully implement the facility's Legionella Water Management Program policy which instructed staff how to monitor residents for Legionnaire's disease, have a water management team as described, follow ASHRAE guidelines, and have a detailed water flow map. The facility failed to ensure staff performed appropriate hand hygiene and changed gloves during the provision of care for three residents (Residents #9, #42, and #38), in a review of 16 sampled residents. The facility failed to implement Enhanced Barrier Precautions for two sampled residents (Residents #9 and #42). The facility failed to ensure proper infection control practices were utilized for respiratory care supplies for three additional residents (Residents #33, #47, and #48). The facility census was 56. 1. Review of the facility's policy, Legionella Water Management Program, dated as last revised September 2022, showed the following:-As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team;-The water management team consists of at least the following personnel: the infection preventionist, the administrator, the medical director (or designee), the director of maintenance and the director of environmental services;-The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease;-The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program;-The water management program includes the following elements: -a. An interdisciplinary water management team (see above); -b. A detailed description and diagram of the water system in the facility, including the following: receiving, cold water distribution, heating, hot water distribution, and waste; -c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks; water heaters; filters; aerators; showerheads and hoses; misters, atomizers, air washers and humidifiers; hot tubs; fountains; and medical devices such as CPAP machines, hydrotherapy equipment, etc; -d. The identification of situations that can lead to Legionella growth, such as: construction; water main breaks; changes in municipal water quality; the presence of biofilm, scale or sediment; water temperature fluctuations; water pressure changes; water stagnation; and inadequate disinfection; -e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); -f. The control limits or parameters that are acceptable and that are monitored; -g. A diagram of where control measures are applied; -h. A system to monitor control limits and the effectiveness of control measures; - i. A plan for when control limits are not met and/or control measures are not effective and -j. Documentation of the program;-The water management program is reviewed at least once a year, or sooner if any of the following occur: -a. The control limits are consistently not met; -b. There is a major maintenance or water service change; -c. There are any disease cases associated with the water system or -d. There are changes in laws, regulations, standards or guidelines. 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. Observations on 06/30/25 between 9:00 A.M. and 9:49 A.M. showed the following:-In room [ROOM NUMBER], the temperature of the hot water was 109 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 106 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 108 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 108 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 103 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 112 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 112 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 110 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 110 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 109 degrees F;-In room [ROOM NUMBER], the temperature of the hot water was 108 degrees F. During an interview on 06/30/25 at 8:15 A.M., the Maintenance Director said the following:-He and Maintenance Worker U were the only staff on the water management team;-The facility had not had any water management meetings;-He checked the temperature of the hot water weekly;-Hot water should not be over 120 degrees and had to be at least 105 degrees;-He did not check the temperature of the cold water;-He checked for Legionella monthly using a rapid test strip (test strip dipped in a water sample to detect specific antigens of Legionella);-The facility did not have a water flow map; -He did not know what the ASHRAE guidelines were. During interviews on 06/30/25 at 8:40 A.M., and 4:45 P.M., the Infection Preventionist (IP) said the following:-The Maintenance Director and Maintenance Worker U made up the water management team;-He/She did not know much about Legionella and did not conduct any monitoring for Legionella;-He/She was not aware of the ASHRAE guidelines. During an interview on 07/01/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-The Maintenance Director and Maintenance Worker U were the water management team;-She had not attended any water management meetings. During an interview on 07/01/25 at 4:10 P.M., the Administrator said the following:-The Maintenance Director oversaw the water management program;-The water management team consisted of the Maintenance Director and the Administrator;-They discussed water management monthly;-She did not know if the facility had a water flow map-Staff should check the temperature of the hot and cold water, but she was not sure how often. 2. Review of the facility policy, Handwashing/Hand Hygiene, revised August 2019, showed the following:-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors;-Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with the residents; -Before and after handling an invasive devise (urinary catheters, IV access sites); -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After contact with objects (medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Before and after entering isolation precaution settings;-Hand hygiene is the final step after removing and disposing of personal protective equipment; Review of the facility policy Personal Protective Equipment (PPE)-Gloves, dated 2001, revised July 2009, showed the following:-Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin;-Use of gloves when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure; -Use gloves when handling soiled linen or items that may be contaminated;-Wash your hands after removing gloves. Review of the facility's undated policy, Enhanced Barrier Precaution (EBP) Policy, showed the following:-The facility requires EBP (gown and gloves) to be utilized during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organism (MDROs) to staff hands and clothing. Eye protection may also be utilized when splash or spray may occur but it is not necessary in other situations;-The following situations would require EBP when performing high-contact resident care: device care or use, central line, urinary catheter, feeding tubes, tracheostomy/ventilation, colostomy, and wound care;-Examples of high-contact resident care: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs of assisting with toileting. 3. Review of Resident #9's Physician Order Sheets (POS), dated June 2025, showed the following:-Diagnoses included Extended-Spectrum Beta-Lactamase (ESBL- bacteria causing a urinary tract infection) resistance and urinary incontinence;-Moisture-associated skin damage (MASD) to mid-abdominal fold. Cleanse, apply collagen particles, and cover with dressing each day shift. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/9/25 showed the following:-Required supervision or touch assistance for toileting hygiene;-Frequently incontinent of bladder.-Occasionally incontinent of bowel. Review of the resident's care plan, last revised 6/11/25, showed the following:-Frequently incontinent;-Staff to clean and dry the resident at least every two hours;-When the resident had an open area, staff were to utilize EBP;-The resident had ESBL in his/her urine. Observation on 6/25/25 at 10:20 A.M., showed the following:-A green hand sign (to alert staff the resident was immunosuppressed) hung on the outside of the resident's door. A plastic bin, containing gowns and gloves, sat outside the resident's room; -Nurse Assistant (NA) M and Certified Medication Technician (CMT) S did not put on a gown, entered the resident's room, and without washing their hands, put on gloves;-NA M tucked the urine-soaked incontinence brief under the resident, and without changing gloves or washing his/her hands, rolled the resident to his/her side;-CMT S pulled the urine-soaked incontinence brief from under the resident and placed it in the trash can;-An island dressing (an absorbent dressing surrounded by an adherent tape) was located on the resident's lower abdomen;-CMT S wiped feces from the resident's anal and buttock areas with disposable wipes;-Without changing gloves or washing hands, NA M and CMT S assisted the resident to his/her back. CMT S cleaned the resident's front lower groin areas with disposable wipes, placed the wipes in the trash can, and then put a bed pan under the resident;-CMT S removed his/her gloves, pulled the trash bag from the trash can, tied it and carried the trash bag out of the room. He/She walked to the soiled utility room, grabbed the doorknob, opened the door, threw the trash away, exited, walked to the clean utility room, grabbed the doorknob, opened the door and entered. During an interview on 7/2/25 at 7:46 P.M., CMT S said the following:-Staff should wash hands upon entering a resident's room, when changing gloves after cleaning feces, after providing cares, and before leaving the resident's room;-Staff should change gloves when moving from a dirty task to a clean task and anytime they become soiled;-Staff should wear gowns and gloves when caring for residents with ESBL in their urine and with wounds. During an interview on 7/7/25 at 11:58 A.M., NA M said the following:-He/She would know to wear PPE for EBP if there was a sign outside the room and an EBP bin with PPE outside of the room;-Staff should wear PPE for EBP when caring for residents who have ESBL in their urine or have wounds. 4. Review of Resident #42's significant change MDS, dated [DATE], showed the following:-Frequently incontinent of bladder and bowel;-Required substantial to maximum assistance with toileting;-The resident had a colostomy (an opening in the large intestines that allows for the collection of feces in a bag) which was not addressed. Review of the resident's POS, dated June 2025, showed to check the resident's colostomy and burp gas/empty contents shiftly and, as needed, if greater than 2/3 full. Review of the resident's care plan, last revised 6/10/25, showed colostomy care weekly and as needed. Observation on 6/25/25 at 6:30 A.M., showed the following:-The resident sat on the side of the bed wearing an incontinence brief;-There was no signage outside of the resident's room to indicate the resident was on EBP and no personal protective equipment (PPE) located outside of the room;-NA M entered the resident's room, and without washing his/her hands or applying a gown or gloves, assisted the resident to lay back on the bed;-The resident had a colostomy bag attached to the left side of his/her abdomen. The colostomy bag appeared to be expanded.-CNA F entered the room;-CNA F, without washing his/her hands, put on gloves. CNA F did not put on a gown or face shield. He/She placed a plastic bag under the resident's colostomy bag. He/She unfastened the clip from the bag and released gas from the bag. There were no fecal contents to empty. During an interview on 7/7/25 at 11:58 A.M., NA M said he/she did not think he/she needed to wear a gown when working with a resident with a colostomy, but he/she would definitely wear gloves. 5. Review of Resident #38's quarterly MDS, dated [DATE], showed the following:-Required substantial/maximum assistance for toileting hygiene and lower body dressing;-Dependent on staff for chair/bed-to-chair transfer and toilet transfer;-Frequently incontinent of urine;-Always incontinent of bowel. Observation on 06/26/25 at 1:33 P.M. showed the following:-The resident sat on the bedside commode in his/her room;-The resident had a large loose bowel movement;-NA M and CNA F entered the resident's room, washed their hands, and put on gloves;-CNA F applied a gait belt around the resident's torso and assisted the resident to stand;-NA M performed pericare with disposable wipes;-Feces was visible on the disposable wipes;-Without washing his/her hands or changing his/her gloves, NA M helped pull up the resident's clean incontinence brief and pants and held onto the gait belt while he/she assisted CNA F to pivot the resident to his/her wheelchair;-With the same gloved hands, NA M bagged the trash, opened the door with his/her left gloved hand, opened the dirty utility room door and disposed of the trash. During interviews on 6/30/25 at 9:00 A.M. and 7/1/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-Staff should wash hands prior to care and change gloves and perform hand hygiene after providing pericare and before touching clean items;-Staff should change gloves if they were soiled;-Staff should perform hand hygiene after cleaning feces with gloved hands and prior to touching clean items;-Staff should wear PPE for EBP as required;-If staff could came in contact with urine contaminated with ESBL or a resident with a colostomy, staff should wear gowns and gloves as indicated. 6. Review of the facility's undated policy, Oxygen and Nebulizer Equipment, showed the following:-Oxygen tubing must be stored in a bag off the floor when not in use;-Oxygen tubing must be changed weekly on Sundays. Nursing staff are to sign and date the tubing when it was changed;-All residents have a sealable box for their tubing, mask/mouthpiece, and medication cup to be stored during the day when not in use;-Mouthpiece, medication cup and tubing are to be changed weekly during Sunday evenings. Nursing staff are to sign and date when changed. 7. Review of Resident #33's June 2025 POS showed the following:-Diagnoses included chronic obstructive pulmonary disease (COPD; a chronic lung disease caused by damage to the lungs making it difficult to breathe) and chronic respiratory failure with hypoxia (the persistent inability of the lungs to adequately oxygenate the blood due to long-term lung conditions);-Ipratropium-albuterol solution (bronchodilator- relaxes the muscles in the lungs and widens the airways) 0.5 milligrams (mg)-2.5mg/3 milliliter(ml), administer one vial per nebulizer inhalation four times daily;-Three liters continuous oxygen (O2) using a nasal cannula;-Clean oxygen filter and change oxygen tubing weekly on Sunday. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact;-He/She was independent with activities of daily living (ADLs) and mobility;-He/She used a walker for walking;-He/She received supplemental oxygen. Observation on 06/23/25 at 10:00 A.M. and 2:30 P.M., showed the following:-The oxygen tubing connected to the portable oxygen tank on the resident's wheelchair hung off the oxygen tank and was uncovered and not dated. There was no bag available to store the oxygen tubing and cannula when not in use;-The oxygen tubing connected to the resident's portable oxygen concentrator (stored inside the seat storage on the resident's wheeled walker) hung outside the seat storage, was uncovered, and was not dated; -The resident's nebulizer mask lay on the bedside table and was uncovered. Observation on 06/24/25 at 9:35 A.M., showed the following:-The oxygen tubing connected to portable oxygen tank on the resident's wheelchair hung off the oxygen tank and was uncovered and not dated. There was no bag available to store the oxygen tubing and cannula when not in use;-The oxygen tubing connected to the resident's portable oxygen concentrator that is stored inside the seat storage of the resident's wheeled walker, hung outside the seat storage, was uncovered, and was not dated;-The resident's nebulizer mask lay on the bedside table and was uncovered. Observation on 06/26/25 at 11:15 A.M., showed the following:-The oxygen tubing connected to portable oxygen tank on the resident's wheelchair hung off the oxygen tank and was uncovered and not dated. There was no bag available to store the oxygen tubing and cannula when not in use;-The oxygen tubing connected to the resident's portable oxygen concentrator that is stored inside the seat storage of the resident's wheeled walker, hung outside the seat storage, was uncovered, and was not dated;-The resident's nebulizer mask lay on the bedside table and was uncovered. Observation on 06/30/25 at 11:50 A.M., showed the following:-The oxygen tubing connected to portable oxygen tank on the resident's wheelchair hung off the oxygen tank and was uncovered and not dated. There was no bag available to store the oxygen tubing and cannula when not in use; -The oxygen tubing connected to the resident's portable oxygen concentrator that is stored inside the seat storage of the resident's wheeled walker, hung outside the seat storage, was uncovered, and was not dated;-The resident's nebulizer mask lay on the bedside table and was uncovered. 8. Review of Resident #47's care plan, dated 04/18/25, showed the following:-At risk for impaired gas exchange related to COPD;-Maintain oxygen saturation to at least 91%. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact;-Independent with most ADLs and mobility;-He/She received supplemental oxygen. Review of the resident's June 2025 Physicians Order Sheet showed the following:-Diagnoses included COPD and emphysema (a chronic lung disease that progressively damages the alveoli (tiny air sacs) in the lungs;-Obtain oxygen saturation every shift;-Ipratropium-albuterol solution 0.5-2.5 mg/3 ml, one vial per inhalation three times a day. Observation on 06/23/25 at 10:15 A.M., showed the resident's oxygen tubing and nasal cannula, connected to the oxygen concentrator, lay on the floor. During an interview on 06/23/25 at 10:15 A.M., the resident said he/she only used the oxygen when needed. He/She could not recall when he/she last used the oxygen. Observation on 06/24/25 at 11:40 A.M., showed the resident's oxygen tubing and nasal cannula, connected to the oxygen concentrator, lay on the floor. Observations on 06/25/25 at 8:35 A.M. and 12:05 P.M., showed the resident's nebulizer mask and tubing lay uncovered on the bed. Observation on 06/26/25 at 11:20 A.M. and 3:10 P.M., showed the resident's nebulizer mask and tubing lay uncovered on the bed. Observation on 06/30/25 at 11:35 A.M., showed the resident's oxygen tubing and nasal cannula, connected to the portable oxygen tank on the resident's wheelchair, lay across the handles of the wheelchair and was uncovered. 9. Review of Resident #48's annual MDS, dated [DATE], showed the following:-Cognition was intact;-Received supplemental oxygen. Review of the resident's June 2025 Physician Order Sheet showed the following:-Diagnoses included emphysema and pulmonary fibrosis (a chronic lung disease that occurs when lung tissue around the air sacs becomes damaged and scarred, making it difficult to breathe);-Oxygen saturations every shift. Document if wearing oxygen and the flow rate;-Ipratropium-albuterol 20-100 micrograms (mcg), one vial inhalation three times a day. Observation on 06/23/25 at 10:41 A.M. showed the resident's nebulizer mask and tubing lay uncovered on the table in the resident's room.During an interview on 06/23/25 at 10:41 A.M., the resident said the staff turn the nebulizer on and off for him/her. Observation on 06/25/25 at 12:00 P.M. showed the resident's nebulizer mask and tubing lay uncovered on the table in the resident's room. Observation on 06/26/25 at 11:24 A.M. showed the following:-The resident's nebulizer mask and tubing lay uncovered on the table in the resident's room;-The resident's oxygen tubing, connected to the portable oxygen tank, was wrapped around the handle of the wheelchair and was uncovered. Observation on 06/30/25 at 11:40 A.M. showed the following:-The resident's nebulizer mask and tubing lay uncovered on the table in the resident's room;-The oxygen tubing, connected to the portable oxygen tank, was wrapped around the handle of the wheelchair and was uncovered. During an interview on 06/26/25 at 3:15 P.M., CNA F said the nebulizer mask, tubing and oxygen tubing were to be stored in a plastic container. During an interview on 06/26/25 at 2:50 P.M., Certified Medication Technician (CMT) E said nebulizer and oxygen tubing was to be stored in plastic containers when not in use. During an interview on 06/26/25 at 2:45 P.M., Registered Nurse (RN) A said the following:-Staff changed nebulizer masks and tubing and oxygen tubing every Sunday night;-Staff should date the tubing;-Tubing should be stored in a plastic container or plastic bag when not in use. During an interview on 07/01/25 at 3:27 P.M., the DON said the following:-The night shift staff changed the oxygen tubing and nebulizer mask and tubing weekly;-Staff should date oxygen and nebulizer tubing;-Oxygen tubing and nebulizer tubing and masks should be stored in a plastic bag or plastic container when not in use.

Based on interview and record review, the facility failed to ensure staff treated three residents (Resident #15, #46 and #38), in a review of 16 sampled residents, with dignity and respect when a staff member (Certified Medication Technician (CMT)/Certified Nurse Aide (CNA) N spoke to residents in a harsh, stern, and hurried manner. The facility census was 56. Review of the facility policy, Dignity, revised February 2021, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem;-Residents are always treated with dignity and respect;-The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's stay;-Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility;-Staff always speak respectfully to residents. 1 Review of Resident #46's care plan, revised 05/09/25, showed the following:-The resident's cognition is intact;-The resident has impaired mobility, requiring him/her to need partial assistance with some of his/her Activities of Daily Living (ADLs) of one staff member;-Staff anticipate and meet his/her needs;-The resident was at risk for ineffective coping skills related to his/her diagnosis of depression;-Staff will allow the resident to vent his/her feelings and encourage positive coping skills when needed. Review of the resident's Prospective Payment System (PPS)/5 day admission Minimum Data Set (MDS), dated [DATE] showed the following:-Cognitively intact;-No behaviors;-Diagnoses of depression. During interviews on 06/24/25 at 8:09 A.M. and 06/30/25 at 4:30 P.M., the resident said the following:-CMT/CNA N gives him/her problems;-CMT/CNA N's tone was very harsh and stern;-He/She dreads the weekends that CMT/CNA N works because of this;-With CMT/CNA N, it's his/her way or the highway. 2. Review of Resident #38's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses of depression. During an interview on 06/26/25 at 1:40 P.M., the resident said the following:-CMT/CNA N worked a lot;-He/She wished CMT/CNA N would just go away;-CMT/CNA N had an attitude; CMT/CNA N always tells him/her to hurry up and eat his/her dinner;-He/She doesn't like the way CMT/CNA N talks to him/her and it makes him/her mad;-CMT/CNA N treats him/her with disrespect. During an interview on 06/25/25 at 9:10 A.M., the resident's family member said the following:-He/She talked to the resident every day;-CMT/CNA N was stern with the resident when he/she encouraged the resident to eat;-CMT/CNA N was always in a hurry to get things done and sometimes CMT/CNA N was short with the resident and other residents. 3. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/28/25 showed the following:-Cognitively intact;-Diagnoses of diabetes, stroke, and bipolar disorder (mental health disorder);-No therapeutic diet. Review of the resident's Care Plan, revised 04/12/25, showed the following:-The resident was cognitively intact;-The resident frequently has ineffective coping skills and was at risk for violence related to his/her diagnosis of bipolar disorder, anxiety, and depression;-Staff will ask the resident to take his/her shower at the times the resident has requested but at the time the resident would rather go smoke and then come back and demand his/her shower;-The resident can be demanding;-Staff encourage positive coping skills as needed;-Staff should speak calmly to the resident when he/she becomes upset. The resident usually stays in his/her room alone until he/she calms down. During an interview on 06/23/25 at 2:31 P.M. and 3:03 P.M., the resident said the following:-CMT/CNA N talks rough to residents;-CMT/CNA N tells Resident #46, who is slower and uses a walker to come on, come on;-CMT/CNA N got onto Resident #6 on Sunday night, because Resident #6 was hollering;-CMT/CNA N was very stern towards residents. During interviews on 06/30/25 at 9:00 A.M. and 07/01/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-She would expect staff to treat residents with dignity and respect;-It would not be appropriate for staff to talk to residents in a harsh or stern tone. During interviews on 06/25/25 at 4:40 P.M. and 07/01/25 at 4:09 P.M., the Administrator said the following:-No one had reported any staff misconduct towards residents including staff speaking in a stern, harsh tone or in a degrading manner;-Staff should not argue with a resident; she would expect staff to educate the resident nicely.

Based on observation, interview and record review, the facility failed to ensure a system to consistently communicate code status for two residents (Resident #15 and #206), in a review of 16 sampled residents, and one additional resident (Resident #49). The facility census was 56.Review of the facility policy, Advance Directives, dated [DATE], showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.Review of the facility policy, Cardiopulmonary Resuscitation (CPR) (an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until spontaneous breathing and heartbeat can be restored), dated [DATE] showed the following:-Residents who have Full Code status will be given CPR in the absence of vital signs;-Resident code status will be determined/reviewed on admission and yearly;-Resident's attending physician will order Full Code or Do Not Resuscitate (DNR) as resident chooses (or Durable Power of Attorney (DPOA)/guardian, if in effect);1. Physician order is received by licensed nurse for Full Code or DNR from physician and is entered into the physician's orders;3. If Full Code is chosen, a licensed nurse designates this with a green full code sticker on the resident's name plate;The facility policy did not include the definition or meaning for a red sticker. 1. Review of Resident #15's face sheet showed the resident had a responsible party but made his/her own decisions. Review of the resident's Care Plan, dated [DATE], showed the following:-The resident's code status was DNR;-If the resident is found with no pulse or respirations, no lifesaving interventions will be implemented per signed order. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the resident was cognitively intact. Review of the resident's Physician's Orders, dated [DATE], showed an order for Full Code. Review of the resident's Care Plan showed no documentation regarding the resident's change from DNR to Full Code status. Review of the green paper at the nursing desk, listing those residents who were identified as being a full code status, showed the residents name on the list as a Full Code. Observation on [DATE] at 5:10 A.M. outside the resident's room showed the following:-No name plate/sticker for the resident;-Numerous red dot stickers. During an interview on [DATE] at 2:00 P.M., the resident said the following:-He/She recently moved from his/her room on the 200 hall to the 300 hall;-When he/she returned from the hospital, hospice care was considered;-He/She was a DNR for a brief period of time and was now a full code. 2. Review of Resident #206's face sheet showed the resident admitted to the facility on [DATE]. He/She was his/her own person. Review of the resident's care plan, dated [DATE], showed the resident was a DNR. Review of the resident's Physician's Orders, dated [DATE], showed the resident was a DNR. Review of the resident's medical record showed a signed DNR form, indicating the resident had selected a DNR code status. Review of the green paper at the nursing desk, listing those residents who were identified as being a Full Code status, showed no documentation of the resident's name on the list. Observations on [DATE] at 2:15 P.M. and [DATE] at 5:15 A.M., outside the resident's room showed the following:-No name plate/sticker for the resident;-No red or green dot sticker. During an interview on [DATE] at 2:15 P.M., the resident said the following:-He/She was admitted to the facility on [DATE] and he/she is not sure what he/she signed and what he/she didn't sign;-He/She did not know if he/she wanted to be a Full Code or a DNR. 3. Review of Resident #49's face sheet showed the resident was his/her own person. Review of the resident's Care Plan, dated [DATE], showed the resident was a DNR. Review of the resident's Physician's Orders, dated [DATE], showed the resident was a DNR. Review of the green paper at the nursing desk, listing those residents who were identified as being a Full Code status, showed the resident's name was not on the list. Observation on [DATE] at 2:58 P.M. outside the resident's room showed the following:-The resident's name;-No red or green dot sticker. 4. During an interview on [DATE] at 2:25 P.M., Nurse Aide (NA) AA said the following:-He/She was new to the facility;-He/She had no official training on resident code status;-There was a list at the desk with residents who were Full Code;-If there was no dot on the resident's door, that might mean the resident did not want CPR, he/she was not sure;-He/She would have to get help if he/she didn't know a resident's code status. During an interview on [DATE] at 3:03 P.M., Certified Nurse Aides (CNA) BB said the following:-There was a green paper at the desk indicating residents with Full Code status;-The red dots on the door indicated DNR;-The green dots on the door indicated Full Code;-If there was no dot on the door, the resident's code status was not updated yet and if that resident was found unresponsive, he/she would have to check the list at the desk. During an interview on [DATE] at 3:05 P.M., Certified Medication Technician (CMT) B said the following:-There was a green paper at the desk listing residents who were Full Code;-Resident #49 was a temporary admission, so he/she was not sure what the resident's code status was, he/she would have to check the green paper at the desk;-The Social Services Director (SSD) and the Infection Preventionist (IP) update resident code status. During an interview on [DATE] at 3:18 P.M., the SSD said the following:-She talked to residents/family about code status, assists with the paperwork and notifies the nurse of the resident's code status;-There was a list of full code residents posted at the nurses' station;-Activities was responsible to place a red or green sticker on the resident's door indicating code status;-A red dot meant DNR, and green dot meant Full Code;-Resident #15 recently changed back to Full Code and he/she should have a green sticker on his/her door. During interviews on [DATE] at 9:00 A.M. and [DATE] at 3:27 P.M., the Director of Nursing (DON) said the following:-She would expect resident code status to be consistent throughout the medical record, in the care plan, and the dot on the resident's door;-The SSD or Activities was responsible for the code status stickers on the resident doors;-When a resident moves from one room to another, the resident's name plate and code status should be moved as soon as possible;-The red or green sticker on the resident's door should match the resident's code status. During an interview on [DATE] at 4:09 P.M., the Administrator said the following:-She would expect code status/dot system to be consistent. Code status should match and if the resident changes rooms, code status information should follow the resident;-On admission, the activity department takes the resident's photo for the name plate and places either the red or green dot on the name plate outside the resident's door.

Based on observation, interview and record review, the facility failed to ensure staff performed complete perineal care for three residents (Residents #7, #38 and #106), in a review of 16 sampled residents, who had been incontinent. The facility census was 56. Review of the facility policy, Guidelines for Providing Resident Care, dated 01/01/2025, showed the following:-To provide an optimum level of care for our residents;-All residents unable to adequately do Activities of Daily Living (ADL) are to have assistance with washing peri-area (genitals) each morning;-Residents who are bedfast must be given peri care and turned every two hours or more often if assessment warrants. Review of the facility policy, Urinary Continence and Incontinence-Assessment and Management, last revised 8/2022, showed the following:-A 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. 1. Review of Resident #38's Care Plan, revised 06/18/25, did not address continence or assistance required for ADLs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 06/23/25, showed the following:-Required substantial/maximum assistance for toileting hygiene;-Frequently incontinent of urine;-Always incontinent of bowel. Observation on 06/25/25 at 6:58 A.M. showed the following:-The resident lay in bed and wore a urine soaked incontinent brief;-Certified Nurse Assistant (CNA) O and Nurse Assistant (NA) M entered the room and prepared to perform morning cares;-Staff assisted the resident to the side of the bed where NA M applied a clean brief around the resident's ankles, along with pants, socks and shoes;-CNA A and NA M assisted the resident to stand;-NA M pulled the soiled brief down, and along with CNA O, assisted the resident to sit on the commode;-NA M removed the soiled brief and placed it in the trash can;-After using the commode, staff assisted the resident to stand, NA M pulled up the clean brief and pants and transferred him/her to the wheelchair;-Neither staff performed any incontinent care. 2. Review of Resident #26's care plan, last revised 04/30/25, showed the following:-Total dependence for ADLs;-Incontinent of urine. Review of the resident's quarterly MDS, dated [DATE], showed the resident was always incontinent of bowel and bladder. Observation on 06/25/25 at 5:40 A.M. showed the following:-The resident lay in his/her bed;-CNA O and CNA Q entered the resident's room to perform morning cares;-CNA O used wipes to clean the bilateral groin areas and then wiped down the front perineal area but did not cleanse the genitalia;-CNA Q and CNA O rolled the resident and CNA O wiped the resident's genital area from behind and wiped feces from the anal area. Staff did not cleanse the buttocks or the back of the resident's thighs;-CNA O tucked and pulled the urine saturated incontinent brief out from under the resident. 3. Review of Resident #7's significant change MDS, dated [DATE], showed the following:-Substantial to maximum assist for rolling left to right and toileting hygiene;-Frequently incontinent of bladder and bowel. Review of the resident's care plan, last revised 06/17/25, showed the following:-Impaired skin integrity related to intermittent incontinence of bowel and bladder;-Wore incontinence briefs;-Ensure resident clean and dry after an incontinent episode. Observation on 06/24/25 at 7:55 A.M. showed the following:-The resident lay in the bed;-CNA O and CNA R checked the resident for incontinence;-CNA R pulled a urine soiled incontinent brief down from the resident's perineal area, picked up a wipe and wiped the groin areas. With a second wipe he/she wiped down over the front genitalia;-CNA O and CNA R rolled the resident to his/her side;-CNA R used wipes and cleaned feces from the rectum;-CNA R did not perform full front perineal care or clean the resident's buttocks that had been in contact with urine. During an interview on 07/07/25 at 11:58 A.M., NA M said the following:-Perineal care should be performed anytime a resident has been incontinent;-All areas soiled should be cleansed. During an interview on 07/03/25 at 4:29 P.M., CNA O said the following:-All of the perineal area, including the genitals, should be cleansed on an incontinent resident; During an interview 07/07/25 at 12:13 P.M., CNA R said all areas of the perineal area (front and back) including the genitals should be cleaned during incontinent care. During an interview on 06/30/25 at 3:35 P.M., Registered Nurse (RN) Y said the following:-He/She would expect any area of the resident's skin that was soiled to be cleaned during incontinent care (thighs, genitalia, front and back). During an interview on 07/01/25 at 3:27 P.M., the Director of Nursing said the following:-She would expect perineal care to be performed on an incontinent resident before applying a clean brief;-She would expect all soiled areas of a resident's skin to be cleansed during incontinent care.

Based on observation, interview and record review, the facility failed to ensure safe and secure storage of narcotic medications when staff failed to secure the narcotic medications behind two locks. The facility also failed to remove and destroy expired stock medications (over-the-counter medications used for more than one resident) from medication carts and the medication room and failed to destroy medication for one resident (Resident #23), in a review of 16 sampled residents and three discharged residents (Resident #300, #301 and #302). The facility census was 56. Review of the facility policy titled, Storage of Medications, revised November 2020 showed the following:-The facility stores all drugs and biologicals in a safe, secure, and orderly manner;-Drugs and biologicals used in the facility are stored in locked compartments;-Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;-Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed;-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use;-Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Review of the facility policy titled, Discarding and Destroying Medications, revised April 2019 showed the following:-Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances;-All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of;-Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. 1. Observation of the A hall medication room on 06/25/25 at 11:30 A.M., showed a wooden cabinet hung on the back wall with a key lock at the top and the bottom of the cabinet door. The cabinet door was unlocked, and the door opened without the use of a key or code. The cabinet contained the following medications:-Resident #40's bottle of morphine sulfate (schedule II narcotic controlled substance for pain) oral solution 100 milligrams (mg)/5 milliliters (ml), (30 plus mls remained);-Resident #7's bottle of morphine sulfate oral solution 100 mg/5ml, dosage 0.25 ml every four hours, (30 plus mls remained);-Resident #1's bottle of morphine sulfate oral solution 100 mg/5ml, dosage 0.5ml by mouth every one hour as needed, (30 plus mls remained);-Resident #206's bottle of morphine sulfate oral solution 100 mg/5ml, dosage 0.5mls every two hours as needed (PRN) (23 mls remained);-Resident #206's bottle of morphine sulfate oral solution 100 mg/5ml, dosage 0.5 ml every two hours as needed (30 plus mls remained);-Resident #22's card of morphine sulfate 15 mg extended release tablets with 20 tabs remaining;-Resident #206's morphine sulfate 30 mg extended release with 24 tablets remaining; -Resident #206's card of lorazepam (Schedule IV narcotic controlled substance for anxiety) 0.5 mg tablets with 49 tablets remaining;-Resident #206's oxycodone hydrochloride instant release (Schedule II narcotic controlled substance for pain) 10 mg tablets with 19 tablets remaining;-The narcotics were stored behind one lock, the medication room door, and not two locks. During observation and interview on 06/25/25 at 11:40 A.M., Licensed Practical Nurse (LPN) T said the following:-He/She did not know the door on the cabinet was open (unlocked);-Sometimes the bottom lock would just spin and not lock as it should;-LPN T walked to the cabinet and spun the lock, demonstrating the lock did not work;-He/She did not use the lock at the top of the cabinet as the narcotics only had to be double locked and the bottom lock and the medication room door were two locks;-He/She had requested for maintenance to fix the lock, but could not recall when.-He/She had never destroyed medications at the facility;-It was usually the Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Administrator who destroyed medications. During an interview on 06/30/25 at 8:10 A.M., the maintenance director said the following:-He had not received any requests regarding a malfunctioning lock on the narcotic cabinet in the A hall medication room until today, when he was asked to get a padlock and new latch system for it;-A request for a malfunctioning lock on a narcotic box would be of high priority;-He would expect for staff to use the top and bottom locks to store narcotics in the cabinet. 2. Observation of the A hall medication room on 06/25/25 at 10:40 A.M., showed a top cabinet shelf that held the following:-Enteric coated (smooth coating that protects the medication from stomach acid, allowing the medication to be released in the intestine instead of the stomach) aspirin 325 mg (four full bottles, with no prescription label and no name);-Aspirin 81 mg (one full bottle, with no prescription label or name;-Ibuprofen (anti-inflammatory) 200 mg (one full bottle, with no prescription label or name;-Enteric coated Aspirin 81 mg (11 tablets) with no prescription label or name;-Docusate sodium (stool softener)100 mg (25 tablets with no prescription label or name;-One unopened bottle of fluticasone (corticosteroid nasal spray) 200 micrograms (mcg)/25 mcg, labeled for Resident #42;-A bottle of ciprofloxacin (antibiotic) eye drops, labeled for Resident #42 (1/2 bottle);-Resident #5's duloxetine (depression) 20 mg (six caplets);-Resident #6's geritussin (cough and cold) (473 milliliters (mls));-Resident #6's Floranex (probiotic supplement) (full bottle);-Resident #7's ear wax removal (full bottle);-Resident #26's Floranex (full bottle). 3. Observation on 06/25/25 at 11:18 A.M. of a plastic tub on the top shelf in the A hall medication room showed the following:-A box of 45 ipratropium (inhaled medication used to relax and open the airways in the lungs, making breathing easier) 0.02 percent (%) solution vials, expired 01/2025 and labeled for current Resident #23;-A partial vial of Lispro (fast-acting) insulin 100 unit/milliliter (ml) labeled for Resident #300 (who was discharged from the facility on 05/30/25);-14 Bisacodyl (laxative) 10 mg suppositories labeled for Resident #301 (who passed away in the facility on 04/22/25);-A full 5 ml bottle of Atropine (eye medication) 1% solution labeled for Resident #302 (who passed away in the facility on 05/01/25). During an interview on 06/25/25 at 10:45 A.M. and 06/26/25 at 2:19 P.M., Certified Medication Technician (CMT)/Certified Nurse Aide (CNA) N said the following:-The medications on the top shelf, including those on the shelf and in the tub, were all to be destroyed. None of them could be returned to the pharmacy;-He/She did not destroy medications;-He/She did not know how long they had been there, but they were there to be destroyed;-Some of them were discontinued or the residents had discharged ; -Two licensed nurses are required to destroy medications. 4. Observation on 06/25/25 at 8:17 A.M. of the 100 hall/200 hall medication cart showed the following stock medications:-A full bottle of zinc (supplement) 50 mg tablets expired 3/2025;-One bottle of aspirin 81 mg chewable tablets (approximately 3/4 full) expired 3/2025. 5. Observation on 06/25/25 at 8:17 A.M. of the 200 hall/300 hall medication cart showed the following stock medications:-A full bottle of zinc (supplement) 50 mg tablets expired 3/2025;-One bottle of aspirin 81 mg chewable tablets (11 tablets) expired 03/2025. 6. During an interview on 06/26/25 at 2:19 P.M., CMT/CNA N said the following:-The stock medications in the A hall medication carts were in use and administered to residents;-Licensed Practical Nurse (LPN) DD checked the medication carts for expired stock medications. During interviews on 06/30/25 at 9:00 A.M. and 07/01/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-Narcotic medication should be stored behind two locked doors;-The narcotic storage cabinet should be locked;-She was not aware the lock on the A hall narcotic cabinet was not working;-Two nurses are responsible for medication destruction. Pharmacy also assists in medication destruction. The local pharmacy was last in the facility in February 2025. The current pharmacy began in the facility in April; so, destruction probably was not happening monthly like he/she expected;-Pharmacy also check medication carts for expired medications. Pharmacy should destroy expired medications. Since the changes, the carts probably were not getting checked like they should be.

Based on observation, interview and record review, the facility failed to offer a bedtime snack to all residents. The facility census was 56. Review of the undated facility Bedtime Snack Policy showed the following:Policy Purpose:-To ensure that all residents of the facility receive a safe, nutritionally appropriate, and person-centered bedtime snack option consistent with their care plan, dietary needs and preferences;Policy Statement:-The facility is committed to providing bedtime snacks to residents who desire them, as part of a holistic approach to nutrition, comfort, and individualized care. Snacks are offered daily and will meet nutritional, therapeutic, and safety standards;1. Availability of Bedtime Snacks:-Bedtime snacks will be offered to residents between bedtime medication pass unless residents request a different time;-Snacks may include but are not limited to: graham crackers, pudding, yogurt, cheese, fruit, milk, and juice or anything requested by the resident. 1.During a group interview on 06/24/25 at 3:22 P.M., six of the six residents said staff come around with water at night, but do not offer snacks in the evening or at bedtime. They would like to be offered evening snacks. One resident, who said he/she was a diabetic, said they do not always offer him/her snacks and he/she would like one. 2. Observation on 06/30/25 at 8:52 A.M. in the A hall kitchenette showed the following:-A small refrigerator held several diet sodas, an energy drink and several small Styrofoam bowls with white lids, making the contents not visible, and dated 06/29/25; none of the items had resident names on them;-There was a partial package of saltine crackers in the cabinet and various condiments in the cabinet drawers. 3. During an interview on 06/30/25 at 4:40 P.M., Certified Nurse Aide (CNA) CC said the following:-He/She works the evening shift;-Dietary sends snacks to the floor for specific residents only;-Staff do not offer or pass bedtime snacks to all residents unless the resident requests a snack. During an interview on 06/30/25 at 8:45 A.M., the Dietary Manager said the following:-Dietary delivers bedtime snacks for specific residents only to the nurses' stations around 2:00 P.M. daily;-Nursing is responsible for passing bedtime snacks;-The dietary department does not send out bedtime snacks unless specifically requested by nursing;-Dietary has the following snacks available upon request: rice crispy treats, mini Oreos, Gold Fish, pudding, applesauce, sugar free lemon cookies and sugar free puddings. These snacks will be sent out when requested by nursing, but are not delivered to the halls on a routine basis;-Any snacks kept on the halls would be stored in the kitchenette. During an interview on 06/30/25 at 8:55 A.M., Registered Nurse (RN) A said the only snacks on the hall are in the kitchenette. Nursing staff would have to go to the kitchen/dietary for additional snacks. During an interview on 07/01/25 at 4:09 P.M. the Administrator said all residents should be offered a bedtime snack.

Based on interview and record review, the facility failed to provide an appropriate diagnosis for the use of psychotropic medications (medications that alter the levels of chemicals in the brain that influence mood, behavior and perception) for three residents (Residents #8, #50, #53) in a review of sixteen sampled residents. The facility failed to ensure one resident's physician (Resident #50) was made aware of a pharmacy recommendation to reduce his/her antipsychotic and failed to ensure gradual dose reductions (GDRs) were attempted, or documented as clinically contraindicated, for two resident (Residents #50 and #53). The facility census was 56. Review of the facility's policy, Psychotropic Medication Use, revised July 2022, showed the following:-Residents will not receive medications that are not clinically indicated to treat a specific condition;-A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior;-Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications (anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics);-Psychotropic medication management includes (indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences);-Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record;-Consideration of the use of any psychotropic medication is based on comprehensive review of the resident;-Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Review of the facility's policy, Antipsychotic medication use, revised July 2022, showed the following:-Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review;-Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective;-The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others;-The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications;-The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions;-Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident;-Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition in the Diagnostic and Statistical Manual of [NAME] Disorders (schizophrenia, schizoaffective disorder, delusional disorder, mood disorders (bipolar disorder, depression with psychotic features, and treatment refractory major depression), psychosis in the absence of dementia, medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania, Tourette's disorder, Huntington disease, hiccups, nausea and vomiting associated with cancer or chemotherapy;-Diagnoses alone do not warrant the use of antipsychotic medication; in addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met (the behavioral symptoms present a danger to the resident or others and the symptoms are identified as being due to mania or psychosis or behavioral interventions have been attempted and included in the plan of care, except in an emergency);-Resident diagnosis is based on a comprehensive assessment and evidence-based criteria and is consistent with professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders;-For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are (not due to a medical condition or problem that can be expected to improve or resolve as the underlying condition is treated or the offending medications is discontinued, and persistent or likely to reoccur without continued treatment, and not sufficiently relieved by non-pharmacological interventions, and not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety, and not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his/her cognitive impairment that can be expected to improve or resolve as the situation is addressed;-Antipsychotic medications will not be used if the only symptoms are one or more of the following (wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention, sadness or crying alone, fidgeting, nervousness, and uncooperativeness;-Staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications;-The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of the facility policy titled, Medication Regimen Reviews (MRR), revised May 2019, showed the following:-The consultant pharmacist reviews the medication regimen of each resident at least monthly;8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains:a. The resident's name;b. The name of the medication;c. The identified irregularity;d. The pharmacist's recommendation;9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 1. Review of Resident #8's care plan, dated 02/15/25, showed the following:-Diagnosis of depression;-No documentation of dementia, schizophrenia, or bipolar disorder;-No documentation of antipsychotic use;-No documentation to monitor for side effects or adverse reactions to antipsychotic. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/26/25, showed the following:-Moderate cognitive impairment;-No behaviors or rejection of cares;-Antipsychotics were received on a routine basis; Review of the resident's Physicians Order Sheet (POS), dated June 2025, showed the following:-Diagnosis of dementia and depression;-Zyprexa (antipsychotic medication used to treat schizophrenia and bipolar disorder) 2.5 milligrams (mg) daily was started on 05/23/25 and discontinued 06/23/25;-Zyprexa 5 mg at bedtime was started on 05/22/25 and discontinued on 06/23/25;-Zyprexa 2.5 mg every eight hours as needed for 14 days, for agitation due to dementia; start date of 06/24/25;-Seroquel (antipsychotic used for schizophrenia and bipolar) 25 mg two times daily (BID) with start date of 06/24/25 for dementia. The resident's medical record showed no documentation to support the resident had an appropriate diagnosis for the use of psychotropic medications, including Zyprexa and Seroquel. 2. Review of Resident #50's May 2025 POS showed the following:-Diagnoses of unspecified dementia;-Seroquel 50 mg three times a day (TID) with start date of 01/28/25. Review of the residents MRR, dated 05/15/25, showed the pharmacist recommended the following:-The following psychotropic medication is due for a gradual dose reduction (GDR);-Seroquel 50 mg TID to Seroquel 50 mg twice daily (BID);-Or other medication change;-Or reduction clinically contraindicated, with resident specific rationale for the contraindication. Review of the resident's medical record for May 2025 showed no documentation the resident's MMR of 05/15/25 had been sent to the physician. Review of the resident's care plan, dated 05/21/25, showed the following:-Behaviors and noncompliance with care related to dementia;-Behaviors monitored each shift. Review of the resident's significant change MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Behaviors and rejection of cares happened one to three days of the seven day look back period;-Antipsychotics were received on a routine basis;-GDR had not been attempted;-GDR had not been documented by physician as clinically contraindicated. Review of the resident's June 2025 POS showed an order for Seroquel 50 mg three times a day (TID) with start date of 01/28/25. Review of the residents MRR, dated 06/23/25, showed the pharmacist recommended the following:-Recommendations Pending Response: recommendation date of 05/15/25, reduce Seroquel 50 mg TID to Seroquel 50 mg BID;-Outcome pending (no response from the physician). The resident's medical record showed no documentation in the resident's June 2025 nursing notes or medication administration record the resident had behaviors and no documentation to support the resident had an appropriate diagnosis for the use of psychotropic medications, including Seroquel. Further review showed the facility did not share with the physician, the pharmacist's recommendation to decrease the resident's Seroquel, had not attempted a GDR, or had the physician document the GDR was clinically contraindicated for the resident's Seroquel. 3.Review of Resident #53's June 2025 POS showed the following:-Diagnoses of alcohol dependence with alcohol induced persisting dementia;-Depakote (medication used to treat seizures and bipolar disorder) 250 mg at bedtime with start date of 03/24/25;-Seroquel 50 mg at bedtime with start date of 04/11/25. Review of the resident's care plan, revised 06/11/25, showed the following:-At risk for aggressive behaviors related to alcohol dependence with alcohol induced persisting dementia;-Remain compliant with antipsychotic medications; Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact;-Behaviors happened one to three days of the seven day lookback period;-Antipsychotic was received on a routine basis;-GDR had not been attempted;-GDR had not been documented by physician as clinically contraindicated. The resident's medical record showed no documented behaviors since April 2025, no documentation to support the resident had an appropriate diagnosis for the use of psychotropic medications, including Seroquel. Further review showed the resident did not have a documented diagnoses for Depakote and the facility had not attempted a GDR, or had the physician document that a GDR was clinically contraindicated for the resident's Seroquel or Depakote. During an interview on 06/30/25 at 9:00 A.M. and 07/01/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-Residents should have an appropriate diagnosis for treatment with an antipsychotic medication;-Physicians should respond to pharmacist recommendations including GDRs timely. The facility has had problems with physician response in the past; -She sends the GDRs to the physicians, however the primary physician will not address psych medications;-No one had been monitoring;-The pharmacist had reviewed until March and the new pharmacist did not take over until the end of May 2025.

Based on interview and record review, the facility failed to update care plans to reflect current care needs for two residents (Residents #6 and #8), in a review of 16 sampled residents. The facility census was 56. Review of the facility's undated policy, Care Plan Policy, showed the following:-Care plans will be updated by nursing and administrative staff as needed for each resident;-Within seven days after every quarterly and annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, the resident and/or durable power of attorney (DPOA) will be offered a meeting with the facility administrative staff to discuss changes and concerns;-Within that same seven-day time frame, the care plan will be updated, and the next review target date will be triggered. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following:-Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change;-The IDT reviews and updates the care plan when there has been a significant change, when the desired outcome in not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required quarterly MDS. 1. Review of Resident #6's Care Plan, dated 03/17/25, showed the following:-The resident was at risk for falls due to his/her impaired cognitive ability and limited mobility;-The resident had a pressure alarm to alert staff when he/she was up for his/her safety and his/her history of falls. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/11/25, showed the following:-Severe cognitive impairment;-No falls since prior assessment;-No anti-anxiety medication. Review of the resident's Care Plan, revised 04/18/25, showed the following:-The resident had cognitive impairment related to dementia;-The resident was usually pleasantly confused. Staff re-directed the resident when needed;-The resident had impaired physical mobility related to multiple fractures of the pelvis and pain;-Staff will assist the resident with all transfers;-Staff continuously encourage the resident to utilize the call light and let staff assist him/her;-The resident was at risk for social isolation related to his/her diagnosis of dementia and anxiety. Review of the resident's physician's orders, dated 04/23/25, showed a new order for buspirone (anti-anxiety medication) 5 milligrams (mg), give 0.5 tablet by mouth three times a day for anxiety. Review of the resident's Care Plan showed no documentation regarding the use and management of the newly ordered anti-anxiety medication. Review of the resident's progress notes, dated 05/25/25 at 11:15 P.M., showed the following:-Staff found the resident sitting on the floor in his/her room by the bed on his/her buttocks (bottom);-The resident said he/she fell on his/her buttocks;-Staff assisted the resident up off the floor, and assisted the resident into bed;-The resident's only complaint was tenderness of at the medial malleolus (inner ankle). Review of the resident's progress notes, dated 05/27/25 at 7:08 P.M., showed the following:-Fall occurred in the resident's room;-The resident said he/she was getting ready for school;-No injury. Review of the resident's Care Plan showed no evidence staff evaluated current fall interventions and/or implemented new interventions after the resident falls on 05/25/25 and 05/27/25. 2. Review of Resident #8's care plan, dated 02/15/25, showed he/she had a diagnosis of depression. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the following:-Diagnosis of dementia and depression;-Zyprexa (antipsychotic medication used to treat schizophrenia and bipolar disorder) 5 milligrams (mg) at bedtime with start date of 05/22/25;-Zyprexa 2.5 mg daily with start date of 05/23/25. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/26/25, showed the following:-Diagnosis of dementia;-Antipsychotic medications were received on a routine basis. Review of the resident's care plan showed no documentation related to the resident's diagnosis of dementia, and no documentation to address the use and management of the antipsychotic medication. 3. During an interview on 07/01/25 at 11:20 A.M., Registered Nurse (RN) A said the following:-He/She works as a charge nurse in the facility;-The charge nurse notifies the Care Plan Coordinator of changes in resident conditions, including falls, and the Care Plan Coordinator updates the care plans. During an interview on 07/01/25 at 3:58 P.M., the Infection Preventionist/Care Plan Coordinator said the following:-The previous Assistant Director of Nursing (ADON) revised the care plans; -For the last two months, she and the Administrator tried to revise care plans with changes as needed;-Items such as use of psychotropic medications and side effects should be on a resident's care plan;-Staff should review and update the care plan as needed after a resident fell;-She hadn't been able to update all the care plans yet. During an interview on 06/30/25 at 9:00 A.M. and 07/01/25 at 3:27 P.M., the Director of Nursing (DON) said the following:-The previous care plan coordinator, who was responsible for revising the care plans, quit in March;-The IP was the current care plan coordinator; however, she had not had much training on care plans;-The IP and the administrator were responsible for revising the care plans. -Care plans should be updated and reviewed/revised as needed after a fall, weight loss, new diagnoses and medications that require monitoring; those updates should be made within seven days of the change.

Based on observation, interview and record review, the facility failed to ensure two nurse aides, (NAs) (NA M and NA Z), of five NAs reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 56. 1. Review of the facility provided list of employees hired since the last annual inspection showed NA M's date of hire was 02/26/25. Review of the facility schedule showed the following:-On 06/24/25 NA M was scheduled to work the B Hall for the 6:00 A.M. to 2:00 P.M. shift;-On 06/25/25 NA M was scheduled to work the A Hall for the 6:00 A.M. to 2:00 P.M. shift. Observation on 06/26/25 at 1:33 P.M., showed NA M provided toileting hygiene and transfer assistance to Resident #38. Review of NA M's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 2. Review of the facility provided list of employees hired since the last annual inspection showed NA Z's date of hire was 11/08/24. Review of the facility schedule showed the following:-On 06/24/25 NA Z was scheduled to work the A Hall for the 6:00 A.M. to 2:00 P.M. shift;-06/25/25 NA Z was scheduled to work the A Hall for the 6:00 A.M. to 2:00 P.M. shift;-06/26/25 NA Z was scheduled to work the A Hall for the 6:00 A.M. to 2:00 P.M. shift. Review of NA Z's employee file showed the following:-NA Z transferred from housekeeping to a NA position on 01/24/25;-No documentation he/she completed a nurse aide training program within four months of his/her start date in a NA position. 3. During an interview on 06/30/25 at 1:08 P.M., the Business Office Director (BOD) said the following:-She was responsible for enrolling NAs in CNA class;-She usually waited about a month after hire to enroll the NAs in CNA class;-The facility used the area Career Technical Education Center for in person CNA classes;-The area Career Technical Education Center went without an instructor for CNA class for a period making it difficult to get NAs enrolled in class;-NA Z was hired in housekeeping November 2024, was signed up for CNA class on 01/13/25 and transferred to being a NA on 01/24/25;-NA Z tested on [DATE] and failed the knowledge portion of the test;-NA M started CNA class online on 04/30/25, but wasn't ready to test because he/she hadn't completed the on-the-job (OTJ) training portion of the course;-Neither NA M or NA Z were certified within four months of hire as a NA and both continued to work as NAs providing resident care;-She thought NAs had to be enrolled in CNA class within four months of hire. During an interview on 07/01/25 at 4:09 P.M., the Administrator said the following:-The facility used the Career Area Technical Center for CNA certification classes and testing;-The Career Area Technical Center was without an instructor for a period making it difficult to get the NAs into class and certified within four months of hire.

Refer to FL1K12. Based on observation, interview, and record review, the facility failed to obtain an order for port-a-catheter (device connected to a vein in the chest or neck by a small, thin tube/catheter with an injectable disc that can be accessed for administration of IV (intravenous) medications or fluid) care for one resident (Resident #1), in a review of one resident with a port-a-catheter, per the discharge instructions after the placement of the device. The census was 58. Review of the facility policy, IV Therapy: Central Line Management Protocol, effective 03/11/21, showed the following: -Purpose: To outline the nursing management of residents who have a central line catheter and to specify nursing responsibilities in obtaining samples; -Interdependent (requires physician order to implement); -Flushes: Flush all unused or intermittently used IV ports with ten milliliters (ml's) of normal saline as follows: -Every 12 hours; -After the infusion of any medications; -Flush used port with five ml Heparin (blood thinner) after each infusion; -Flush other unused ports with five milliliters of heparin daily (10 units/ml). Review of Resident #1's physician order sheet, dated June 2024, showed an order for the following: Port: left chest, access port and flush with ten milliliters (mls) normal saline and five mls Heparin (blood thinner) monthly (once a day on the 13th of the month) 6:00 A.M. - 2:00 P.M. Deaccess once complete. Review of the resident's hospital discharge instructions, Implanted Port Insertion (procedure to put in a port and catheter), dated 06/14/24, obtained from the resident's facility medical record, showed the following: -Hand written note on front of sheet: Left side port removed and new port placed on the right side; -The implanted port is used as a long term intravenous (IV) access; -The port will need to be flushed and checked as told by your health care provider, usually every few weeks; -No documentation staff acknowledged reviewing these instructions. Review of the resident's progress notes showed there was no documentation staff communicated with any physician regarding the care of the resident's right sided chest port-a-cath as the hospital discharge instructions of 06/14/24 instructed. Review of the resident's physician order sheets (POS), Medication Administration Record (MAR), Treatment Administration Record (TAR) and Injectable Administration History, dated June 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated July 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated August 2024 through October 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, dated 10/17/24 to 10/31/24, showed the following: -An order dated 10/18/24, procedure to verify patency (unobstructed) of subclavian (large vein in the upper chest) port; no specific location documented; -An order dated 10/22/24, portogram procedure (diagnostic imaging used to assess the function of a port) to verify patency of port; no specific location documented. Physician requesting dye test to ensure patency of port; no specific location documented. Review of the resident's portogram result from the hospital, dated 10/28/24, showed the impression read: Contrast readily flows through the tip of the port device (no specific location of port indicated) with no reflux along the margins of the distal catheter that would suggest presence of a fibrous plug. The port freely draws blood as was demonstrated clinically prior to injecting the contrast. No evidence of thrombosis (blood clot) or fibrosis (formation of fibrous tissue) (define). There was no suggested follow up care or orders for the port listed. Review of the resident's POS, MAR, TAR, Injectable Administration History and progress notes, dated November 2024, showed no orders for the care of a right sided chest port-a-cath or communication to the physician related to the resident's right sided chest port. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated December 2024 thru January 2025, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated February 2025 thru April 2025, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated May 2025, showed no orders for the care of a right sided chest port-a-cath. Observation on 05/16/25 at 1:00 P.M., showed the resident sat in his/her wheelchair at the nursing desk. He/She had a small nodule located on the right upper chest area with an approximate four-centimeter incision line directly above it. The resident acknowledged the area was his/her port-a-cath. During interviews on 05/15/25 at 2:02 P.M. and 05/16/25 at 1:09 P.M., Licensed Practical Nurse (LPN) C said the following: -He/She believed there was only one resident (not Resident #1) who had a port-a-cath; -He/She believed Resident #1's port-a-cath had been discontinued; -He/She would know if a resident had a port-a-cath if there was an order to do something with it as it would show up on the POS and MAR. It would be specific to a Registered Nurse (RN), who would be qualified to ensure the order was completed; -Staff should be aware if a resident has a port-a-cath present; -The MAR/TAR would list the correct location of the port. During an interview on 05/16/25 at 2:07 P.M., RN B said the following: -He/She was aware the resident had had a port-a-cath a few weeks ago, but had assumed it had been discontinued as there were no orders to flush it; -Normally, a port was flushed monthly despite usage; -Flushing the port kept it open in case it would need to be used in the future; -The physician should know if a port was not being used; -He/She would have expected the resident to have orders for flushing the port after the patency was checked at the hospital. During an interview on 05/23/25 at 2:39 P.M., RN D said the following: -He/She was aware the resident had a port-a-cath (was not specific to location) and had flushed it in the past; -At one time they were flushing the port-a-cath monthly and at some point he/she thought the flush had been missed; He/She phoned Physician I's office and was told by the Physician Assistant not to do anything with the port as the office would be handling the care of the port (flushes, blood draws). During an interview on at 05/23/25 at 3:07 P.M. and 05/30/25 at 2:04 P.M., RN E said the following: -Port-a-caths are usually flushed monthly, but they would follow the physician's orders; -Physician orders should be followed; -He/She recalled receiving an order to discontinue the flushes for the resident's port-a-cath and he/she discontinued it from the electronic record; -He/She could not recall why he/she had received that order; -He/She could not recall which side the resident's port was located. During an interview on 05/16/25 at 2:15 P.M , the Director of Nursing (DON) said the following: -Staff should be aware of the presence of a resident's port-a-cath; -The presence of the device (implanted device) should be in the medical record; -She would expect there to be documentation in the medical record to show the care of a port or at least the presence of it; -Ports should be flushed timely and as ordered; -Her experience with ports was that they should be flushed every four to six weeks if maintaining patency; -She expected nursing to document any conversation they had with the physician who said there was no longer a need to flush the port so there would not be a situation like this; -Staff call the physician and go over orders upon a resident's return from the hospital, but the nurse who received the resident back may not have known why the resident was sent out due to staffing being moved around in the building; -If hospital discharge instructions noted the port would need to be flushed and checked as told by the health care provider, usually every few weeks, she would have expected staff to call the provider at that time to obtain an order. She thought they had, but there was no documentation of that; -She was aware the resident had a right sided chest port; -When staff are are a resident has an implanted port-a-cath, they should ensure facility policy is followed and orders obtained for care of the port-a cath; again, she thought that had been addressed with the resident's physician and no orders for care had been given; -She was not aware of any staff being responsible for reviewing physician orders to ensure proper care was provided. During an interview on 05/16/25 at 2:31 P.M., the Administrator said the following: -She would expect staff to be aware of the presence of the resident's port-a-cath; -She would expect any conversations with the physician regarding the care of the port to be documented in the progress notes. During an interview on 05/16/25 at 11:11 A.M., Physician G said the following: -He would expect a port-a-cath to be flushed monthly to keep it patent; -Missed flushes could cause the catheter to clot off making it un-useable; -He would recommend for staff to follow the recommendation of the facility/physician which placed the catheter. During an interview on 05/22/25 at 9:32 A.M., the resident's current primary physician, Physician H, also the facility medical director, said the following: -Port-a-caths were normally flushed every 30 days with heparin to keep the port patent; -If a port-a-cath was left in place and not flushed, it would clog from non-use; -If a resident returned from the hospital with an incision/port-a-cath, he would expect staff to inquire about care of the port if no orders were were received. MO253801

Based on interview and record review, the facility failed to ensure staff responded to call lights timely for five residents (Residents #1, #2, #3, #4 and #6), in a review of six sampled residents. Staff failed to accommodate the residents' needs for assistance, including assistance with toileting, which resulted in episodes of incontinence. The facility census was 59. Review of the facility policy titled, Nurse Call System, revised 11/15/2023, showed the following: Call escalation: -Call made, activates Certified Nurse Aide (CNA) pagers; -Repeat call goes out to CNA, at seven minutes; -Call escalates to Restorative Nurse and Certified Medication Technician (CMT) if call is not responded to within 14 minutes; -Call escalates to charge nurse at the 21 minute mark; -Director of Nursing (DON) cell phone activated at the 28 minute mark. 1. Review of Resident #3's care plan, revised 12/31/24, showed the following: -The resident was continent of bowel and bladder; -The resident needed assistance to complete the majority of his/her activities of daily living (ADLs); -The resident needed staff assistance with toileting and transfers; -Please check on him/her at least every two hours and ensure he/she was dry and clean; Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/17/25 showed the following: -Cognitively intact; -Understands others; -Makes self understood; -Required substantial/maximal assistance for toileting hygiene and toilet transfers; -Required partial/moderate assistance for sit to stand; -Required supervision or touching assistance for walking 10 feet; -Used a wheelchair; -Occasionally incontinent of bladder; -Continent of bowel; -Diagnoses of heart failure and diabetes; -Takes a diuretic. During an interview on 04/03/25 at 7:24 A.M., Resident #3 said the following: -He/She required staff assistance of one for ambulation and use of his/her walker; -He/She used his/her call light for staff assistance to toilet; -He/She took a fluid pill, needed to urinate a lot and when he/she needs to go, he/she needed to go; -He/She had been incontinent several times when waiting for staff assistance for toileting; -He/She felt bad when he/she was incontinent and staff had to clean up after him/her. 2. Review of Resident #1's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Makes self understood; -Required substantial/maximal assistance for toileting hygiene, sitting to standing, toilet transfers and for walking 10 feet; -Uses a wheelchair; -Occasionally incontinent of bladder; -Always continent of bowel; -Diagnoses of urinary tract infection (an infection in any part of the urinary system) last 30 days, diabetes and dementia. Review of the resident's care plan, revised 01/07/25, showed the following: -The resident had a fall prior to admission to the facility that resulted in a left femur (leg bone) fracture that was surgically repaired in the hospital; -The resident was at high risk for falls; -The resident was occasionally incontinent of bowel and bladder; -The resident needed extensive assistance of one staff with toileting; -The resident ambulated with a walker, gait belt (a sturdy strap with a buckle, typically made of canvas, nylon, or leather, used by healthcare providers to safely support and guide residents who have difficulty walking or standing, and to assist with transfers) and staff assist of one. Review of the resident's call light logs, dated 03/10/25 to 04/03/25, showed the following: -On 03/24/25 the call light was activated at 6:19 P.M. and remained on for 24 minutes before being deactivated; -On 03/26/25 the call light was activated at 6:07 P.M. and remained on for 23 minutes before being deactivated; -On 03/26/25 the call light was activated at 6:36 P.M. and remained on for 22 minutes before being deactivated; -On 03/29/25 the call light was activated at 7:34 A.M. and remained on for 28 minutes before being deactivated; -On 03/30/25 the call light was activated at 1:05 P.M. and remained on for 30 minutes before being deactivated; -On 03/31/25 the call light was activated at 6:05 P.M. and remained on for 22 minutes before being deactivated; -On 04/2/25 the call light was activated at 12:20 P.M. and remained on for 21 minutes before being deactivated. During an interview on 04/03/25 at 8:25 A.M., the resident said the following: -He/She needed help from staff getting to the bathroom; -He/She had been incontinent waiting for staff to answer his/her call light; -It made him/her feel bad when he/she has an accident (was incontinent). During an interview on 04/03/25 at 8:25 A.M., the resident's family member said the following: -He/She visited the resident daily; -The resident needed staff assistance for toileting and personal care; -The resident has had to wait 30 minutes to an hour for his/her call light to be answered by staff. 3. Review of Resident #4's care plan, revised 12/31/24, showed the following: -The resident was alert and able to make his/her needs known to staff; -The resident has left sided weakness; -The resident needs assist of one staff member with transfers using a gait belt; -Remind the resident frequently to ask for assistance for his/her safety; -The resident was continent of bowel and bladder; -The resident required substantial assistance with toileting hygiene. Review of the resident's call light logs, dated 03/10/25 to 03/20/25, showed the following: -On 03/10/25 the call light was activated at 5:35 P.M. and remained on for 38 minutes before being deactivated; -On 03/14/25 the call light was activated at 8:52 P.M. and remained on for 29 minutes before being deactivated; -On 03/15/25 the call light was activated at 10:33 A.M. and remained on for 24 minutes before being deactivated; -On 03/15/25 the call light was activated at 6:29 P.M. and remained on for 40 minutes before being deactivated; -On 03/17/25 the call light was activated at 5:39 P.M. and remained on for 41 minutes before being deactivated; -On 03/17/25 the call light was activated at 5:53 P.M. and remained on for 27 minutes before being deactivated; -On 03/19/25 the call light was activated at 8:14 A.M. and remained on for 24 minutes before being deactivated; -On 03/19/25 the call light was activated at 10:29 A.M. and remained on for 24 minutes before being deactivated; -On 03/20/25 the call light was activated at 4:10 P.M. and remained on for 31 minutes before being deactivated; -On 03/20/25 the call light was activated at 5:45 P.M. and remained on for 24 minutes before being deactivated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Made self understood; -Used a walker and a wheelchair; -Required supervision and touching assistance for toileting hygiene, toilet transfers, sitting to standing and for walking; -Always continent of bladder and bowel; -Diagnoses of cancer and seizure disorder; -Takes a diuretic (also called water pills, medication designed to increase the amount of water and salt expelled from the body as urine). Review of the resident's call light logs, dated 03/21/25 to 04/03/25 showed the following: -On 03/23/25 the call light was activated at 11:24 A.M. and remained on for 20 minutes before being deactivated; -On 03/24/25 the call light was activated at 12:52 P.M. and remained on for 22 minutes before being deactivated; -On 03/24/25 the call light was activated at 7:28 P.M. and remained on for 22 minutes before being deactivated; -On 03/26/25 the call light was activated at 6:06 A.M. and remained on for 26 minutes before being deactivated; -On 03/26/25 the call light was activated at 10:29 A.M. and remained on for 32 minutes before being deactivated; -On 03/27/25 the call light was activated at 10:12 A.M. and remained on for 22 minutes before being deactivated; -On 03/27/25 the call light was activated at 3:59 P.M. and remained on for 20 minutes before being deactivated; -On 03/28/25 the call light was activated at 5:46 P.M. and remained on for 22 minutes before being deactivated; -On 03/30/25 the call light was activated at 7:55 P.M. and remained on for 21 minutes before being deactivated; -On 03/31/25 the call light was activated at 5:58 P.M. and remained on for 28 minutes before being deactivated; -On 03/31/25 the call light was activated at 8:30 P.M. and remained on for 29 minutes before being deactivated; -On 04/01/25 the call light was activated at 7:22 P.M. and remained on for 20 minutes before being deactivated; -On 04/02/25 the call light was activated at 1:30 P.M. and remained on for 30 minutes before being deactivated; -On 04/02/25 the call light was activated at 4:32 P.M. and remained on for 21 minutes before being deactivated; -On 04/02/25 the call light was activated at 7:57 P.M. and remained on for 28 minutes before being deactivated; -On 04/03/25 the call light was activated at 11:13 A.M. and remained on for 22 minutes before being deactivated; -On 04/03/25 the call light was activated at 2:08 P.M. and remained on for 27 minutes before being deactivated. During an interview on 04/03/25 at 2:28 P.M., the resident said the following: -He/She had left side weakness and a history of seizures and falls; -He/She needed staff assist of one for ambulation to and from the bathroom; -He/She has had to wait 25 minutes or more for staff to answer his/her call light; -He/She has a cloth incontinence pad in his/her bed and in his/her recliner, but he/she would rather go to the bathroom and use the toilet; -He/She did not want to urinate in his/her bed or his/her chair. 4. Review of Resident #2's care plan,, revised 11/26/24 showed the following: -The resident has a diagnosis of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety and depression; -The resident takes a fluid pill daily that can increase his/her risk of dehydration; -The resident was frequently incontinent of bowel and bladder; -The resident needed total assistance with using a bedpan; -The resident used a urinal and at times needed assistance using it; -The resident will use his/her call light for staff to assist him/her with toileting; -The resident had both lower limbs amputated due to diabetes; -The resident requires extensive assistance with using a mechanical lift. Review of the resident's call light logs, dated 03/10/25 to 03/28/25, showed the following: -On 03/11/25 the call light was activated at 7:01 A.M. and remained on for 25 minutes before being deactivated; -On 03/13/25 the call light was activated at 7:01 A.M. and remained on for 33 minutes before being deactivated; -On 03/13/25 the call light was activated at 1:52 P.M. and remained on for 26 minutes before being deactivated; -On 03/13/25 the call light was activated at 9:22 P.M. and remained on for 58 minutes before being deactivated; -On 03/14/25 the call light was activated at 4:00 P.M. and remained on for 22 minutes before being deactivated; -On 03/14/25 the call light was activated at 5:16 P.M. and remained on for 21 minutes before being deactivated; -On 03/14/25 the call light was activated at 6:00 P.M. and remained on for 21 minutes before being deactivated; -On 03/17/25 the call light was activated at 3:12 P.M. and remained on for 31 minutes before being deactivated; -On 03/17/25 the call light was activated at 4:01 P.M. and remained on for 29 minutes before being deactivated; -On 03/18/25 the call light was activated at 1:42 P.M. and remained on for 24 minutes before being deactivated. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Made self understood; -Dependent on staff for toileting hygiene and chair/bed to chair transfers; -Used a motorized wheelchair; -Occasionally incontinent of bladder and bowel; -Diagnoses of diabetes, stroke and hemiplegia (muscle weakness or partial paralysis on one side of the body); -Functional limitation in range of motion for lower extremities, both sides; -Takes a diuretic. Review of the resident's call light logs, dated 03/29/25 through 04/03/25, showed the following: -On 03/29/25 the call light was activated at 10:27 A.M. and remained on for 25 minutes before being deactivated; -On 03/30/25 the call light was activated at 9:25 A.M. and remained on for 32 minutes before being deactivated; -On 04/01/25 the call light was activated at 9:09 P.M. and remained on for 33 minutes before being deactivated; -On 04/02/25 the call light was activated at 6:24 A.M. and remained on for 25 minutes before being deactivated; -On 04/02/25 the call light was activated at 11:48 A.M. and remained on for 29 minutes before being deactivated; -On 04/02/25 the call light was activated at 1:39 P.M. and remained on for 22 minutes before being deactivated; -On 04/02/25 the call light was activated at 7:13 P.M. and remained on for 21 minutes before being deactivated; -On 04/03/25 the call light was activated at 6:57 A.M. and remained on for 25 minutes before being deactivated; -On 04/03/25 the call light was activated at 9:10 A.M. and remained on for 30 minutes before being deactivated. During an interview on 04/03/25 at 11:25 A.M., the resident said the following: -He/She needed staff assistance for toileting and transfers; -Sometimes it took up to an hour to get assistance from staff. 5. Review of Resident #6's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Required substantial/maximal assistance for toileting hygiene, toilet transfers and sit to stand; -Unable to walk; -Used a wheelchair; -Always incontinent of bladder; -Frequently incontinent of bowel; -Diagnoses of heart failure and dementia; -Takes a diuretic. Review of the resident's call light logs, dated 03/10/25 to 04/03/25, showed the following: -On 03/14/25 the call light was activated at 11:18 A.M. and remained on for 23 minutes before being deactivated; -On 03/18/25 the call light was activated at 5:32P.M. andd remained on for 22 minutes before being deactivated; -On 03/19/25 the call light was activated at 7:57 P.M. and remained on for 21 minutes before being deactivated; -On 03/23/25 the call light was activated at 1:36 P.M. and remained on for 22 minutes before being deactivated; -On 03/29/25 the call light was activated at 9:50 A.M. and remained on for 21 minutes before being deactivated; -On 04/01/25 the call light was activated at 1:23 P.M. and remained on for 20 minutes before being deactivated; -On 04/02/25 the call light was activated at 7:59 P.M. and remained on for 25 minutes before being deactivated. Review of the resident's care plan, revised 04/08/25, showed the following: -The resident required extensive assistance with his/her ADLs due to poor mobility and cognitive deficit; -Staff will ensure the resident is toileted at least every two hours; -The resident was frequently incontinent of bowel and bladder; -The resident was a fall risk due to impaired cognition and mobility as well as use of diuretics; -Staff will ensure the resident's call light was within reach and frequently remind him/her to use if for assistance as needed. During an interview on 04/03/2025 at 3:20 P.M. and 4/16/25 at 1:36 P.M. the Director of Nurses said the following: -She prefers for staff to answer call lights within 10 minutes; -She and the Administrator received a daily and weekly report of call light logs and review what happened the day prior; -She was unaware Resident #3 had been incontinent due to waiting for staff assistance to toilet; -They had not identified longer call light response times for any residents other than Resident #2; -She receives alerts on her cell phone for call lights on greater than 28 minutes; -When she receives the alerts, she talked to staff to figure out the reason for the longer call light response times; -If they see a pattern of a resident's call light on for an excessive amount of time, she talked to the staff on duty during those times. During an interview on 04/08/25 at 11:20 A.M. and 4/16/25 at 12:21 P.M. the Administrator said the following: -She would expect staff to answer call lights within seven minutes; -More than 20 minutes to answer a call light would be too long; -She and the DON monitored call light response times daily; -She reviewed the call light logs for longer call light response times; -She discussed the longer call light response times in morning meeting to try to figure out why the response times were longer; -She looks at the time of the longer response times and talks with staff on duty during that time. MO 251821

Based on observation, interview, and record review, the facility failed to obtain an order for port-a-catheter (device connected to a vein in the chest or neck by a small, thin tube/catheter with an injectable disc that can be accessed for administration of IV (intravenous) medications or fluid) care for one resident (Resident #1), in a review of one resident with a port-a-catheter, per the discharge instructions after the placement of the device. The census was 58. Review of the facility policy, IV Therapy: Central Line Management Protocol, effective 03/11/21, showed the following: -Purpose: To outline the nursing management of residents who have a central line catheter and to specify nursing responsibilities in obtaining samples; -Interdependent (requires physician order to implement); -Flushes: Flush all unused or intermittently used IV ports with ten milliliters (ml's) of normal saline as follows: -Every 12 hours; -After the infusion of any medications; -Flush used port with five ml Heparin (blood thinner) after each infusion; -Flush other unused ports with five milliliters of heparin daily (10 units/ml). Review of Resident #1's physician order sheet, dated June 2024, showed an order for the following: Port: left chest, access port and flush with ten milliliters (mls) normal saline and five mls Heparin (blood thinner) monthly (once a day on the 13th of the month) 6:00 A.M. - 2:00 P.M. Deaccess once complete. Review of the resident's hospital discharge instructions, Implanted Port Insertion (procedure to put in a port and catheter), dated 06/14/24, obtained from the resident's facility medical record, showed the following: -Hand written note on front of sheet: Left side port removed and new port placed on the right side; -The implanted port is used as a long term intravenous (IV) access; -The port will need to be flushed and checked as told by your health care provider, usually every few weeks; -No documentation staff acknowledged reviewing these instructions. Review of the resident's progress notes showed there was no documentation staff communicated with any physician regarding the care of the resident's right sided chest port-a-cath as the hospital discharge instructions of 06/14/24 instructed. Review of the resident's physician order sheets (POS), Medication Administration Record (MAR), Treatment Administration Record (TAR) and Injectable Administration History, dated June 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated July 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated August 2024 through October 2024, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, dated 10/17/24 to 10/31/24, showed the following: -An order dated 10/18/24, procedure to verify patency (unobstructed) of subclavian (large vein in the upper chest) port; no specific location documented; -An order dated 10/22/24, portogram procedure (diagnostic imaging used to assess the function of a port) to verify patency of port; no specific location documented. Physician requesting dye test to ensure patency of port; no specific location documented. Review of the resident's portogram result from the hospital, dated 10/28/24, showed the impression read: Contrast readily flows through the tip of the port device (no specific location of port indicated) with no reflux along the margins of the distal catheter that would suggest presence of a fibrous plug. The port freely draws blood as was demonstrated clinically prior to injecting the contrast. No evidence of thrombosis (blood clot) or fibrosis (formation of fibrous tissue) (define). There was no suggested follow up care or orders for the port listed. Review of the resident's POS, MAR, TAR, Injectable Administration History and progress notes, dated November 2024, showed no orders for the care of a right sided chest port-a-cath or communication to the physician related to the resident's right sided chest port. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated December 2024 thru January 2025, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated February 2025 thru April 2025, showed no orders for the care of a right sided chest port-a-cath. Review of the resident's POS, MAR, TAR and Injectable Administration History, dated May 2025, showed no orders for the care of a right sided chest port-a-cath. Observation on 05/16/25 at 1:00 P.M., showed the resident sat in his/her wheelchair at the nursing desk. He/She had a small nodule located on the right upper chest area with an approximate four-centimeter incision line directly above it. The resident acknowledged the area was his/her port-a-cath. During interviews on 05/15/25 at 2:02 P.M. and 05/16/25 at 1:09 P.M., Licensed Practical Nurse (LPN) C said the following: -He/She believed there was only one resident (not Resident #1) who had a port-a-cath; -He/She believed Resident #1's port-a-cath had been discontinued; -He/She would know if a resident had a port-a-cath if there was an order to do something with it as it would show up on the POS and MAR. It would be specific to a Registered Nurse (RN), who would be qualified to ensure the order was completed; -Staff should be aware if a resident has a port-a-cath present; -The MAR/TAR would list the correct location of the port. During an interview on 05/16/25 at 2:07 P.M., RN B said the following: -He/She was aware the resident had had a port-a-cath a few weeks ago, but had assumed it had been discontinued as there were no orders to flush it; -Normally, a port was flushed monthly despite usage; -Flushing the port kept it open in case it would need to be used in the future; -The physician should know if a port was not being used; -He/She would have expected the resident to have orders for flushing the port after the patency was checked at the hospital. During an interview on 05/23/25 at 2:39 P.M., RN D said the following: -He/She was aware the resident had a port-a-cath (was not specific to location) and had flushed it in the past; -At one time they were flushing the port-a-cath monthly and at some point he/she thought the flush had been missed; He/She phoned Physician I's office and was told by the Physician Assistant not to do anything with the port as the office would be handling the care of the port (flushes, blood draws). During an interview on at 05/23/25 at 3:07 P.M. and 05/30/25 at 2:04 P.M., RN E said the following: -Port-a-caths are usually flushed monthly, but they would follow the physician's orders; -Physician orders should be followed; -He/She recalled receiving an order to discontinue the flushes for the resident's port-a-cath and he/she discontinued it from the electronic record; -He/She could not recall why he/she had received that order; -He/She could not recall which side the resident's port was located. During an interview on 05/16/25 at 2:15 P.M , the Director of Nursing (DON) said the following: -Staff should be aware of the presence of a resident's port-a-cath; -The presence of the device (implanted device) should be in the medical record; -She would expect there to be documentation in the medical record to show the care of a port or at least the presence of it; -Ports should be flushed timely and as ordered; -Her experience with ports was that they should be flushed every four to six weeks if maintaining patency; -She expected nursing to document any conversation they had with the physician who said there was no longer a need to flush the port so there would not be a situation like this; -Staff call the physician and go over orders upon a resident's return from the hospital, but the nurse who received the resident back may not have known why the resident was sent out due to staffing being moved around in the building; -If hospital discharge instructions noted the port would need to be flushed and checked as told by the health care provider, usually every few weeks, she would have expected staff to call the provider at that time to obtain an order. She thought they had, but there was no documentation of that; -She was aware the resident had a right sided chest port; -When staff are are a resident has an implanted port-a-cath, they should ensure facility policy is followed and orders obtained for care of the port-a cath; again, she thought that had been addressed with the resident's physician and no orders for care had been given; -She was not aware of any staff being responsible for reviewing physician orders to ensure proper care was provided. During an interview on 05/16/25 at 2:31 P.M., the Administrator said the following: -She would expect staff to be aware of the presence of the resident's port-a-cath; -She would expect any conversations with the physician regarding the care of the port to be documented in the progress notes. During an interview on 05/16/25 at 11:11 A.M., Physician G said the following: -He would expect a port-a-cath to be flushed monthly to keep it patent; -Missed flushes could cause the catheter to clot off making it un-useable; -He would recommend for staff to follow the recommendation of the facility/physician which placed the catheter. During an interview on 05/22/25 at 9:32 A.M., the resident's current primary physician, Physician H, also the facility medical director, said the following: -Port-a-caths were normally flushed every 30 days with heparin to keep the port patent; -If a port-a-cath was left in place and not flushed, it would clog from non-use; -If a resident returned from the hospital with an incision/port-a-cath, he would expect staff to inquire about care of the port if no orders were were received. MO253801

Based on interview and record review, the facility failed to ensure one resident (Resident #7). in a review of seven sampled residents, remained free of significant medication error. The resident had an order for a Fentanyl patch (a powerful opiod medication for pain control). The resident became nauseated and unresponsive requiring two doses of Narcan (a medication used to reverse opioid overdose) before becoming responsive again. The resident was then transferred to the hospital for evaluation where hospital records showed the resident had two Fentanyl (narcotic pain medication) patches on the resident's skin (the resident's physician order was for one patch). The facility census was 59. The facility did not provide a policy for following physician's orders. Review of www.drugs.com showed the following regarding Fentanyl patch usage: -Opioid medication can slow or stop breathing, and death may occur. Seek emergency medical attention if you have slow breathing with long pauses, blue colored lips, or if you are hard to wake up; -Remove the skin patch and call your physician at once if you have confusion, severe drowsiness, feeling like you might pass out; -Never use Fentanyl in larger amounts, or for longer than prescribed; -Wear the Fentanyl skin patch around the clock, removing and replacing the patch every 72 hours (3 days). Do not wear more than one patch at a time unless your physician has told you to. 1. Review of Resident #7's care plan dated 10/5/23 showed the following: -The resident reports having pain all over but mostly in his/her bilateral legs and feet; -The resident is diabetic and has neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet); -The resident has a pain patch that is applied and changed every three days. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/23 showed the following: -Cognitively intact; -No acute mental status changes; -Diagnoses of heart failure and anxiety. Review of the resident's January 2024 physician's orders showed an order for Fentanyl 25 micrograms (mcg)/hour (hr) every 72 hours transdermal (through the skin) (start date 10/6/23). Review of the resident's January 2024 Medication Administration Record (MAR) dated 1/4/24 showed staff applied Fentanyl25 mcgg/hour transdermal patch. Review of the resident's January 2024 MAR showed no documentation regarding the removal of a Fentanyl patch on 1/4/24. Review of the resident's progress notes dated 1/5/24 at 10:57 A.M. showed the following: -This nurse and aide assisted the resident to the bathroom, transferring from wheelchair to toilet and back to his/her wheelchair, while propelling wheelchair to recliner, resident said I feel nauseous; -This nurse and aide again transferred the resident to the recliner; -After the resident sat in the recliner, resident had dazed look on his/her face, eyes open and unable to respond to nurse calling his/her name x 3; -Emergency Medical Services (EMS) and physician were notified via phone; -Family was present and agreed to send resident to the hospital. Review of the resident's progress notes dated 1/5/24 at 11:00 A.M. showed the following: -Resident went unresponsive upon his/her return transfer to recliner so event was witnessed; -Resident was leaned forward in chair with agonal gasps (when someone who is not getting enough oxygen is gasping for air); -The resident's teeth were falling out of his/her mouth and his/her lips were blue; -Resident sat back in chair; -Absence of vital signs while staff spoke loudly to the resident and did sternal rub (a commonly used method of assessing response to painful stimuli in assessing the neurological status of an individual); -After a period of apnea (breathing stops) lasting 25 seconds, resident gasped and opened eyes; -Physician notified with orders to remove Fentanyl patch and give a dose of Narcan; -Patch removed and 0.4 milligrams (mg) of Narcan administered; -Resident continued to dry heave; -Paramedic initiatedintravenouss (IV) (a soft, flexible tube placed inside a vein) while in the facility to administer IV Zofran (medication for nausea) and another dose of Narcan. Review of the resident's progress notes dated 1/6/24 at 12:11 A.M. showed the resident was admitted to the hospital with congestive heart failure and urinary tract infection (UTI). Review of the resident's hospital progress note dated 1/9/24 showed on presentation to the hospital, resident was noted to have two Fentanyl patches in place which was reversed with Narcan x 2. During an interview on 2/21/24 at 1:47 P.M. and 2/22/24 at 11:32 A.M. Licensed Practical Nurse (LPN) F said the following: -Staff had just taken the resident to the bathroom; -The resident was sitting in the recliner; -The resident had a blank look and went unresponsive; -He/She called for help, contacted the physician and gave the resident Narcan; -When staff were getting the resident ready to go to the hospital they pulled two Fentanyl patches off the resident. During an interview on 2/21/24 at 2:00 P.M. the paramedic said the following: -He/She was told in report by the facility staff that the resident's Fentanyl patch was removed; -He/She did not see a Fentanyl patch, but he/she did not examine the resident's chest or back; -The resident was alert but very drowsy during the ambulance ride. During an interview on 2/20/24 at 1:20 P.M. the resident's family member said the following: -The day the resident was transferred to the hospital the resident acted like he/she was drugged; -Hospital staff said the resident had two Fentanyl patches on when he/she arrived at the hospital. During an interview on 2/22/24 at 4:04 P.M. the Director of Nursing (DON) said the following: -She would expect staff to follow physician's orders; -If a resident had an order for one Fentanyl patch she would expect only one Fentanyl patch to be on the resident; -Having two Fentanyl patches on could increase the resident's risk of altered mental status/decreased responsiveness unless one of the patches was at the end of the three days then it would not be as potent. MO 231008

Based on interview and record review, the facility failed to ensure staff transferred one resident (Resident #6), in a review of seven sampled residents, who required staff assistance and use of a gait belt (belt used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and ambulation). Both staff and the resident fell . The resident had a history of falls and a left hip fracture. The resident sustained a skin tear, muscle/ligament tears, and had increased pain after the fall. The facility census was 59. Review of the facility policy Gait Belt for Transfer dated 10/10/12 showed gait belts are provided to assist staff to safely transfer or ambulate residents. 1. Review of Resident #6's hospital discharge orders dated 12/8/23 showed the following: -Fracture of left hip; -Past medical history of stroke; -Discharge activity included non-weight bearing to left hand. Can use platform walker and bear weight on the forearm. 75% weight bearing to the left leg. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/23 showed the following: -admitted to the facility 12/8/23; -Cognitively intact; -Required partial to moderate assistance for toileting hygiene, sit to stand transfer, chair-bed to chair transfer and toilet transfer; -Required supervision or touching assistance for walking; -Used a wheelchair; -Always continent of bladder and bowel; -Diagnoses of hemiplegia (one-sided paralysis)/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and depression; -Frequent pain; -Pain almost constantly affects sleep; -Pain intensity 9 (scale 0-10); -History of fall in the last month prior to admission; -Had a fracture related to a fall in six months prior to admission. Review of the resident's progress notes dated 12/21/23 at 4:45 P.M. showed the following: -Called into resident's room by staff; -Witnessed resident and a staff member both on the ground; -Resident reported usual 5/10 left hip pain; -Rotation of left hip noted which resident reports has been normal since recent fracture and repair to left hip; -Resident had left elbow skin tear. Pressure applied. Steri-stips applied with non-adherent dressing and gauze wrap applied after bleeding was controlled. Review of the resident's fall incident report dated 12/21/23 at 5:16 P.M. showed range of motion (ROM): ROM painful/limited in lower extremity. Review of the resident's bilateral hip X-Ray results dated 12/21/23 showed the following: -Increasing pain of the left hip after recent fall, hip fracture repaired five weeks ago; -There is proximal distraction (separated by a gap) of the lesser trochanteric fragment from the previous hip fracture. Review of the resident's progress notes dated 12/22/23 at 9:25 A.M. showed X-Ray faxed to orthopedic physician's office. Review of the resident's physician orders dated 12/24/23 showed the following: -Non-weight bearing (NWB) left lower extremity (LLE); -Hoyer lift (full body mechanical lift); -MRI (magnetic resonance imaging)(medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body) left hip; -Norco (narcotic pain medication) 5-325 milligrams (mg) three times daily. Review of the resident's progress notes dated 12/25/23 at 9:25 P.M. showed the resident requires extensive assist of two for transfers with Hoyer lift (mechanical lift) since hip injury. Review of the resident's care plan revised 1/17/24 showed the following: -The resident has reported frequent chronic pain in his/her left hip and lower extremity; -He/She has interventions for pain. Administer or apply as needed and ordered; -He/She had a fall and broke his/her left hip. He/she is working with therapy; -He/She needs assistance with toileting and dressing; -The resident scored as being a high risk for falls; -He/She has had falls in the last six month; -He/She has weakness/deficits to his/her left side due to a stroke; -He/She has an unsteady gait; -On 12/21/23 he/she was ambulating with staff and fell . Staff was not using a gait belt. Staff was educated on gait belt use and it's importance for both staff and his/her safety; -Please keep his/her call light within reach; -He/She transfers with two staff members using a gait belt. Review of the resident's MRI of the left hip dated 1/30/24, showed left gluteus minimus (smallest muscle of the glute) and medius (primary hip abductor) tendon partially torn with diffuse left gluteal muscle edema (swelling). Review of the resident's orthopedic physician's notes dated 2/6/24 showed the following: -Left lateral hip and iliotibial band (ITB) (a painful inflammation of the iliotibial band, a thick, tendon-like portion of a muscle that travels from the hip down the outer side of the thigh to the knee. Iliotibial band pain syndrome (ITBS) results in pain, aggravated by activity, that is usually felt on the outer side of the knee) pain after second fall; -Tender to palpation (TTP) over left hip fracture bolt and ITB; -Orders for ultrasound guided left greater trochanter (GT) (located at the top of the thighbone (femur) and is the most prominent and widest part of the hip) bursa (small fluid filled sacs found near joints) and gluteal tendon injection. During an interview on 2/20/24 at 9:51 A.M. the resident said the following: -When he/she was admitted to the facility he/she was walking with a walker and staff assist of one; -Currently he/she required staff assist of two for transfers and ambulation; -He/She has had a stroke, fell and broke his/her hip a few months ago and had a fall in December which has caused him/her increased pain; -Certified Nurse Aide (CNA) H was walking him/her to the bathroom, he/she lost his/her balance and both he/she and CNA H fell in the bathroom; -He/She doesn't remember CNA H putting a belt around his/her waist when he/she fell in December; -He/She suffered torn ligaments and muscles from the fall in December; -He/She has had to return to the orthopedic physician and the plan is for him/her to receive a steroid injection in his/her left hip to hopefully help relieve the pain. If the injection does not work he/she will have to another surgery. During an interview on 2/20/24 at 4:50 P.M. CNA H said the following: -He/She walked the resident to the bathroom; -He/She stood behind the resident and held onto the sides of the resident's waist with his/her hands; -The resident lost his/her balance; -He/She tried to catch the resident and tripped over the resident's walker; -Both he/she and the resident fell ; -He/She did not use a gait belt; -He/She was supposed to use a gait belt. During an interview on 2/22/24 at 10:42 A.M. the MDS Coordinator said the following: -He/She was called to the resident's room the day he/she fell ; -CNA H and the resident both laid on the bathroom floor; -The resident told CNA H just to grab around his/her waist during the transfer and ambulation to the bathroom so no gait belt was used; -Since the fall the resident has been having increased pain and has required further testing; -The resident also sustained a skin tear to his/her arm during the fall. During an interview on 2/27/24 at 10:20 A.M. Physical Therapist K said the following: -The resident has experienced a muscle injury and increased pain after the 12/21/23 fall; -The resident also has a surgical issue in which the screw is sticking of the rod in the resident's hip which was probably jolted by the fall; -She would have expected staff to use a gait belt for transfers and ambulation. During an interview on 2/22/24 at 4:04 P.M. the Director of Nursing (DON) said staff should use a gait belt for all transfers and ambulation needing hands-on staff assistance. Not using a gait belt for a resident that needs hands-on assistance for transfers and ambulation could increase a resident's risk for falls.

Based on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility and was responsible for the management of the facility to ensure effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 59. Review of the facility's undated job description for Job Title: Administrator showed the following: -General Statement of Duties: Responsible for the general health, welfare and safety of the residents, for maintaining sufficient personnel care of residents, and for keeping the facility in a clean and orderly condition at all times. Responsible for maintaining a cheerful homelike atmosphere;- -Supervision Received: Reports directly to the Board of Directors; -Supervision Exercised: Supervises all departments within the facility; Nursing Home Administrator Duties: This list may not include all duties assigned; but not be limited to: 1. Administer all functions of the Nursing Home following applicable laws and regulations; 2. To be the liaison officer between the Board of Directors, facility staff, residents, families, the community, physicians, and all other facilities or persons who have reason to do business with the facility; 3. Make decisions regarding the operation of the facility and to carry out the requirements of the Department of Health and Senior Services necessary to comply with current regulations; 4. To select all Department Heads and coordinate and provide leadership to each department and ensure that they work together effectively; 5. Be responsible for the selection and firing of personnel and arranging for consultation services as required so that the needs of residents are met; 6. To attend all board meetings and provide current resident census, employee and financial information; 7. To inform the board of any major repairs or expenses needed in the operation of the facility; 8. To prepare an annual budget and make recommendations to the Board regarding rate increases or changes needed to maintain the facility financially solvent and also prepare the board budget annually; 9. Maintain morale among staff; 10. Maintain high standards of resident care. 11. Establish written policies and procedures regarding all aspects of the operation of the facility and regarding the rights and responsibilities of the residents; 12. Maintain records and reports as required and submitting of records and reports as may be required by the Department of Health and Senior Services and other agencies; 16. Be responsible for residents receiving continuing medical supervision, medications, and treatments. 1. Observation on [DATE] at 8:50 A.M. in the facility's front foyer showed the following: -A black board with a list of the facility's department heads; -The List noted an Interim Administrator: Interim Administrator/Human Resources (HR) Director. During an interview on [DATE] at 10:17 A.M. the Dietary Manager said she goes to the Interim Administrator/HR Director for day-to-day issues. During an interview on [DATE] at 10:15 A.M. the Director of Nursing (DON) said the following: -She goes to the Interim Administrator/HR Director for day-to-day issues; -She discusses hospital referrals, problems with staff, open staffing positions, etc. with the Interim Administrator/HR Director; -She has only seen the facility Administrator once since she assumed the DON position at the end of [DATE]. During an interview on [DATE] at 8:54 A.M. and 10:40 A.M. the Interim Administrator/HR Director said the following: -She started as Interim Administrator last week; -The previous Administrator quit in [DATE]; -Corporate Staff K was at the facility September-[DATE]; -Corporate Staff L came in [DATE] and stayed until February 12, 2024; -The Administrator is in the facility ,d+[DATE] times/month; -She doesn't have an administrator's license; -Her administrator's license is expired; -The corporation asked her to fill in as Interim Administrator; -The Administrator works for the corporation; -The facility is under a consulting agreement with the corporation; -Full time employee status is at least 30 hours a week; -The Administrator is employed by the corporation, not the facility; -The Administrator does not have an employee file; -She reports to the Corporate VP of Health Care Administration as she has been more involved in the facility. The Corporate VP of Health Care Administration is her day-to-day contact. During an interview on [DATE] at 2:30 P.M. the Corporate [NAME] President (VP) of Health Care Administration said the following: -She is not employed by the facility; -She is employed by the corporation; -The corporation is in an advisory agreement with the facility at this time; -She is currently interim administrator at another facility; -She tries to visit the facility ,d+[DATE] times/week; -The Interim Administrator/HR Director's title is HR director but she is currently sitting in as Interim Administrator; -She did not ask the Interim Administrator/HR Director to assume the role of Interim Administrator, she can't do that; -Only the facility's Board of Directors can appoint an Interim Administrator or Administrator. During an interview on [DATE] at 9:11 A.M. the Administrator said the following: -She is the corporation's Assistant [NAME] President of Operations; -On paper she is the facility's Administrator; -Her company is in a consulting agreement with the facility's Board of Directors; -She is not a paid employee of the facility; -She visits the facility every ,d+[DATE] days to meet the 30 day requirement; -The Corporate VP of Health Care Administration is coming to the facility on Mondays and Fridays; -Corporate Staff K is also coming to the facility occasionally; -Corporate Staff K tried to get a temporary administrator's license but could not as he already had one in the past; -Corporate Staff L was considered administrator when she was in the facility; -Corporate Staff L was supposed to get a Missouri Nursing Home Administrator license but she never did; -She is would not say she is aware of the day-to-day activities of the facility as she does not get a lot of communication from the facility; -She thinks the facility communicates a lot with the Corporate VP of Health Care Administration as she is more of the hands-on person; -She is not aware of the job duties in regards to being the facility's Administrator; -The facility has not provided her with the job duties of Administrator; -She has not attended any Quality Assurance (QA) meetings or board meetings; -Corporate Staff K attends the QA meetings; -She is not at the facility full time because that is not her job. She was only supposed to be filling in as the facility's Administrator until the position could be filled.

Based on observation, interview, and record review, the facility failed to ensure staff responded to call lights timely for four residents (Residents #1, #2, #3 and #4), in a review of seven sampled residents. Staff failed to accommodate the residents' needs for assistance, including assistance with toileting, which resulted in episodes of incontinence for four residents (Resident #1, #2, #3 and #4). The facility also failed to ensure one resident (Resident #6)'s call light was within reach which resulted in the resident not being able to call for staff assistance when he/she hadpain. Thee facility census was 59. The facility did not provide a policy regarding call light response time. 1. Review of the Residents' Council meeting notes dated 12/5/23 showed the following: -13 residents attended; -One resident said he/she had his/her light on for over an hour during supper and wanted to know why there wasn't someone on the floor answering lights; -One resident said his/her light has not been answered in a timely manner. He/she said sometimes it has been on for 30 minutes to an hour. Review of the Residents' Council meeting notes dated 1/2/24 showed the following: -11 residents attended; -One resident said his/her light has not been answered in a timely manner. He/She said sometimes it has been on for 30 minutes to an hour; -A couple of residents said that their call lights are not being answered in a timely manner. 2. Review of Resident #1's annual Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/11/24, showed the following: -The resident was cognitively intact; -He/She required moderate assistance by two or more staff for toileting; -He/She required moderate assistance by two or more staff for transfers; -He/She used a wheelchair. Review of the resident's Face Sheet, undated, showed the resident's diagnoses included congestive heart failure, depression, osteoarthritis, muscle weakness, and history of methicillin-resistant staphylococcus aureus in the urine (MRSA) infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections. Review of the resident's care plan, updated on 1/17/24, showed the following: -He/She was continent of bowel and bladder but needed extensive assistance with toileting. -He/She would use his/her call light for staff to assist him/her with toileting. Review of the resident's call light logs, dated 12/01//23 through 02/20/24 showed the following: -On 12/11/23 at 4:51 P.M., 34 minutes; -On 12/15/23 at 7:34 A.M., 37 minutes; -On 12/16/23 at 7:13 P.M., 56 minutes; -On 12/22/23 at 8:25 P.M., 34 minutes; -On 12/25/23 at 7:34 A.M., 54 minutes; -On 12/25/23 at 7:53 P.M., 58 minutes; -On 12/29/23 at 9:50 A.M., 1 hour and 37 minutes; -On 12/31/23 at 11:20 A.M., 1 hour and 3 minutes; -On 01/06/24 at 7:39 A.M., 32 minutes; -On 01/08/24 at 10:43 P.M., 37 minutes; -On 01/17/24 at 6:40 P.M., 44 minutes; -On 01/20/24 at 8:09 A.M., 36 minutes; -On 02/10/24 at 7:09 P.M., 31 minutes; -On 02/11/24 at 7:27 P.M., 32 minutes; -On 02/12/24 at 7:02 P.M., 39 minutes; -On 0213/24 at 10:02 A.M., 40 minutes; -On 02/13/24 at 4:08 P.M., 46 minutes. During an interview on 02/20/24 at 08:43 A.M., the resident said the following: -He/She needs staff assistance to go to the bathroom; -He/She has had episodes of bladder incontinence in the past, due to waiting for staff to answer his/her call light. 3. Review of Resident # 2's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She Required maximum assistance from two or more staff members for transfers and toileting; -He/She was frequently incontinent of bowel and bladder; -He/She used wheelchair with moderate assistance Review of the resident's Face Sheet, undated, showed the resident's diagnosis included peripheral vascular disease, Parkinson's disease (movement disorder), chronic obstructive pulmonary disease, and a history of urinary tract infection. Review of the resident's care plan, updated 01/04/24, showed the following: -He/She was frequently incontinent but required maximum assistance for toileting; -He/She would use call light for assistance with toileting Review of the resident's call light logs, dated 12/20/23 through 02/20/24, showed the following: -On 12/13/23 at 12:40 P.M., 30 minutes; -On 12/15/23 at 12:32 P.M., 46 minutes; -On 12/16/23 at 6:02 P.M., 1 hour and 18 minutes; -On 12/18/23 at 8:10 A.M., 36 minutes; -On 12/23/23 at 12:50 P.M., 37 minutes; -On 12/29/23 at 12:15 P.M., 36 minutes; -On 01/04/24 at 11:07 P.M., 46 minutes; -On 01/06/24 at 3:36 P.M., 1 hour and 9 minutes; -On 01/06/24 at 6:41 P.M., 1 hour and 18 minutes; -On 01/10/24 at 12:48 P.M., 32 minutes; -On 01/12/24 at 12:20 P.M., 34 minutes; -On 01/15/24 at 5:52 P.M. 37 minutes; -On 01/22/24 at 6:47 P.M., 39 minutes; -On 01/24/24 at 8:59 P.M., 40 minutes -On 02/11/24 at 6:05 P.M., 41 minutes; -On 02/14/24 at 6:08 P.M., 52 minutes. During interview on 02/20/24 at 09:00 A.M., the resident said the following: -They need more staff after supper; -He/She needs assistance with getting up and transferring; -He/She has had bowel and bladder incontinence due to staff not answering his/her call light timely. 5. Review of Resident # 3's quarterly MDS, dated [DATE], showed the following: -The resident had mild cognitive impairment; -He/She required maximum assistance for transfers and toilet use; -He/She was occasionally incontinent of bladder and bowel; -He/She used wheelchair. Review of the resident's Face Sheet, undated, showed the resident's diagnosis included muscle weakness, hemiplegia, hemiparesis (paralysis on one side) following cerebral infarction, chronic obstructive pulmonary disease and depression. Review of the resident's care plan, last updated 02/15/24, showed the following: -The resident was occasionally incontinent of bladder and bowel; -He/She needed extensive staff assistance for transfers and toileting; -The staff were to keep the call light within the resident's reach. Review of the resident's call light logs, dated 12/01/23 through 02/20/24, showed the following: -On 12/01/23 at 8:11 P.M., 21 minutes; -On 12/03/23 at 4:09 P.M., 24 minutes; -On 12/03//23 at 5:43 P.M., 24 minutes; -On 12/05/23 at 5:43 A.M., 24 minutes; -On 12/18/23 at 2:56 P.M., 23 minutes; -On 01/02/24 at 4:24 P.M., 21 minutes; -On 01/04/24 at 2:59 P.M., 24 minutes; -On 01/17/24 at 12:24 P.M., 24 minutes; -On 01/18/24 at 11:16 A.M., 21 minutes; -On 02/01/24 at 8:41 P.M., 30 minutes; -On 02/06/24 at 7:27 A.M., 33 minutes; -On 02/11/24 at 2:01 P.M., 22 minutes. During an interview on 02/20/24 at 09:55 A.M., the resident said the following: -His/Her call light is on for more than fifteen minutes throughout the day; -He/She transferred without assistance because he/she could not wait any longer; -The resident had sat in his/her recliner all night; the recliner was urine soaked and had to be removed and deep cleaned. Staff did not check on him/her during the night. 6. Review of Resident #4's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Lower extremity limitation in functional range of motion on both sides; -Required partial/moderate assistance for toileting hygiene, sit-to-stand transfers, chair transfers and toilet transfers; -Used a wheelchair; -Always incontinent of urine; -Frequently incontinent of stool; -Diagnoses of diabetes and heart failure; -Taking diuretic medication. Review of the resident's call light logs dated 12/1/23 through 1/7/24 showed the following: -On 12/1/23 at 4:13 P.M., 32 minutes 44 seconds; -On 12/2/23 at 1:07 P.M., 1 hour 21 minutes; -On 12/11/23 at 4:10 P.M., 51 minutes 42 seconds; -On 12/12/23 at 4:10 P.M., 44 minutes 56 seconds; -On 12/18/23 at 4:00 P.M., 49 minutes 7 seconds; -On 12/19/23 at 9:00 A.M., 57 minutes 26 seconds; -On 12/20/23 at 9:00 A.M., 47 minutes 23 seconds; -On 12/26/23 at 7:00 P.M., 55 minutes 41 seconds; -On 12/27/23 at 9:31 A.M., 40 minutes 1 second; -On 1/1/24 at 6:59 P.M., 46 minutes 16 seconds; -On 1/6/24 at 9:20 A.M., 1 hour 6 minutes; -On 1/7/24 at 8:38 A.M., 48 minutes 30 seconds; -On 1/7/24 at 7:02 P.M., 1 hour 23 minutes. Review of the resident's annual MDS dated [DATE] showed the following: -Cognitively intact; -Required partial/moderate assistance for toileting hygiene, sit-to-stand transfers, chair transfers and toilet transfers; -Used a wheelchair; -Occasionally incontinent of urine; -Diagnosis of urinary tract infection (UTI) in the last 30 days. Review of the resident's care plan dated 1/18/24 showed the following: -The resident is intermittently incontinent of bladder; -He/She needs extensive assistance with toileting; -He/She takes a fluid pill which increases his/her urinary urgency and frequency. Review of the resident's call light logs dated 1/22/24 through 2/20/24 showed the following: -On 1/22/24 at 11:28 A.M., 53 minutes 41 seconds; -On 1/23/24 at 4:09 P.M., 53 minutes 25 seconds; -On 1/27/24 at 12:49 P.M., 52 minutes 20 seconds; -On 2/1/24 at 4:40 P.M., 48 minutes 7 seconds; -On 2/5/24 at 4:56 P.M., 40 minutes 21 seconds; -On 2/13/24 at 7:38 P.M., 59 minutes 58 seconds. During an interview on 2/20/24 at 8:40 A.M. the resident said following: -Sometimes it takes 30 minutes to an hour for staff to answer his/her call light; -He/She takes a water pill (diuretic); -30 minutes to an hour was too long when he/she has to go to the bathroom; -Sometimes he/she doesn't make it to the bathroom on time. 7. Review of Resident #5's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Lower extremity limitation in functional range of motion on both sides; -Used a wheelchair; -Dependent on staff for chair to bed transfer and toileting hygiene; -Occasionally incontinent of urine; -Diagnoses of heart failure and diabetes; -Weight 351 pounds; -Taking diuretic medication. Review of the resident's care plan dated 1/4/24 showed the following: -The resident has had both his/her lower limbs amputated due to diabetes; -He/She needs extensive assist with activities of daily living (ADLs); -He/She uses the Hoyer lift (full body mechanical lift); -The resident is mostly continent of bowel and bladder, but he/she needs total assist with using a bed pan; -He/She will use his/her call light for staff to assist with toileting; Review of the resident's call light logs dated 1/30/24-2/8/24 showed the following: -On 1/31/24 at 8:46 A.M., 39 minutes 30 seconds; -On 2/2/24 at 8:28 A.M., 20 minutes 40 seconds; -On 2/2/24 at 6:51 A.M., 29 minutes 20 seconds. During an interview on 2/20/24 at 11:00 A.M. the resident said the following: -He/She needs staff to hold the urinal when he/she uses it; -He/She turns on the call light and if staff don't come promptly it's too late and he/she is incontinent; -He/She has been incontinent when waiting for staff to assist him/her with toileting and he/she doesn't like being incontinent. 8. Review of Resident #6's admission Minimum Data Set (MDS) dated [DATE] showed the following: -Cognitively intact; -Required partial to moderate assistance for toileting hygiene, sit to stand transfer, chair-bed to chair transfer and toilet transfer; -Required supervision or touching assistance for walking; -Used a wheelchair; -Always continent of bladder and bowel; -Diagnoses of hemiplegia/hemiparesis and depression; -Frequent pain; -Pain almost constantly affects sleep; -Pain intensity 9 (scale 0-10). Review of the resident's care plan revised 1/17/24 showed the following: -The resident has reported frequent chronic pain in his/her left hip and lower extremity; -He/She has interventions for pain. Administer or apply as needed and ordered; -He/She had a fall and broke his/her left hip. He/she is working with therapy; -He/She needs assistance with toileting and dressing; -He/She has weakness/deficits to his/her left side due to a stroke; -He/She has an unsteady gait; -Please keep his/her call light within reach; -He/She transfers with two staff members using a gait belt. During an interview on 2/20/24 at 9:51 A.M. the resident said the following: -A couple of nights ago he/she hurt so bad; -He/She reported his/her pain to the two night Certified Nurse Aides (CNAs) around 1:00 A.M.; -The two CNAs said they would tell the charge nurse about his/her complaints of pain but no one ever came; -The staff dropped his/her call light down on the floor and he/she couldn't reach the call light and call for help; -He/She told the staff around 1:00 A.M. that he/she was having pain, but he/she didn't receive any pain medication until day shift staff came on duty the next morning; -He/She couldn't call for help because he/she couldn't reach his/her call light; -The pain hurt real bad; -The resident was tearful during the interview. During an interview on 2/24/24 at 3:43 P.M. Nurse Aide (NA) I said the following: -The resident required assist of two and use of a gait belt for transfers and ambulation; -The resident had his/her call light on around 1:30-2:00 A.M.; -He/She and CNA J provided care to the resident and he/she left the room before CNA J; -He/She did not know whether the resident had his/her call light within reach because he/she left the room first; -The resident complained of pain around 1:30-2:00 A.M. and he/she reported the resident's complaints to Certified Medication Technician (CMT) G; -He/She assisted the resident up out of bed the next morning (Monday morning); -The resident complained of pain that morning and he/she told the charge nurse; -That morning the resident acted like he/she was having pain because he/she was grimacing, and making pain like noises, his/her mood was different. During an interview on 2/22/24 at 9:50 A.M. CNA J said the following: -The resident has left side weakness, he/she can't use his/her left hand too much and he/she requires assist of 1-2 staff for all activities of daily living (ADLs); -During the night the resident used his/her call light, went to the bathroom and he/she and NA H assisted the resident back to bed; -He/She went into the resident's room around 6:30 A.M. the next morning and the resident told them he/she didn't have his/her call light from around 1:30 A.M. to that time; -As he/she was covering the resident up in bed the resident's call light might have slipped or he/she might have knocked the call light off onto the floor; -He/She usually lays the call light over the bedside table or clips the call light on the pillow but he/she guesses he/she didn't that night; -He/She does not enter the resident's room unless the resident pushes his/her call light. During an interview on 2/22/24 at 10:49 A.M. CMT G said the following: -The resident is continent; -The resident is not checked every two hours; -The resident is cognitively intact and is able to make his/her needs known to staff; -The resident should have his/her call light within reach at all times; -He/She is dependent on staff for ADL assistance; -No one reported to him/her that the resident had increased pain and requested pain medication that night. During an interview on 2/21/24 at 3:20 P.M. the Assistant Director of Nursing (ADON) said the following: -The resident told CNA J he/she was hurting, CNA J left his/her room and said he/she would tell the nurse and be right back. No one came into his/her room until day shift staff came on duty; -She was not aware the resident couldn't access his/her call light; -Call lights should be within reach at all times. During an interview on 02/20/24 at 1:16 P.M., Certified Medication Technician (CMT) A said the following: -The ideal time frame is to respond to call lights within five minutes. -If call lights continue to go off on other halls and they have time and adequate staff for their hall, they should respond to call lights going off on other halls. During an interview on 02/20/24 at 4:00 P.M., the director of nursing said the following: -She expected call light response time to be as soon as possible, realistically it will take a few minutes; -She was not sure if anyone is monitoring call light logs; -If the call light alert is on after 20 minutes it will ring to his/ her cell phone, then he/she calls the facility to check on why it is not being answered; -She was aware there were some lengthy call light response times, and have had a staff meeting to discuss; -She was not aware of residents in resident's council meeting complained of lengthy call light response times.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility failed to ensure nursing staff performed appropriate hand hygiene during care for four residents (Residents #23, #35, #39, and #42); failed to ensure staff wore proper personal protective equipment (PPE) when providing care to one resident in isolation (Resident #39); failed to properly clean and disinfect a mechanical lift between residents with a transmissible conditions; and failed to store respiratory and oxygen equipment in a manner to protect it from contamination when not in use for four residents (Residents #1, #14, #33, and #35), in a review of 18 sampled residents and four additional residents. The facility census was 58. Review of the facility's undated handwashing policy showed all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing nose, after using the toilet, before handling food, and when hands become obviously soiled. Review of the facility's undated policy, Technique/Transmission Based Precautions, showed the following: -The director of nursing (DON), registered nurse supervisor, and charge nurse educate and supervise the staff in the maintenance of isolation techniques; -Charge nurse will post Red Hand on resident doorway, informing visitors to inquire at nurse's station before entering room; -Protective apparel and supplies will be placed immediately inside the resident room for donning (putting on) upon entrance; A. Supplies include but are not limited to: a) Disposable gown; b) Masks; c) Gloves. -Gowns are indicated when providing care to a resident on isolation precautions if clothes are likely to be soiled with secretions or excretions: A. Water resistant disposable gowns are used; B. Gowns are worn once and discarded in the proper receptacle; C. If gown becomes wet while caring for a resident, it is discarded immediately. -Wearing gloves does not replace the need for hand washing; -Hand washing is the single most important means of preventing the spread of infection. Wash hands before and after providing resident care. Review of the facility's undated policy, Using Gloves, showed the following: -Gloves should be used: 1. When touching excretions, secretions, blood, body fluid, mucus membranes or non-intact skin; 2. When handling potentially contaminated items; 3. When it is likely that hands will come in contact with blood, body fluids, or other potentially infectious material; -Wash hands after removing gloves. Gloves do not replace handwashing. Review of the facility's Nebulizer Maintenance policy, dated 10/1/12, showed equipment should be stored in a plastic bag to prevent contamination. Review of the facility's undated policy for Portable Oxygen Concentrator, showed no instructions regarding storage or oxygen tubing and nasal cannulas when not in use. 1. Review of Resident #35's nurse progress note, dated 4/7/23 at 3:10 P.M., showed urinalysis resulted in extended spectrum beta-lactamase (ESBL) (an enzyme making the germ harder to treat with antibiotics) Klebsiella pneumonia (common bacteria often living in the intestines that can be dangerous if found in other parts of the body) urinary tract infection (UTI). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/6/23, showed the following: -The resident had severe cognitive impairment; -He/She required extensive assistance of two staff members for transfers and toilet use; -He/She was always incontinent of bladder; -He/She received supplemental oxygen. Review of the resident's care plan, dated 8/16/23, showed the following: -The resident had an order for breathing treatments (use medication to fight infections, remove mucus, dilate parts of the respiratory system, and improve breathing). -The nursing staff transferred the resident with extensive assistance using the stand-up lift; -The resident was usually incontinent of urine; -The resident required total assist with incontinence care; -No documentation the staff placed the resident in contact isolation for a UTI with ESBL. Review of the resident's physician orders, dated September 2023, showed the following: -Ipratropium-albuterol solution [bronchodilator (relaxes the muscles in the lungs and widens the airways) combination] for nebulization 0.5 milligrams (mg)-3 mg/3 milliliter (ml), administer one vial per nebulizer inhalation four times a day for wheezing; -Ipratropium-albuterol solution for nebulization 0.5 mg-3 mg/3 ml, administer one vial per nebulizer inhalation three times a day as needed. -Cefpodoxime (an antibiotic) 200 mg, administer one tablet orally twice a day with meals; -Contact precautions for ESBL in urine. Remind staff to wear gown and gloves when providing toileting assist. Special instructions: gown/gloves outside room with trash container kept in room until 2 negative specimens have been collected. Observation on 9/10/23 at 10:13 A.M., showed the following: -Personal protective equipment cart sat in the hallway outside of the resident's room; -A sign hung on the resident's doorframe with a red hand (meaning stop before going into room). Observation on 9/10/23 at 10:13 A.M., showed the nebulizer kit and mask sat on the nebulizer machine on the resident's bedside table, and were open to air. During an interview on 9/10/23 at 10:13 A.M., Registered Nurse (RN) A said the resident had ESBL in his/her urine. Observation on 9/10/23 at 10:48 A.M., showed the following: -Certified Nurse Assistant (CNA) A and CNA B entered the resident's room and did not put on a disposable gown for contact isolation; -The staff told the resident to grab the handles of the stand-up lift. (The resident did not perform hand washing nor use hand sanitizer prior to grabbing the handles of the lift); -The resident's pants were wet on the creases of the groin and on the buttocks; -CNA B cleaned the resident's buttocks and posterior inner thighs with disposable wipes; -CNA B removed his/her gloves, washed his/her hands, and left the room; -CNA A removed his/her gloves and left the room, without washing his/her hands; -CNA A returned to the resident's room, did not wash his/her hands, and put on clean gloves. He/She assisted the resident to put on clean incontinence brief and clean pants, and then took the stand-up lift from the resident's room to the storage room. CNA A did not clean or sanitize the lift prior to taking it out of the resident's room. During an interview on 9/11/23 at 9:49 A.M., CNA A said the facility had one stand-up lift for residents on the 400 and 600 halls. Observation on 9/11/23 at 1:58 P.M., showed the resident sat in the recliner in his/her room. The nebulizer kit and mask, connected to the nebulizer machine, was left open to air on the resident's bedside table. Observation on 9/12/23 at 6:50 A.M., showed CNA A took the stand-up lift out of another resident's room (the resident was on contact isolation for vancomycin-resistant Enterococcus (VRE) (type of bacteria that is resistant to many antibiotics, including vancomycin) in the urine) and put it back in the storage area. CNA A did not clean the lift prior to placing it back in storage. Observation on 9/12/23 at 7:00 A.M., showed the following: -CNA D took the stand-up lift to the resident's room (after using it to transfer the resident on contact isolation for VRE); -CNA D and CNA A used the stand-up lift to transfer the resident from his/her bed to wheelchair. During an interview on 9/12/23 at 11:54 A.M., CNA D said the staff did not clean the stand-up lift after leaving a contact isolation room, but should have since the resident had VRE infection in the urine and staff had assisted the resident to toilet. During an interview on 9/12/23 at 1:10 P.M., CNA A said the following: -He/She washed his/her hands before resident contact and after removing gloves; -He/She was not aware he/she did not change gloves or wash hands between clean and dirty tasks, but said he/she should have done both; -He/She forgot to wear an gown in Resident #35's room (the isolation room for ESBL); -He/She did not clean the stand-up after use in an isolation room, but probably should have since the resident and staff touched it. 2. Review of Resident #39's significant change MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -He/She was dependent on two staff for bed mobility, transfers, and toilet use; -He/She was always incontinent of bladder and bowel. Review of the resident's care plan, dated 8/11/23, showed the following: -The resident required total assist with bed mobility; -He/She was incontinent of bladder and bowel and did not use the toilet anymore; -He/She required total assist to be cleaned after an incontinent episode; -He/She required a mechanical lift with transfers. Observation on 9/11/23 at 10:07 A.M., showed the following: -CNA E unfastened the resident's wet incontinence brief and pushed it down between the resident's legs; -CNA A wiped the resident from mid-perineum down through the gluteal cleft (the groove between the buttocks that runs from just below the tail bone to the perineum) using disposable wipes; -CNA A grabbed ahold of the wipes package with his/her gloved hands as he/she pulled out disposable wipes from the package between each wipe; -CNA E removed the resident soiled incontinence brief, and without removing his/her gloves, pulled the right side of the clean brief out from under the resident. During an interview on 9/12/23 at 11:15 A.M., Licensed Practical Nurse (LPN) F said the staff were to wash hands after removing gloves, when hands were visibly dirty, and before leaving an isolation room. 3. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She received oxygen therapy. Review of the resident's care plan, updated 7/5/23, showed the following: -The resident completed most of his/her ADLs independently; -No documentation the resident received supplemental oxygen. Review of the resident's physician orders, dated September 2023, showed an order for oxygen at 2 liters (L)/nasal cannula (NC) to keep saturation above 92%. Observation on 9/10/23 at 10:16 A.M., showed the resident's nasal cannula was wrapped up and stuffed between the resident's recliner cushion and the left arm of the recliner. The cannula was not covered or stored in a bag. During an interview on 9/10/23 at 10:16 A.M., the resident said the following: -He/She wore the oxygen at night; -He/She kept the oxygen cannula next to him/her so it was easy to find at bedtime; -If the staff offered something to store the nasal cannula, then he/she would use it. Observation on 9/11/23 at 10:40 A.M., showed the resident sat in recliner chair with the nasal cannula wrapped up between him/her and the arm of the recliner. The nasal cannula was not covered or stored in a bag. 4. Review of Resident #1's face sheet, undated, showed the resident's diagnoses included chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident has severely impaired cognition; -No documentation the resident received oxygen therapy. Review of the resident's physician orders, dated September 2023, showed the following: -Apply oxygen at 2 L/NC to maintain oxygen saturation greater than 92%; -Ipratropium-albulterol solution for nebulization, 0.5 mg-3 mg, 1 vial, inhalation, as needed. Observation on 9/11/23 at 9:15 A.M. showed the resident was asleep in the recliner and was covered with a blanket. The resident's nasal cannula lay on top of the blanket and was not covered or in a bag. Observation on 9/11/23 at 9:50 A.M. showed the following: -The oxygen concentrator in the resident's room was not on. The tubing lay across the top of the machine and was not in a storage bag; -The resident's nebulizer mask dangled across the bedside table and was not covered or in a storage bag. 5. Review of Resident #33's face sheet, undated, showed the resident's diagnoses included obstructive sleep apnea (intermittent airflow blockage during sleep), acute bronchitis due to other specified organisms (caused by infection of the large airways commonly due to viruses) and dementia. Review of the resident's care plan, updated 7/13/23, showed the resident has a continuous positive airway pressure (CPAP; a machine that uses mild air pressure to keep breathing airways open while you sleep) that he/she is to wear at bedtime and when he/she is napping. Review of the resident's physician orders, dated September 2023, showed an order to wear CPAP when sleeping and with any daytime naps. Observation on 9/11/23 at 9:43 A.M. showed the resident sat in wheelchair. The resident's CPAP mask lay face down on the bedside table. The mask was not covered or stored in a bag. Observation on 9/13/23 at 8:16 A.M. showed the resident's CPAP mask lay on the bedside table and was not covered or stored in a bag. During an interview on 9/12/23 at 11:15 A.M., Licensed Practical Nurse (LPN) F said the following: -The nurse was to put the nebulizer kit back in the individual resident box with a lid when not in use; -The staff were to put oxygen cannula/tubing in a box or bag when not in use. 6. Observation on 09/11/23 at 11:15 A.M. showed the following: -Certified Medication Technician (CMT) J opened and emptied an albuterol sulfate solution (a medication that helps to open the airways of the lungs) vial into a nebulizer mask (a specialized mask that has a device attached to allow a liquid medication to become a mist that is easily inhaled) and assisted Resident #42 to place it over his/her face, left the room and entered Resident #23's room; -He/She did not wear gloves and did not wash his/her hands or use hand sanitizer before or after the medication administration for Resident #42; -CMT J entered Resident #23's room, placed the resident's oxygen nasal tubing into the resident's nose, assisted the resident to reposition in bed by lifting his/her feet into the bed, checked the resident's oxygen level with the pulse oximeter, picked up the resident's Bipap mask (a specialized mask that helps to deliver pressurized air into the airways of the lungs), placed it on the resident's head, adjusted it, and left the room; -He/She did not wear gloves or wash his/her hands or use hand sanitizer before or after assisting Resident #42 with his/her care; -CMT J said he/she probably should have used hand sanitizer between resident care. 7. Review of the facility's Legionnaire's Policy, dated September 2018, showed the following: -Potential hazards/Areas where Legionella can grow and spread: -City water; -Decorative fountain (outside); -Ice machine in the kitchen; -Sinks (in every resident room, public bathrooms, shower rooms, kitchenettes, and main kitchen); -Whirlpool tubs (shower room on [NAME] Creek and Crooked Creek); -Water heaters-three in boiler room; -Water heater-in the special needs units (SNU) kitchen; -Water storage tank (boiler room); -Sewer; -Hydrocollator (a liquid heating device that is used in physical therapy to heat and store hot packs for therapeutic uses) (therapy room); Water Management Team: -Maintenance Supervisor; -Administrator; -Director of Nursing (DON); -Infection Preventionist Nurse; -Monitoring: -Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth are not occurring; -Water heaters should be maintained at appropriate temperatures; -Decorative fountains should be kept free of debris and visible biofilm; -Disinfectant and other chemical levels in cooling towers and hot tubs should be maintained and regularly monitored. Whirlpools are cleaned with disinfectant between resident uses; -Surfaces with any visible biofilm (slime) should be cleaned. Shower rooms, sinks and whirlpools are cleaned at least daily; -Staff should inform the maintenance supervisor when disinfectants are running low or when there are changes in the equipment or changes in the appearance of the water. During an interview on 09/13/23 at 11:20 A.M., the maintenance supervisor said the following: -He was not aware of or responsible for the facility's assessment or monitoring for Legionnaire's Disease (LD); -The administrator was responsible for the water management program; -He records water temperatures in one room on each side of the resident halls after allowing the water to run for two minutes, one time each week and he alternates the rooms each week; -Hot water temperatures should register between 105-120 degrees Farenheit; -He did not check water temperatures in the resident shower rooms, staff bathrooms or kitchen. 8. During an interview on 9/13/23 at 10:00 A.M. and 5:00 P.M., the Director of Nursing said the following: -The maintenance supervisor was responsible for the facility's water management program regarding Legionella; -She expected all staff to wash their hands prior to and after removing gloves when providing personal care to a resident; -She expected the medication nurse to use hand sanitizer or wash his/her hands between dispensening medication to each resident; -She expected staff to wipe down/clean the Hoyer lift and/or stand-up lift in between use with residents, including residents with a communicable infection; -She expected staff to wear a gown and gloves when toileting residents with VRE and ESBL infections; -Staff was to store oxygen tubing, nebulizer and CPAP masks and tubing in a container or in a plastic bag. 45563 46506 47246

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of five residents, a resident with diagnosis of dementia and anxiety ,received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. Staff failed to investigate underlying causes of the resident's agitation and anxiety. Staff failed to develop and implement individualized interventions for the resident which caused the resident emotional distress when staff routinely woke him/her prior to 6:00 A.M. against the resident's wishes and for the purpose of staff convenience. Staff administered an antipsychotic medication on two occasions due to the resident's increased anxiety and subsequent behaviors following an incident when staff woke the resident against his/her wishes. The facility also failed to obtain the resident's history and prior level of functioning on admission to identify appropriate goals and interventions and create a plan of care for the resident and failed to identify his/her response to stressors, including waking the resident from sleep early in the morning and the resident's fear of transferring with the mechanical lift (a device used to move a resident from one surface to another). This caused the resident continued anxiety and emotional stress. The resident worried during the night, was fearful of the mechanical lift and staff documented he/she cried and was tearful in the mornings and required time to calm down after getting out of bed. On two occasions staff documented administration of an antipsychotic injectable medication not appropriate for residents with dementia for increased anxiety and agitation as a result of staff transferring the resident with the mechanical lift. The facility census was 57. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 at 2:00 P.M. which began 3/2/23. The IJ was removed on 4/26/23 7:00 P.M. as confirmed by surveyor onsite verification. During interview on 4/25/23 at 5:40 P.M. the administrator said the facility did not have a policy regarding dementia care and treatment or behavioral health care treatment and services. 1. Review of Resident #1's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 1/19/23 showed the following: -Moderately impaired cognition; -No hallucinations or delusions; -Physical and verbal behavioral symptoms directed toward others was not exhibited; -Other behavioral symptoms not directed toward others (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days; -Required extensive assistance of two staff members with bed mobility and dressing; -Required total assistance of two staff members with transfers and toileting; -Required a wheelchair for mobility; -Very important for the resident to choose what clothes to wear and chose his/her own bedtime. Review of the resident's Physician Order Sheet (POS) dated February 2023 showed the following: -Diagnosis of dementia with anxiety, anxiety disorder, chronic pain. and history of falling; -On 2/1/23 check blood sugar before meals three times daily at 6:00 A.M., 11:30 A.M. and 4:30 P.M.; -On 2/3/23 Buspar (medication used to treat anxiety) 15 milligrams (mg) three times daily for anxiety; -On 2/27/23 Remeron (medication used to treat depression) 15 mg daily at bed time for depression. Review of the resident's Care Plan dated 3/1/23 showed the following: -The resident had dementia and moderate anxiety. Staff should report to the nurse if the resident was anxious or had changes in mental status; -The resident was known to become very anxious and emotional and at times scream when working with staff. Staff should redirect as needed; -The resident was cognitively intact. Staff should orient the resident as needed and report any confusion or changes in cognition to the nurse; -The resident had an overall decline in Activities of Daily Living (ADLs). Staff should provide assistance with transfer, the resident transferred better with one staff member due to anxiety. He/She had chronic knee pain, staff should be patient as he/she moved slowly; -The resident was a high risk for falls. Staff should keep the resident's call light in reach. - The care plan did not include the use of Haldol as a intervention or the parameters for its use. Review of the resident's nurses' note dated 3/2/23 at 6:54 A.M., showed staff documented the resident threw things, ripped up a magazine, screamed and attempted to throw himself/herself on the floor from the wheelchair. The resident was currently on the mechanical lift sling (a mobile transfer device used to move a resident from one surface to another with the resident placed in a sling, elevated off the surface and lowered onto another surface) due to refusing to stand on the previous shift. Two staff attempted to lift the resident back in the chair to prevent a fall, the resident screamed, kicked, hit and pinched the staff. Additional staff assistance was called, required five staff members to transfer the resident to the recliner. The physician was notified and order received for Haldol (antipsychotic medication) 5 milligrams (mg) injection now. Haldol was administered, the resident remained combative, called staff names and screamed for everyone to go to hell. The resident required one on one care and told staff she did not care if he/she got hurt or hurt anyone else. Review of the resident's Physician Order Sheets dated 3/2/23 showed Haldol 5 mg injection now for one dose. Review of the resident's Medication Administration Record dated 3/2/23 showed staff documented Haldol 5 mg injection administered. Review of Drugs.com showed the following regarding Haldol: -An antipsychotic medication used to treat schizophrenia (a mental illness causing hallucinations and delusions); -Not approved for use in older adults with dementia-related psychosis; -Might increase the risk of death in older adults with dementia-related psychosis; -Common side effects might include drowsiness, headache, dizziness, feeling restless or anxious, and sleep problems. Review of the resident's nurses' showed staff documented the following: -On 3/2/23 at 1:56 P.M., the resident rested with eyes close in recliner most of the day after 8:00 A.M. and then he/she ate lunch. Staff transferred the resident to the wheelchair with the mechanical lift and assisted him/her to the table. The resident remained sharp and short with staff but sat at the table in the wheelchair with no current negative behaviors; -On 3/3/23 at 4:59 A.M. the resident would not stand on 3/1/23 or 3/2/23. Staff had to use the mechanical lift. He/She would not stand up with the walker, yelled and screamed and carried on. The resident would not put his/her legs in a position where it was safe to transfer with the walker and gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair). Review of the resident's POS dated 3/7/23 showed and order to decrease Buspar to 15 mg twice daily at breakfast and bedtime. Review of the resident's nurses' notes showed staff documented the following: -On 3/14/23 at 5:50 P.M. at the start of the shift, another resident picked up a plant that Resident #1 believed was his/hers. The plant was returned. This started aggression and irritation. At supper he/she refused the meal and refused drinks, the resident would not eat. He/She began to say there were more cars coming and going and something bad was happening. He/She said it's something deadly, began to yell, and had extreme agitation and delusional thoughts with visual hallucinations. Refused all care and was suspicious of all staff. The physician was notified and orders received for Haldol 5 mg injection for one dose. Review of the resident's Physician Order Sheets dated 3/14/23 showed Haldol 5 mg injection now for one dose. Review of the resident's Medication Administration Record dated 3/14/23 showed staff documented Haldol 5 mg injection administered. Review of the resident's nurses' notes showed staff documented the following: -On 3/24/23 at 5:27 A.M., staff transferred the resident to get out of bed and he/she would not stand up, pulling buttocks in. The staff had to turn the resident without the resident's help. This was happening most every morning to get the resident out of bed. It was a hard transfer. Used the mechanical lift to get resident up to wheelchair that morning; -On 4/3/23 at 5:57 A.M., the resident laid in bed crying around 5:30 A.M. staff asked the resident what was wrong. The resident said he/she just wanted to get up so staff tried to dress the resident and he/she still cried and screamed. Staff asked what was wrong and why the resident still cried. The resident said he/she liked to cry. As three staff members tried to get the resident to stand, the resident cried and screamed and would not stand with three staff trying to help. Instead the resident pushed himself/herself backwards, bent over while holding onto the walker and about hit his/her face on the walker. The resident propelled himself/herself down the hall to the dining area and continued to scream and cry, then yelled at other residents to shut up; -On 4/6/23 at 11:14 A.M., night shift staff reported that morning the resident refused to allow staff to get him/her up that morning and requested to remain in bed. Staff also reported they attempted to stand the resident and the resident became agitated and refused to get up. The resident required maximum staff assistance of three staff members and a gait belt to get up and into the wheelchair. The resident refused medications and breakfast initially but eventually took the medications and ate breakfast; -On 4/10/23 at 2:21 P.M., the resident was pleasant with staff all day. Pivot transferred multiple times in the bathroom with stand by assistance to minimal assistance of one staff member. He/She continued to be a difficult transfer from bed to wheelchair in the mornings when night shift attempted to get the resident up for breakfast. The resident verbalized that he/she was afraid he/she would be forced to use the mechanical lift for transfers. The charge nurse assured the resident they would continue to work on his/her confidence as well as strength and endurance with transfers and would not use a mechanical lift unless the resident's safety or staff safety was an issue; -On 4/11/23 at 5:46 A.M., staff requested the charge nurse witness the resident's transfer. The resident screamed no I can't do it, dropped his/her buttocks below the level of his/her knees and refused to stand for the transfer. The charge nurse educated the resident this method of transfer was unsafe for the resident and the staff; -On 4/11/23 at 3:54 P.M., the resident continued to be a very difficult bed to wheelchair transfer in the mornings putting both resident and staff safety at risk. The physician witnessed the resident transfer from wheelchair to the toilet. The resident stood, held the grab bars in the bathroom with verbal cues from the staff to look up. The resident stood and supported his/her own weight with no needed physical assistance and sat on the toilet without difficulty. The resident did not have grab bars near the bed. The physician ordered nursing to collaborate with therapy to transition from mechanical sling lift to mechanical sit to stand lift (a mechanical transfer device with a strap secured around the resident's chest and fastened to a movable bar with legs and feet strapped to the base. The resident is lifted to a standing position as the bar is raised turned and lowered to another surface) if appropriate. Review of the resident's POS dated 4/11/23 showed mechanical sit to stand lift for bed to wheelchair transfers in the mornings. Review of the resident's care plan showed no updated interventions or staff direction regarding the resident's transfer status and behavior management. Review of the resident's nurses' notes showed staff documented the following: -On 4/12/23 at 5:27 A.M., staff attempted to use the mechanical sit to stand lift for transfer into the wheelchair from bed. The resident yelled and screamed out during the entire transfer and hung by his/her arms and could not hold himself/herself up onto the lift. Staff asked the resident if it hurt to use this lift and the resident said no, he/she yelled out because he/she could; -On 4/13/23 at 1:30 P.M., staff documented the resident was very upset and sobbing at 6:00 A.M. that morning, was not able to verbalize what he/she was upset about but said, I'd be better off dead. Spoke with the resident at length but was only able to comfort him/her enough to get him/her to stop crying. The resident eventually laid his/her head on his/her arms on the breakfast bar and continued to cry until about 7:30 A.M. when the resident finally agreed to eat some breakfast. After breakfast the resident gradually returned more to his/her normal self. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Other behavioral symptoms not directed toward others (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days but less than daily. Review of the resident's nurses' notes showed staff documented the following: -On 4/14/23 at 4:58 P.M., staff documented the resident was tearful that morning at 6:00 A.M., crying quietly at his/her table alone. Spoke with the resident who declined to discuss why he/she was crying. The resident agreed to coffee and orange juice. He/She eventually stopped crying and received his/her breakfast; -On 4/17/23 at 6:49 A.M., Certified Medication Technician (CMT) A documented at 5:00 A.M. he/she went into the resident's room to get the resident's blood sugar (finger stick blood test). The resident became very snarky and mumbled under his/her breath that CMT A did not need to check anything. CMT A asked the resident if he/she could check the resident's blood sugar and the resident started screaming, crying and smacked everything out of CMT A's hands. CMT A asked the resident what was wrong and why he/she was being hateful that morning. The resident responded he/she liked to be hateful. The resident started screaming at CMT A. CMT A told the resident that was uncalled for and inappropriate, the resident screamed he/she did not care. CMT A then called the charge nurse Licensed Practical Nurse (LPN) D over to observe the resident's behavior. LPN D tried to obtain the resident's blood sugar, the resident still refused and was very vulgar and hateful, while he/she laid there kicking his/her legs out of the bed and continued to scream at the top of his/her lungs and cried out. CMT A then again asked the resident what was wrong, the resident said he/she was playing. CMT A asked the resident what he/she was playing, the resident said playing house. CMT A repeated to the resident you are playing house? The resident replied yes then continued to scream and cry; -On 4/18/23 at 4:58 A.M., staff bed checked the resident and told the resident he/she was wet and staff needed to change the resident's soiled brief. Staff began to roll the resident and he/she yelled out and said I can't. Staff continued to change the resident as he/she continued to yell out the entire time; -On 4/18/23 at 8:14 A.M., the resident was in his/her wheelchair after a mechanical stand up lift transfer. The resident continued to yell out. When asked what was the matter the resident said nothing. Staff continued to get the resident ready for the day and he/she continued to yell out; -On 4/18/23 at 8:55 A.M., the Director of Nurses (DON) documented the night shift reported the resident was agitated and yelled out since Buspar was decreased in March. The resident refused to use the mechanical stand up lift. The physician was notified and orders received to increase Buspar back to three times daily and therapy evaluate and treat for transfers. Review of the resident's POS dated 4/18/23 showed Buspar 15 mg three times daily for anxiety. Review of the resident's care plan showed no updated interventions or staff direction regarding the resident's transfer status and behavior management. Review of the resident's nurses' notes showed staff documented the following: -On 4/18/23 at 2:22 P.M., the resident was quiet and tearful at 6:00 A.M. that morning. He/She did not offer a reason and would not answer when asked what was wrong. Staff gave the resident time to have coffee alone and sob. At 7:00 A.M. the resident ate breakfast. Pleasant throughout the rest of the day, bathroom transfers with stand by staff assistance; -On 4/20/23 at 10:42 A.M., the resident was very upset and angry early that morning, would not talk with staff or make needs known. Gradually became more pleasant and interactive with staff. During interview on 4/21/23 at 9:15 A.M. the DON said the resident had increased anxiety and behaviors at night. Night shift was responsible to get the resident up before the end of the shift (6:00 A.M.) During the night the resident refused to get up, he/she was difficult to get up. On day shift the resident did better. Staff used the mechanical lift in the night to transfer the resident. During interview on 4/21/23 at 10:50 A.M. LPN C said the following: -He/She was the care plan coordinator and charge nurse; -The resident was cognitively intact and very much alert and oriented, he/she had dementia with anxiety and lived on the locked special care unit (SCU); -The resident hollered out frequently and had fear with transfers and fear of falling. He/She required one staff member assistance with transfers. The resident hollered out and was anxious during transfers; -Staff should approach the resident calmly and help the resident rest and remain calm. Night shift staff woke the resident early in the morning and got the resident up for the day before the end of the night shift (6:00 A.M.). The resident had increased anxiety during the night, but night shift staff woke the resident and got him/her up early. Breakfast was at 7:00 A.M.; -He/She did not know how night shift approached the resident. There was no specific care plan interventions for night shift regarding the resident's anxiety and fear with transfers; -The resident's Buspar was increased for the anxiety; -No new interventions were added to the resident's care plan following the increase in Buspar and therapy evaluation and no new interventions for staff to allow the resident to remain in bed if he/she was resting. Observation on 4/21/23 at 10:55 A.M. showed the resident sat in a wheelchair in the common dining area of the SCU near the front windows. During interview on 4/21/23 at 11:00 A.M. the resident said the following: -He/She worried at night, about going home and what will happen. Staff get him/her up by 6:00 A.M. every day and used the mechanical lift to get out of bed, he/she hated the thing (mechanical lift). Staff say they can use the lift even if he/she does not like the lift. Staff say to each other they are not going to put up with him/her. He/She heard what staff said. He/She did not like it. Staff would not let him/her sleep any longer, they have to dress him/her. Staff put his/her pants on about to the knee during the night, until they get the lift. Then they put the sling underneath him/her and transfer him/her to the wheelchair. They pull his/her pants up after getting in the wheelchair. Staff stand him/her up and pull up his/her pants. The mechanical lift was painful and stressful, it made him/her feel like he/she was not good enough and staff did not want to work with him/her; -He/She had fallen a lot at home; -The staff were pretty awful, they said they were not going to break their backs over him/her. Staff woke him/her between 3:00 A.M. and 4:00 A.M. for blood sugar checks, he/she hollered out after that and said I'm not ready for this. Staff tell him/her to Be quiet, you don't have to be like this; -He/She preferred not to use the mechanical lift, it usually happened every night. During interview on 4/21/23 at 11:20 A.M. CMT G said staff woke the resident between 4:45 A.M. and 5:00 A.M. and checked the resident's blood sugar. There was no reason staff had to wake the resident and staff should not force the resident to get out of bed. Staff now use a mechanical lift transfer in the early mornings, the rest of the day one or two staff could assist the resident with a pivot transfer. The resident did not usually holler unless staff was getting her up. During interview on 4/21/23 at 11:45 A.M. LPN I said the resident was tearful through breakfast that morning and tearful most mornings. The resident wanted to sleep in and night shift staff did not let her sleep in. After breakfast the resident laid his/her head on the table. It took a while after the resident got up in the morning for him/her to calm down. During interview on 4/21/23 at 3:40 P.M. LPN B said the following: -He/She was the SCU day shift charge nurse; -The resident usually had behaviors in the early mornings. The resident did not like the mechanical lift or getting up early. There was no reason for night shift to wake the resident. Observation on 4/25/23 at 10:05 A.M. showed the resident asked to use the toilet. The resident sat on a mechanical lift sling pad in the wheelchair. The resident grabbed the bathroom grab bar and stood with one staff member assistance and pivoted to the toilet. The resident remained on the toilet and yelled out when finished. The resident stood with one staff member assistance and pivoted back to the wheelchair. The resident hollered I can't during the transfers. During interview on 4/25/23 at 10:45 A.M. LPN H said early mornings were rough for the resident. Staff started getting residents up between 5:00 A.M. and 6:00 A.M. every morning. Resident #1 struggled in the mornings. It mattered how staff approached the resident; some went in and told the resident what they wanted or planned to do,. If the resident hollered staff should wait, switch staff and let the resident settle down. The resident got anxious. Staff started getting residents up early to work for the nurses' schedules. If staff check the resident's blood sugars early it was because of the need to get everything done by the end of the shift. The resident's behavior depended on how the staff approached the resident. During interview on 4/25/23 at 11:15 A.M. the Physical Therapist said the resident could transfer with a walker when secured by staff for stability. He/She was not sure why night shift staff could not transfer the resident or why the resident had to get up so early. The resident hollered, but hollering did not mean the resident could not do the transfer. Staff should be consistent. The resident hated the mechanical lift, it hurt the resident and the resident did not like being made to do something. During interview on 4/25/23 at 3:00 P.M. the resident said it was a bad morning, he/she had a hard time in the mornings. Staff woke him/her at 4:00 A.M. or so to check his/her blood sugar, he/she preferred not to wake up that early. He/She liked his/her bed and wanted to get up around 6:00 A.M. or so. He/She did not want staff to use the mechanical lift, he/she hated the lift. Staff used the mechanical lift this morning because he/she was upset after they woke him/her. Finally he/she told the staff go ahead just get the mechanical lift and they got him/her up with the lift. Staff talk about him/her and he/she could hear them. Staff don't do what he/she asks and today he/she finally just said fine, get the lift. During interview on 4/25/23 at 5:03 P.M. CNA F said the following: -Resident #1 was hard to deal with, he/she screamed, yelled, and cried when staff woke him/her in the night. The resident was alert and oriented, aware of his/her surroundings and got anxious and agitated in the early morning. When staff asked if the resident was ready to get up, he/she usually said no; -Night shift bed checks were between 10:30 P.M. to 11:30 P.M. and 1:30 A.M. to 3:30 A.M. During bed checks staff woke the resident, turned the lights on, changed the resident if soiled and turn the lights off; -At 3:30 A.M., staff routinely woke the resident for bed check and put the resident's pants partially on, up to the knees or thighs. Partially dressing the resident helped the staff with the 5:00 A.M. routine of getting residents up for the day. There were three residents night shift got up every day before 6:00 A.M. on the SCU; -When staff woke the resident in the night, the resident screamed and said no he/she did not want to get up. When the resident cried or yelled, he/she went in frequently and checked on the resident asking what the resident needed. It was hard to figure out why the resident was crying and upset; -If the resident was upset he/she would not do anything for the staff or try to help his/herself. Early in the morning the resident screamed and cried saying I can't with his/her buttocks stuck out and bent at the waist when night shift staff attempted a pivot transfer. The resident was grouchy. It was a morning thing, morning was not a good time for the resident; -Staff did say to the resident if you cannot stand up to transfer we will have to get the lift (mechanical lift). Staff tell the resident he/she is going to hurt their backs; -At 5:00 A.M. to 6:00 A.M. staff got the resident dressed and up out of bed. The resident usually laid flat in bed and cried while staff got him/her up. CNA F said he/she did not know what the resident's deal was. If the resident liked the staff member, he/she tried harder to please the staff member; -CNA F did not know the resident was afraid of the mechanical lift and afraid of falling; -There was no direction on how to care for the resident, no one had shown staff how to transfer the resident with a gait belt and the walker; -No one had directed CNA F on interventions for the resident, the resident just needed to be up by 6:00 A.M. During interview on 4/25/23 at 3:15 P.M. the resident's family member said the following: -The resident cried out when he/she was afraid and had anxiety with transfers. Staff should be calm with the resident; -He/She was anxious in the mornings and was that way before the resident came to the facility. If staff let the resident sit and settle down, he/she did better; -Staff had not asked him/her about the resident and how to care for him/her. He/she cared for the resident at home prior to facility admission; -The resident hated the mechanical lift, the lift made the resident anxious, he/she cried and was afraid. Using the lift caused the resident increased anxiety and fear; -At home, the resident sat on the side of the bed for awhile before he/she tried transferring the resident to the chair. Sometimes for fifteen to thirty minutes. The resident would be calmer and the transfer was easier and caused less anxiety; -The resident was a 6:00 A.M. to 7:00 A.M. riser most of his/her life. It was not necessary to check the resident's blood sugar at 4:00 A.M. Staff should not wake the resident for a blood sugar unless they were concerned the blood sugar might be low. Staff needed to be calm with the resident, not demanding and not rush him/her; -A couple of staff told the resident if he/she did not stand during the transfer or do what staff wanted him/her to do, staff would get the lift. Staff threaten the resident with the use of the mechanical lift and used the mechanical lift to get the resident to do something. The resident hated the lift. During interview on 4/21/23 at 2:25 P.M. and 4/25/23 at 3:30 P.M. the DON said the following: -Staff should not obtain a fasting blood sugar at 3:00 A.M. to 4:00 A.M., this was way too early. Staff should let the resident rest and if asleep do not wake the resident; -Staff was concerned about the resident's transfer status. The resident could transfer with one or two staff member assistance during the day. Night shift staff requested the mechanical lift for early morning because of the resident's behaviors and problems with transfers; -Staff had some dementia care training, but were not appropriately trained and were not aware of dementia care and how to approach residents with dementia. Staff needed dementia care and behavior management education; -Staff should implement individualized care plans for all residents and educate staff regarding the resident's care plans, treatments and interventions. Each resident's care plan should reflect the resident's condition and current needs; -Staff should not put the resident's pants on half way during the night, this was restrictive to the resident's movements; -Pre-dressing the resident and checking the resident's blood sugar at 4:00 A.M. was task oriented to staff needs instead of resident oriented. Getting residents up early was for the convenience of staff; -Staff should allow residents to sleep as late as they wanted; -The resident had anxiety before facility admission. Staff did not know specifically the resident's normal morning wake time and what the family did for the resident at home; -On admission the resident yelled a lot early in the morning. It was decided to move the resident to the SCU because the resident yelled and woke other residents. During interviews on 4/21/23 at 1:30 P.M. and 4/26/23 at 2:00 P.M. the administrator said the following: -All residents should have individualized care plans; -He expected staff to evaluate residents on admission for needs and implement resident centered care to meet the resident's needs. The care plan interventions should be individualized and direct the resident's care; -Staff should not pre-dress residents during the night and should not check blood sugars in the night, this was not appropriate. Staff should not provide care based on staff convenience; -All staff should be aware of the resident's needs, anxiety and how to respond to calm the resident and not make the anxiety worse; -He was concerned about the resident's anxiety with transfers, the staff wanted to use the mechanical lift for safety; -Staff should have direction on how to care for each resident and how to respond to changes in care needs; -The resident's transfer status should be included on the resident's care plan. No residents should be required to get up before the end of night shift. It should be the individual's choice when to get up for the day; -Staff were educated yearly on dementia care; -The facility had a SCU for residents with dementia, but the facility did not have a specific program and treatment plan for residents with dementia or behavior issues. The facility should provide increased staff education and a treatment program for residents with dementia and behavior issues. During interview on 5/11/23 at 1:30 P.M. the resident's physician said waking the resident every two hours for incontinence care and pre-dressing the resident caused the resident increased anxiety and confusion. There was no reason to wake the resident for early morning blood sugars before 6:00 A.M. Staff should allow the resident to rest to keep the resident's sleep cycle consistent. He preferred the resident saw the sun in the morning and avoid a night time of confusion. The resident had dementia with behaviors and became very anxious easily. Staff should provide consistent care and a consistent routine. He saw the resident stand and pivot transfer a couple of weeks ago and was aware the resident did not like the mechanical lift. The charge nurse informed him the resident hated the mechanical lift. Staff should not transfer the resident with the mechanical lift. He directed staff about two weeks ago to no longer utilize the mechanical lift as it caused the resident increased anxiety. Night shift needed direction on how to care for the resident with dementia and to specifically care for this resident. NOTE: At the time of the [T

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) in a review of five sampled residents, from abuse and neglect with care when Certified Medication Technician (CMT) A recorded the resident on his/her personal cellular phone without the resident's consent while the resident cried out and attempted to get out of bed, wearing only a shirt, incontinence brief and pants up to his/her knees. The resident's arm was through the middle of the grab bar of the bed and his/her legs hung off the side of the bed. CMT A did not provide the resident any assistance or care for approximately three minutes and continued to record as the resident cried out and struggled to get up in an unsafe situation. CMT A could be heard speaking to the resident in a demeaning manner. The resident said he/she had overheard staff say to each other they were not going to put up with him/her and were not going to break their backs over him/her. This made the resident feel he/she was not good enough and hurt his/her feelings. The resident said staff threatened him/her with the use of the mechanical lift (a mobile transfer device used to move a resident from one surface to another with the resident placed in a sling, elevated off the surface and lowered onto another surface) to coerce the resident into activities he/she did not want to do. The resident was fearful of the mechanical lift and said it caused him/her pain and emotional anguish. The facility census was 57. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 at 2:00 P.M. which began on 4/17/23. The IJ was removed on 4/26/23 7:00 P.M. as confirmed by surveyor onsite verification. Review of the facility Abuse Prevention Policy, dated February 2018, showed the following in part: -The facility had a zero tolerance of physical, verbal, sexual, and mental abuse, neglect by employees, family members, visitors or other residents; ms--Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse was defined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to a resident or within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse included, but not limited to, threats of harm, saying things to frighten a resident, such as telling a resident they would never see their family again; -Mental abuse included but was not limited to, humiliation, harassment, threats of punishment or deprivation; -Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress; -Verbal or Nonverbal abuse was any conduct that could cause mental abuse, including but not limited to, nursing home staff taking photographs or recordings of resident that were demeaning or humiliating using any type of equipment, (camera, smart phones and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks; -Mistreatment meant inappropriate treatment or exploitation of a resident; -The facility would have a system in place to prevent abuse and would ensure that all resident's responsible parties and staff understood there was zero tolerance of mistreatment, abuse, and neglect by an employee or any other person know to the resident. Review of the facility Cell Phone policy dated 3/17/23 showed the following: -It was the facility's policy to provide a health care environment and customer service that were not disrupted by distractions of personal cell phone or hand held communication devices; -Because of Health Insurance Portability and Accountability Act (HIPPA) (a federal law to protect sensitive patient health information from being disclosed without the resident's consent or knowledge) privacy practices, employees were not allowed to post or communicate any form of personally identifiable information about residents including photographs or any other information about a resident. 1. Review of Resident #1's Care Plan, dated 3/13/23, showed the following: -Diagnoses of dementia with anxiety, anxiety disorder, chronic pain, and history of falling; -The resident had dementia and moderate anxiety. Staff should report to the nurse if the resident was anxious or had changes in mental status; -The resident was known to become very anxious and emotional and at times scream. Staff should redirect as needed; -The resident was cognitively intact. Staff should orient the resident as needed and report any confusion or changes in cognition to the nurse; -The resident had an overall decline in Activities of Daily Living (ADLs). Staff should provide assistance with transfer, the resident transferred better with one staff member due to anxiety. He/She had chronic knee pain, staff should be patient as he/she moved slowly. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/13/23, showed the following: -Cognitively intact; -Physical and verbal behavioral symptoms directed toward others was not exhibited; -Other behavioral symptoms not directed toward other (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days but less than daily; -Required extensive assistance of two staff members with bed mobility and dressing; -Required total assistance of two staff members with transfers and toileting. Review of the resident's nurses' notes showed the following: -On 4/13/23 at 1:30 P.M. staff documented the resident was very upset and sobbing at 6:00 A.M. that morning, was not able to verbalize what he/she was upset about but said, I'd be better off dead. Spoke with the resident at length but was only able to comfort him/her enough to get him/her to stop crying. The resident eventually laid his/her head on his/her arms on the breakfast bar and continued to cry until about 7:30 A.M. when the resident finally agreed to eat some breakfast. After breakfast the resident gradually returned more to his/her normal self; -On 4/14/23 at 4:58 P.M. staff documented the resident was tearful that morning at 6:00 A.M., crying quietly at his/her table alone. Spoke with the resident who declined to discuss why he/she was crying. The resident agreed to coffee and orange juice. He/She eventually stopped crying and received his/her breakfast; -On 4/17/23 at 6:49 A.M. CMT A documented at 5:00 A.M. he/she went into the resident's room to get the resident's blood sugar (finger stick blood test). The resident became very snarky and mumbled under his/her breath that CMT A did not need to check anything. CMT A asked the resident if he/she could check the resident's blood sugar and the resident started screaming, crying and smacked everything out of CMT A's hands. CMT A asked the resident what was wrong and why he/she was being hateful that morning. The resident responded he/she liked to be hateful. The resident started screaming at CMT A. CMT A told the resident that was uncalled for and inappropriate, the resident screamed he/she did not care. CMT A then called the charge nurse Licensed Practical Nurse (LPN) D over to observe the resident's behavior. LPN D tried to obtain the resident's blood sugar. The resident still refused and was very vulgar and hateful, while he/she laid there kicking his/her legs out of the bed and continued to scream at the top of his/her lungs and cried out. CMT A then again asked the resident what was wrong, the resident said he/she was playing. CMT A asked the resident what he/she was playing, the resident said playing house. CMT A repeated to the resident you are playing house? The resident replied yes then continued to scream and cry. During interview on 4/21/23 at 9:00 A.M. the administrator said on 4/17/23 at about 5:00 A.M., CMT A took a video recording of Resident #1 with his/her personal cellular phone in order to show the Director of Nursing (DON) the resident's behaviors. CMT A videoed Resident #1 and sent the video from his/her personal cellular phone to the facility's cellular phone on the other side of the building. CMT A wanted the charge nurse to see the resident's behavior. The administrator felt the recording was nothing. He had not watched the video but the DON saw the video on 4/17/23 and decided the video was not abuse. The resident was upset, yelling and throwing himself/herself out of bed. The resident had increased anxiety and behaviors at night. CMT A agitated the resident. The day shift charge nurse, LPN B, saw the video and wrote up CMT A. Review of the warning notice dated 4/17/23 showed LPN B wrote the following: -Type of violation was unsatisfactory performance and violation of facility policy and procedures; -Date of incident was 4/17/23 at 5:00 A.M.; -Description of violation was CMT A woke the resident at 4:00 A.M. to check fasting blood sugar (FBS). When the resident became angry about being awakened so early the resident began yelling out. CMT A did not check the resident's FBS, gave as needed Tylenol at 4:03 A.M., and videoed the resident on his/her personal cellular phone; -DON follow up action taken was a warning, no malicious intent. Spoke with CMT A by telephone and informed not to use personal phone. During interview on 4/21/23 at 9:15 A.M. the DON said she saw the video, the resident was upset, yelling and trying to throw his/herself out of the bed. The resident had increased anxiety and behaviors at night. Night shift was responsible to get the resident up before the end of the shift (6:00 A.M.). During the night the resident refused to get up, he/she was difficult to get up. On day shift the resident did better. Staff used the mechanical lift in the night to transfer the resident. Review of the facility's cellular phone saved video on 4/21/23 at 10:00 A.M. showed the following: -CMT A videoed from the resident's doorway as the resident lay in bed next to the window, cried out and attempted to get out of bed, wearing only a shirt, incontinence brief and pants up to his/her knees. The resident's arm was through the middle of the grab bar of the bed and his/her legs hung off the side of the bed. CMT A did not provide the resident any assistance or care for approximately three minutes and continued to record as the resident cried out and struggled to get up in an unsafe situation. Staff could be heard speaking to the resident in a demeaning manner; - CMT A called the resident's name three times and said what are you doing? what are we playing, playing house?. The resident continued to struggle, pulling at the grab bar and his/her pants while crying out and screaming; -CMT A walked over to the edge of the resident's bed and said you don't care laying here screaming and carrying on keeping every one awake? that's not very nice. The resident said I'm not very nice. CMT A said so what's going on this morning? the resident said nothing and continued to cry out struggle, pulling at the grab bar and his/her pants while crying out and screaming; -CMT A said you are going to end up in the floor, the resident moaned and cried out. CMT A called the resident's name and asked the resident to put his/her legs up you are gonna be on the floor, the resident said I don't care; -CMT A said why are you being hateful? the resident said I like being hateful and continued to cry out; -CMT A said you aren't hateful, why are you being like this? During interview on 4/21/23 at 10:50 A.M. LPN C said the following: -He/She was the care plan coordinator and charge nurse; -The resident was cognitively intact and very much alert and oriented, he/she had dementia with anxiety and lived on the locked special care unit (SCU); -The resident hollered out frequently and had fear with transfers and fear of falling. He/She required one staff member assistance with transfers. The resident hollered out and was anxious during when transfers; -LPN C saw the video taken by CMT A. The video was abusive to the resident. Staff should approach the resident calmly and help the resident rest and remain calm. CMT A's behavior would make the resident's anxiety worse. Night shift staff woke the resident early in the morning and got the resident up for the day before the end of the night shift (6:00 A.M.) During interview on 4/21/23 at 11:00 A.M. the resident said the following: -He/She worried at night, about going home and what will happen. Staff get him/her up by 6:00 A.M. every day and use the mechanical lift to get out of bed. He/She hated the thing (mechanical lift). Staff say to each other they are not going to put up with him/her. He/She heard what staff said. He/She did not like it. Staff would not let him/her sleep any longer, they have to dress him/her. Staff put his/her pants on about to the knee, put the sling underneath him/her and then transfer him/her to the wheelchair. The mechanical lift was painful and stressful, made him/her feel like he/she was not good enough and staff did not want to work with him/her; -He/She had fallen a lot at home; -The staff were pretty awful and say they were not going to break their backs over him/her. Staff woke him/her between 3:00 A.M. and 4:00 A.M. for a blood sugar, he/she hollered out after that and said, I'm not ready for this. Staff tell him/her to be quiet, you don't have to be like this; -What staff say hurts his/her feelings and his/her thoughts. He/She did not want to hear staff talking about him/her; -Two night shift staff treat him/her this way and it usually happened every night. During interview on 4/21/23 at 11:20 A.M. CMT G said the following: -On 4/17/23 at 1:30 A.M. he/she came to work. Resident #1 was sleeping at that time; -Sometime after 3:30 A.M. CMT A said the resident was hollering and yelling. CMT G entered the resident's room and found the resident in bed, turned on his/her side yelling with legs out of the bed towards the window. The resident wore a night shirt and an incontinence brief and was exposed. The resident denied pain; -CMT A said she videoed Resident #1 with his/her cellular phone while the resident laid in bed screaming and yelling; -CMT G saw the video. The video showed the resident struggled in the bed, exposed while he/she screamed and cried out. CMT A did nothing to help the resident while he/she videoed. The video was mental and emotional abuse; -There was no reason staff had to wake the resident and staff should not force the resident to get out of bed. Staff now used a mechanical lift transfer in the early mornings, the rest of the day one or two staff could assist the resident with a pivot transfer. The resident did not usually holler unless staff was getting her up. The resident was visibly upset. During interview on 4/21/23 at 2:25 P.M. the DON said the following: -LPN B informed her on 4/17/23 CMT A took a video of Resident #1; -He/She viewed the video and expected staff to have more concern for the resident, and contact the charge nurse for help if unable to calm the resident. Staff should not video residents in distress and should not say the things CMT A said to the resident; -Staff should not obtain a FBS at 3:00 A.M. to 4:00 A.M., this was way too early. Staff should let the resident rest and if asleep do not wake the resident; -Staff were concerned about the resident's transfer status. The resident could transfer with one or two staff member assisting during the day. Night shift requested the mechanical left for early morning because of the resident's behaviors and problems with transfers; -After talking with LPN B, she informed the Administrator CMT A should be terminated for abuse. During interview on 4/21/23 at 3:40 P.M. LPN B said the following: -He/She was the SCU day shift charge nurse on 4/17/23; -On 4/17/23 at change of shift (6:00 A.M.) CMT A pulled out his/her personal cellular phone and showed LPN B a video CMT A took of Resident #1 in the night. LPN B told CMT A he/she was not supposed to video residents, he/she should have called the charge nurse and gotten some help; -CMT A taunted and provoked the resident on the video making the situation worse; -The resident usually had behaviors in the early mornings. He/She did not like the mechanical lift or getting up early. There was no reason for night shift to wake the resident; -He/She informed the DON around lunch time about the video and abuse. On 4/21/23 at 4:20 P.M. CMT A said the following: -He/She worked the night shift usually on the SCU; -The usual routine was bed checks every two hours for incontinence and turn or reposition those who require assistance. Staff usually get Resident #1 and the feeders (residents who require assistance with eating) up out of bed by 5:00 A.M.; -Resident #1 had behaviors of screaming and crying especially at night. The resident liked to cry or be hateful and try to throw his/herself on the floor. During bed checks staff woke Resident #1 every two hours, say the resident's name, turn the lights on and check the resident for incontinence. If the resident was soiled staff provided incontinence care and then turned the lights off. At about 5:00 A.M. staff transferred the resident to the wheelchair with a mechanical lift. The resident hated the mechanical lift; -On 4/17/23 at about 4:00 A.M. or 5:00 A.M. (unsure of exact time) he/she woke the resident and attempted to check the resident's blood sugar. The resident slapped things out of CMT A's hands. The resident was in bed, screaming, yelling, and tried to throw his/herself out of the bed. CMT A grabbed his/her personal cellular phone and recorded the resident's behavior for approximately three minutes while the resident continued to scream and yell, legs hanging off the side of the bed. CMT A texted the video to the facility cellular phone to show the charge nurse how the resident behaved. During interview on 4/25/23 at 5:03 P.M. CNA F said the following: Resident #1 was hard to deal with, he/she screamed, yelled, and cried when staff woke him/her in the night. The resident was alert and oriented, aware of his/her surroundings and got anxious and agitated in the early morning. When staff asked if the resident was ready to get up, he/she usually said no; -At 3:30 A.M. staff routinely woke the resident for bed check and put the resident's pants partially on, up to the knees. When staff woke the resident in the night, the resident screamed and said no he/she did not want to get up; -Staff did say to the resident if you cannot stand up to transfer we will have to get the lift (mechanical lift). Staff tell the resident he/she is going to hurt their backs; -At 5:00 A.M. to 6:00 A.M. staff got the resident dressed and up out of bed. CNA F did not know what the resident's deal was; -CNA F worked on 4/17/23 from 2:00 A.M. to 2:00 P.M.; -He/She was not present when the video was taken but saw part of the video while watching over another staff members shoulder. CMT A should not have taken the video. The video was not appropriate and CNA F did not approve of the video. During interview on 4/25/23 at 3:15 P.M. the resident's family member said the following: -The resident cried out when he/she was afraid and had anxiety with transfers. Staff should be calm with the resident and not rush him/her. The resident was modest and would not want videos or pictures taken, he/she would not approve of that. The resident's family member was unaware staff videoed the resident for approximately three minutes in distress, screaming and crying, while exposed in an incontinence brief and trying to get out of bed. The resident would not like being videoed and being videoed would upset the resident; -The resident hated the mechanical lift, the lift made the resident anxious, he/she cried and was afraid; Staff needed to be calm with the resident, not demanding and not rush him/her; -A couple of staff told the resident if he/she did not stand during the transfer or do what staff wanted him/her to do, staff would get the lift. Staff threaten the resident with the use of the mechanical lift and used the mechanical lift to get the resident to do something. The resident hated the lift. During interview on 4/25/23 at 3:30 P.M. the DON said he/she saw the video on 4/17/23 taken by CMT A that morning. The video was abuse. She informed the administrator CMT A should be terminated at that time. She expected staff to follow the facility abuse policy and should not abuse residents. Videoing residents on personal phones and taking pictures of residents without consent was abuse. During interview 4/26/23 at 2:00 P.M. the Administrator said the following: -He was not aware other staff had seen the video other than CMT A and charge nurse LPN D. Other staff should not have access to the video; -CMT A should have provided the resident assistance and not let the resident remain in distress; -Staff should not use their personal cellular phones for any purpose regarding residents; -He did not think the video was abusive or malicious. MO 00217324 NOTE: 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. 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(s).

Based on interview and record review the facility failed to assess and monitor one resident (Resident #1) who developed a pressure ulcer under a compression dressing of six sampled residents. The facility failed to complete weekly skin assessment on the resident's pressure ulcer, failed to notify the physician when the resident first complained of heel pain where the pressure ulcer developed, the facility had documentation on 3/1/17 regarding the the area and did not notify the resident's physician until 4/23/17 for a total of 53 days. The facility failed to notify the physician when the resident would refuse his/her dressing changes and did not notify the physician in a timely manner when the resident's pressure ulcer did not show improvement. The facility did not follow their policy by not obtaining a physician order for [REDACTED]. 1. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention Quick Reference Guide, dated as revised 2014, showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately; -A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear; -Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. High pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure the resident is exposed to; -The use of repositioning as a prevention strategy must take into consideration the condition of the resident and the support surface in use; -Frequency of repositioning will be influenced by variables concerning the resident and the support surface in use; -Repositioning frequency will be determined by the resident's tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the resident's skin condition; -Avoid subjecting the skin to pressure and shear forces; -Avoid positioning the resident on bony prominence's with existing non-blanchable redness; -Limit the time a resident spends seated in a chair without pressure relief. When a resident is seated in a chair, the weight of the body causes the greatest exposure of pressure to occur over the ischial tuberosities (also known as the sitting bones, when sitting the weight of the body is frequently placed over these bones). As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly; -Selection of an appropriate support surface should take into consideration factors such as the resident's level of mobility within the bed, his/her comfort, the need for microclimate control, and the place and circumstances of care provision; -Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition; -Expect some signs of pressure ulcer healing within two weeks; -If progress toward healing is not seen within two weeks, the individual, the pressure ulcer, and the plan of care should be re-evaluated. 2. Record review of the facility's Pressure Ulcer Policy, dated 1/27/16, showed the following: -Policy: The responsibility of all caregivers is to prevent, care for and provide treatment for [REDACTED].>-Nursing judgment may be used to determine what preventative measures are to be used for each resident; -These measures are included in the resident care plan; -If a pressure ulcer is not responding to treatment protocols, special treatments to be discussed with and ordered by the physician; -Assessments of resident at risk: -Residents whose general condition is rapidly deteriorating; -Residents with alteration in mentation; -Residents with alteration in mobility; -Obese residents; -Lethargic, unresponsive residents; -Residents with motor or sensory deficits (diabetic, orthopedic, neurological, rheumatological and neoplastic residents); -[MEDICAL CONDITION] (swelling) residents (especially [MEDICAL CONDITION] of sacrum and buttocks); -Incontinent residents; -Residents with alteration in nutrition and fluid balance; -Febrile (having a fever) residents; -On each shift, examine residents prone to pressure ulcers for development of redness, discoloration, or blisters over pressure areas. These include ears, shoulder blades, spine, elbows under the breast, sacrum and coccyx, greater trochanter, inner and outer aspects of the knees, inner and outer aspects of the ankles, and heels; -Pressure Ulcer Prevention: -1. On admission and at each Minimum Data Set (MDS), federally mandated assessment completed by facility staff, due date, a BRADEN scale for predicting pressure sore risk will be done. Any score less than 14, to be reported to the Director of Nursing (DON) within 24 hours and recorded on the Administrative report sheet. The MDS (minimum data set, a federally mandated assessment instrument required to be completed by facility staff) coordinator will review at the time of each MDS and care plan will reflect interventions; -2. Institute a preventative plan for any resident who has the potential for developing a pressure ulcer or whose condition is rapidly deteriorating. These interventions are found in the resident's care plan. This plan may include but is not limited to the following: -Develop turning and repositioning schedules; -Provide and ensure the resident receives optimum nutrition; -Observe skin condition on each shift; -Reduce shearing force by lifting resident rather than sliding when repositioning; -Treatment Protocols: -Stage I defined as inflammation or reddening of the intact skin; -Use preventative measures (gel cushions, air mattress or overlay); -Monitor skin condition for the following: signs of healing, signs of increased involvement and deterioration of area, signs of infection; -Provide the following treatment: skin conditioners, [MEDICATION NAME] (barrier cream) as indicated, [MEDICATION NAME] powder or cream for fungal infections; -Stage II defined as skin blister or superficial skin break; -Notify physician of change in condition of resident and notify DON on a timely basis; -Continue preventative measures; -Prevent infection to the area: -Clean area with normal saline rinse and pat dry; -Apply protective covering; -Cleanse with wound cleanser and apply Hydrogel (a gel in which the liquid component is water) and dry gauze dressing to open areas with physician orders; -Stage III defined as full thickness skin loss exposing subcutaneous tissue: -Notify the DON and physician of change in condition of the resident; -Continue preventative measures; -Order obtained from attending physician for consult with a wound specialist; -Treatment per wound specialist orders; -If infection suspected notify the physician; -Stage IV defined as full thickness skin loss exposing muscle or bone; -Continue preventative measures; -Obtain specialized pressure ulcer care orders from physician and initiate them promptly; -Prevent infection of ulcerated area; Documentation made by licensed staff members as follows: -Record treatment in the Treatment Administration Record (TAR) in Matrix; -Record in the Progress notes weekly or as the condition or level of care warrants; -Inform the physician of adverse reactions as needed; -Do PUSH (Pressure Ulcer Scale for Healing) tool on all pressure ulcers weekly on Wednesday. 3. Record review of Resident #1's Significant Change MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -The resident required extensive assistance of two staff members to bathe; -He/she was frequently incontinent of bowel and bladder; -The resident did not have a pressure ulcer; -He she had no dressings to his/her feet; -The resident had MASD (Moisture Associated Skin Damage); -The resident had no venous or arterial ulcers; -The resident rejected care; -He/she used a walker to wheelchair for mobility. Record review of the resident's physician order sheet (POS) dated 2/22/17 showed the following: -Apply [MEDICATION NAME] (antifungal) to the bilateral leg wounds ([DIAGNOSES REDACTED]. -Place calcium alginate (absorbent wound care product) to open areas; -Wrap with Unna boots (special gauze/compression bandage, which can be used for the treatment of [REDACTED]. -Wrap with stretch gauze and Ace wraps daily; -Change the stretch gauze and Ace wraps daily. Record review of the resident's nurse's resident order sheet completed by Registered Nurse (RN) D (outside contractor), dated 3/1/17, showed the following: -Left (right) heel wound 1.5 cm L (length) x 1cm W (width) x 0.2 cm D (depth) with moderate a amount of exudate (a mass of cells and fluid that is seeped out of blood vessels onto a lesion or area of inflammation), full thickness; -Etiology-venous leg ulcer; -No physician orders or treatment administration; -Products ordered non bordered foam for a heel and puracol (a primary dressing for all drainage types). During an interview on 8/3/17 at 12:14 P.M., RN D (contract nurse) said: -He/she initially saw the resident for leg issues; -The resident's heel issue started 3/29/17; -The facility called the wound a venous stasis wound; -He/she said pressure may have exacerbated the wound; -He/she was usually at the facility one time a month; -He/she said he/she did rounds with the treatment nurses on residents with wounds; -If residents allowed, he/she would look at their wounds; -He /she said she did education with staff on what product would be appropriate for the wounds; -Any orders came from the physician; -His/her role was to ensure the resident's insurance will pay for the supplies needed for the residents' wounds; -He/she said it was the facility's responsibility to report the condition of wounds to the physician and seek new orders. He/she said he/she did not communicate with any physician. Record review showed no documentation the physician was notified of the resident's heel wound or the recommended treatment by the outside contractor. Record review of the resident's nurse's notes dated 3/7/17 showed the following: -The resident complained of pain to his/her right heel; -Staff applied an ABD (thick absorbent gauze) pad after the resident's Unna boot for comfort; -Staff did not document color, texture, temperature, or measurement of the heel wound; -There was no documentation showing staff notified the resident's physician the resident had pain to his/her right heel under the Unna boot. Record review of the resident's Weekly Skin Assessment, dated 3/21/17, showed the following: -The resident complained of pain on his/her left (right) heel; -Staff did not document color, texture, temperature, or if the heel wound was open or closed. Record review showed no documentation staff notified the resident's physician of the wound at the resident's right heel under the Unna boot dressing. Record review of the resident's Weekly Skin assessment dated [DATE] showed the following: -The resident had a sore on the bottom of his/her right heel measuring 2.5 cm L x 2 cm W x 0.1 cm D; -The resident complained the area was sore; -Staff did not document color, texture, temperature, drainage, periwound or if the area was opened. Record review showed no documentation staff notified the resident's physician of the resident's right heel wound under the Unna boot dressing. Record review of the resident's nurse's notes dated 4/9/17 showed the following: -The resident continued to complain of being sore on his/her right heel where the open area is located; -Staff did not document measurements, color, texture, temperature, or drainage or periwound of the open area of the heel wound. Record review showed no documentation staff notified the resident's physician of the resident's right heel wound under the Unna boot dressing. Record review showed no wound assessment or documentation of the heel wound between 4/10/17 and 4/22/17 (12 days). (Facility policy directed staff to perform weekly wound assessments). Record review of the resident's nurse's notes dated 4/23/17 showed the following: -An open area to the resident's right heel measured 1 cm L x 0.75 cm W x 0.8 cm D; -The resident complained the area was very sore and hurt often; -Staff did not document color, texture, temperature, drainage or periwound status of the open area of the heel wound; -Staff notified the resident's physician of the resident's wounds and sent photos (53 days after the heel wound was first observed). Record review of the resident's nurse's notes, dated 4/26/17, showed the following: -Contracted wound nurse visited the resident today; -Physician was informed and new orders received for a wound culture of the resident's right heel (56 days after the first documentation of the resident's sore heel wound and nine days after the wound was documented as an open wound); -New orders start Santyl (prescription ointment that cleans wound to make way for healthy tissue) and calcium alginate (helps remove dead or damaged skin) to heel wound and wrap both legs with gauze and Ace wraps. Record review of the resident's physician orders dated 4/27/17 showed the following -Daily dressing changes to the heel wound; -Santyl ointment 250 unit/gram, apply a nickel amount to heel wound; -Cover with calcium alginate and wrap legs with gauze and Ace wraps. Record review of the resident's treatment administration record (TAR), dated 4/27/17, showed the following; -Santyl ointment 250 unit/gram, apply a nickel amount to heel wound; -Cover with calcium alginate and wrap legs with gauze and Ace wraps; -Diagnoses: [REDACTED]. Record review of the resident's nurse's resident order sheet (contract nurse) dated 4/28/17 showed the following: -The left heel wound measured 5 cm L x 4 cm W; -Unable to determine the depth; -Full thickness with heavy exudate. Record review showed no documentation of the residents' right heel wound between 4/29/17 and 5/10/17 (11 days). Record review of the resident's treatment administration record (TAR), dated 5/2/17 to 5/24/17, showed the following: -The resident refused the dressing change to his her right heel on 5/4/17; -The resident refused the dressing change to his/her right heel on 5/9/17; -The resident refused the dressing change to his/her right heel on 5/10/17; -No documentation showing staff notified the resident's physician the resident refused his/her dressing change to his/her right heel wound. Record review of the resident's nurse's notes, dated 5/11/17 no time specified, showed the following: -The resident continued to frequently complain of pain of his/her right foot; -As needed pain medications administered when the resident complained of pain; -Staff did not document measurements, color, texture, temperature, or drainage or periwound status of the resident's heel wound. Record review of the resident's TAR showed the following: -The resident refused the dressing change to his/her right heel on 5/13/17; -The resident refused the dressing change to his/her right heel on 5/15/17; -The resident refused the dressing change to his/her right heel on 5/17/17; -No documentation staff notified the resident's physician the resident refused his/her dressing changes to his/her right heel wound. Record review of the resident's nurse's notes, dated 5/18/17 no time specified, showed the following: -The resident's right heal remains open; -The wound bed is beefy red; -The lower edge with a darker red/gray line around the bottom edge but is less than a week ago; -The resident refused to sit in his/her recliner with his/her feet up which is not unusual for the resident; -Pain medication administered for leg and heel pain; -Staff did not document measurements, or drainage or periwound status of the open area of the heel wound. Record review of the resident's TAR showed the following: -The resident refused the dressing change to his/her right heel on 5/19/17; -The resident refused the dressing change to his her right heel on 5/20/17; -The resident refused the dressing change to his/her right heel on 5/22/17. Review of the resident's TAR dated 5/24/17 showed the following; -Santyl ointment 250 unit/gram, apply a nickel amount to heel wound; -Cover with calcium alginate and wrap legs with gauze and Ace wraps; -[DIAGNOSES REDACTED]. Record review showed no documentation staff notified the resident's physician the resident refused his/her dressing changes to his/her right heel wound. Record review of the resident's care plan dated 5/22/17 showed the following: Problem: Pressure ulcer (not staged): -He/she sat in his/her wheelchair most of the day with my legs hanging down; -His/her legs stay swollen; -His/her skin is in poor condition and at risk for breakdown; -Goal: The resident will have intact skin; -Approach: Both of the resident's legs are red and weep; -His/her lower legs have fragile skin; -He/she had daily treatments; -See progress notes weekly for description and measurements; -PUSH tool to monitor the wounds to be done weekly; -Encourage resident to elevate/her heels off the bed for his/her protection; -He/she refused to wear moon boots or heel protectors so they were discontinued; -His/her right heel is open and sore; -Follow treatments as ordered, assess and chart their effectiveness. Record review of the resident's nurse's notes, dated 5/23/17, showed the following: -The wound on the resident's right heel is oval (shaped) and measured 2 cm L x 2.5 cm W; -The wound be is bright red with scant bleeding; -Skin surrounding the wound is pale pink; -The entire heel is tender; resident felt like something bit him; -The right leg [MEDICAL CONDITION] (swollen), about 50% bigger than the left; Review of the resident's nurse's notes, dated 5/24/17, showed the following; -The resident's skin assessment conducted with contracted nurse present; -Dressing to the left (right) heel now included collagen (a protein that creates a scaffold on which cells can grow) powder to the top of the Santyl ointment, the calcium alginate sheet and wrap as usual; -Staff notified the resident's physician and he approved the dressing changes. Record review of the resident's physician orders dated 5/24/17 showed the following: -Daily dressing changes to the heel wound; -Santyl ointment (enzyme [MEDICATION NAME] ointment) 250 unit/gram, apply a nickel amount to heel wound; -Cover with collagen powder; -Then cover with calcium alginate and wrap legs with gauze and Ace wraps. Record review of the resident's TAR showed no dressing change documented on 5/25/17 or 5/26/17. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnosis: [REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) left (right) heel, rash/other skin disruption, generalized [MEDICAL CONDITION], gout, pain; -Stage III pressure ulcer 2.0 cm L x 2.5 cm W x 0.8 cm D, granulating tissue, and condition worse; -MASD; -Application of dressings to feet; -Always incontinent of bladder; -Functional impairment both sides of lower extremities; -He/she rejected care; -The resident's skin condition worsened; -No venous or arterial ulcers -He/she used a wheelchair for mobility. Record review of the resident's nurse's notes, dated 5/29/17 no time specified, showed the following: -Contracted nurse observed the resident's heel wound; -The heel (right) wound measured 2 cm L x 2.5 cm W x 0.5 cm D; -Treatment completed after the wound nurse observed the wound; Record review of the resident's nurse's resident order sheet (completed by contract nurse), dated 5/29/17 showed the following: -Left (right) heel wound 100% pink tissue per the treatment nurse; -The wound measured 2 cm L x 2.5 cm W x 0.5 cm D with heavy exudate; -Periwound is moist and fragile; -PUSH score 16. Record review of the resident's TAR showed he resident refused the dressing change to his/her right heel on 5/30/17. Record review showed no documentation staff notified the resident's physician the resident had refused the dressing change to his/her right heel. Review of the resident's TAR showed the following: -The resident refused the dressing change to his/her right heel ulcer on 6/2/17; -The resident refused the dressing change to his/her right heel ulcer on 6/6/17. Record review showed no documentation staff notified the resident's physician he/she refused his/her daily dressing changes. Record review of the resident's updated care plan dated 6/7/17 showed the following: -Problem: At risk for a pressure ulcer due to moisture; -Goal: Intact skin without evidence of redness, irritation, maceration, or open areas; -Approach: Check incontinent pads frequently and change every two to three hours and change as needed; -Moisturize dry unbroken skin; -Skin assessment and inspection every shift with close attention to heels. Review of a hand written nurse's note, dated 6/7/17 no time specified, showed the following: -The resident's treatment completed to his/her right heel and bilateral legs after the resident's shower; -The entire wound bed was beefy red in color with light pink at the edges; -Staff did not document measurements, or drainage or periwound status of the resident's right heel wound. Review of the resident's TAR showed the following: -The resident refused the dressing the change to his/her right heel ulcer on 6/11/17; -There was no documentation showing staff notified the resident's physician he/she refused his/her daily dressing changes. Record review of the resident's nurse's resident order sheet (completed by the contract nurse), dated 6/16/17, showed the following: -The left heel wound measured 2 cm L x 2 cm W x 0.3 cm D; -Moderate exudate; -Serosanguenous (blood and blood serum) drainage; -The periwound fragile and macerated (softened). Record review of the resident's TAR showed the following: -The resident refused the dressing change to his/her right heel ulcer on 6/16/17; -The resident refused the dressing change to his/her right heel ulcer on 6/20/17; -The resident refused the dressing change to his/her right heel ulcer on 6/21/17; -There was no documentation showing staff notified the resident's physician he/she refused his/her daily dressing changes. Record review of the resident's POS, dated 6/26/17, showed the following: -Mix Hydrogel (water gel) with Collagen Powder into a paste; -Apply the paste to the right heel wound; -Cover with an alginate dressing; -Pad the wound before wrapping with gauze and Ace wraps. Record review of the resident's TAR dated 6/26/17 showed: -The resident refused the dressing change to his/her right heel ulcer; -There was no documentation showing staff notified the resident's physician he/she refused his/her daily dressing changes. Record review of the resident's nurse's resident order sheet (completed by contract nurse), dated 6/27/17, showed the following; -The wound measured 2 cm L x 2 cm W x 0.3 cm D; -Moderate exudate; -Serosanguineous drainage; -The periwound fragile and macerated; -PUSH score 16. Record review of the resident's nurse's notes showed no documentation of the resident's right heel wound from 6/27/17 to 7/11/17 (14 days). Record review of the resident's TAR showed the the following: -The resident refused the dressing change to his/her right heel wound on 7/4/17; -The resident refused the dressing change to his/her right heel wound on 7/5/17; -The resident refused the dressing change to his/her right heel wound on 7/10/17; -There was no documentation showing staff notified the resident's physician he/she refused his/her daily dressing changes. Review of the resident's nurse's notes dated 7/12/17 at 2:23 P.M. showed the following: -The wound on the bottom of the resident's right heel was worse; -The wound measured 3 cm L x 2.4 cm W x 0.8 cm D; -The wound bed was beefy red, granulation tissue and a moderate amount of sanguineous drainage; -The posterior heel mushy, yellow green in color with areas of dark purple black, oblong in shape and extended from the posterior side of the wound; -The green/yellow area measured 4 cm L x 2.8 cm W and the dark purple/black area within the green/yellow area measured 1.5 cm L x 0.4 cm W.; -The resident's physician aware. Record review of the resident's TAR showed: -The resident refused the dressing change to his/her right heel wound on 7/15/17; -There was no documentation showing staff notified the resident's physician he/she refused his/her daily dressing changes. Record review of the resident's nurse's notes dated, 7/16/17 at 1:12 P.M., showed the following: -The resident refused his shower; -Staff removed the dressing to his/her bilateral lower extremities; -The right heel ulcer was blackened in color with maceration of the heel and side of the foot; -Moderate amount of serous (serum) drainage from the heel; -The resident's physician looked at the wound and spoke to the resident and his/her family; -The resident's physician ordered the resident be sent to the hospital. Record review of the resident's history and physical from an area hospital, dated 7/16/17, showed the following: -The resident had an unstageable pressure ulcer (known, but not stageable due to coverage of the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue); -The pressure ulcer measured 6.5 cm L x 10.5 cm W; -The wound bed was 100% wet brown slough/eschar with a large amount of foul purulent (full of pus) drainage; -The resident complained of great pain with manipulation of that lower leg/foot; -A podiatry consult for debridement; -The resident most likely has osteo[DIAGNOSES REDACTED] (bone infection); Record review of the podiatry consult dated 7/18/17 at 7:49 A.M. showed the following: -Dry open wound full thickness with exposed calcaneus (heel bone), and proximal (toward the center) necrosis (dead tissue); -No infection noted; -Purulent foul odor from the wound, with black necrotic tissue; -Gangrenous tissue to the posterior (back) and medial (side) aspect of the heel; -Undermines (erodes) posteriorly to near the Achilles insertion (the point were the tendon attaches to the heel bone) medial aspect; -Debrided the right heel ulcer without anesthesia, mild discomfort; -Ischemic (a restriction of blood flow to issues) tissue changes suggest debridement calcanectomy at minimal with incision and drainage, vascular compromise posterior heel vs [MEDICAL CONDITION]. During an interview on 7/31/17 at 11:13 A.M., Certified Nurse Aide (CNA) B said: -The resident often rejected care; -He/she said he/she reported changes in the resident's wound to the charge nurse; -He/she said he/she showered the resident and found the resident's heel black and spreading; -She notified the charge nurse and the charge nurse had the physician onsite look at the wound. The resident had refused his dressing change frequently. During an interview on 8/3/17 at 1:19 P.M., Registered Nurse (RN) E said: -There were a couple of nurses that did weekly skin assessments that included measurements and wound description; -The charge nurse was responsible to complete the weekly assessment on Wednesdays; -He/she said on 4/9/17 he/she covered the resident's heel wound with the Unna boot that was used for the resident's leg wounds; -He/she did not notify the resident's physician; -He/she said if she had notified the physician; he/she wound have documented it; He/she said she notified the physician on 7/12/17 of the decline in the wound, but did not receive new orders. The physician wanted the resident evaluated at the wound clinic; -The MDS Coordinator set up an appointment at the wound clinic; -The resident went to the hospital on [DATE]. During an interview on 7/31/17 at 2:45 P.M. RN C said: -The resident had a small open area on the bottom of his foot/heel; -He/she took a photo of the area and sent it to the resident's physician; -He/she was the wound care nurse on the other wing; -A new observation tool ( PUSH) for pressure ulcers was created a couple of months ago, otherwise a detailed progress note is completed on all other wounds at least weekly. During an interview on 8/3/17 at 3:22 P.M., the Director of Nursing (DON) said: -The charge nurse is responsible for weekly skin assessments; -She expected the assessment to include measurements and a complete wound description including location, size, color and drainage; -She expected the charge nurse to report a decline in the wound to the physician; -If the wound did not show improvement in a few days to one week, she expected staff to notify the physician by the next scheduled weekly assessment. During an interview on 8/3/17 at 3:30 P.M., the administrator said: -She expected staff to follow the facility wound/pressure ulcer policy; -She said she expected weekly wound assessments or an additional assessment if there is a decline in the wound; -She expected staff to document location, size, color, drainage, and change in the wound; -If there was no improvement in the wound she expected staff to notify the physician in approximately one week; -The nurse doing the assessment is responsible to notify the physician if there is a decline or no improvement. During an interview on 7/31/17 at 1:00 P.M., the resident's physician said: -He expected staff to notify him either by text or phone when a resident had a change in their condition; -He had given wound care orders when staff reported the wound; -He received notice from staff that the resident's heel was black/bad on 7/12/17. MO# 9

Based on observation, interview and record review, the facility failed to ensure each resident received services to maintain his/her highest practicable physical well being by failure of staff to provide nursing care in accordance with acceptable standards of practice for one of 18 sampled residents (Resident #15) by failure of staff to complete an assessment of the resident's condition after more than one episode of vomiting and failure to notify the attending physician that the resident had more than one episode of vomiting and an abnormally high blood sugar, and failure to initiate emergency measures including calling [DATE], and beginning CPR, after staff found the resident unresponsive and without signs of life. The facility failed to maintain complete content of supplies in two of two emergency boxes for use during a code. The facility census was 78. 1. Review of Resident #15's MDS (Mimimum Data Set), a federally mandated assessment required to be completed by facility staff, dated [DATE], showed his/her BIMS (Brief Interview of Mental Status) was 13 (out of possible 15). Review of Resident #15's Care Plan face sheet dated [DATE], showed for advance directive: Full Code status. Review of the resident's care plan dated [DATE] and last reviewed [DATE], showed the following: -Problem that blood sugar levels have a history of running high, with approach for nursing staff to administer antidiabetics as directed (by physician) and give sliding scale insulin as directed, consult physician when needed; -Review on [DATE] showed the resident's insulins were adjusted for blood sugars between low 78 and high 228 that month; -Review on [DATE] showed the resident seemed to be doing well. Review of a facility document addressed to Resident #15 from the facility showed the following: -At the present time your code status is full code, I understand what this means, and it is my choice to remain unchanged at this time; -Signed by resident's DPOA on [DATE]; -Note added [DATE], also talked with resident per DPOA's request, resident agreed. Review of a photograph of the resident that had been posted near his/her door prior to [DATE], showed it included a symbol of a tool box with handle which indicated the resident was a full code. Review of the facility's policy and procedure for cardiopulmonary resuscitation dated [DATE], showed the following: -Resident code status will be determined/reviewed on admission and yearly; -Resident's attending physician will order "Full Code" or "DNR (Do not resuscitate) as resident chooses; -If Full Code is chosen, licensed nurse designates this with an orange full code sticker on the resident's face sheet in the chart and places a red tool box sticker outside the resident's door; -Full code lists are also maintained in each nursing home vehicle for transport purposes; -If a resident designated "Full Code" is found to be without a pulse, CPR should be initiated immediately; -Code Blue and room number should be announced on overhead pager system so all available licensed nurses can assist with the code; -A licensed nurse should stay with the resident whenever possible and designate other staff to retrieve equipment and call [DATE]; -Yellow code boxes will be found in each CNA workroom and will be equipped with ambu bag and CPR mask; -AED (automated external defibrillator-portable electronic device that detects abnormal heart rhythm) will be found in one clean utility room; -CPR will be continued until ambulance personnel arrive and staff shall assist emergency medical personnel in continuing CPR until physician or coroner arrives or until resident is transferred by ambulance. Review of a statement signed by the DON on [DATE], showed she said that the faciity's policy for CPR prior to the policy dated [DATE] was the current CPR manual from the American Heart Association, which also includes the use of an AED. Review of the resident's physicians orders signed [DATE], showed the following: -an order for [REDACTED]. -[DIAGNOSES REDACTED]. -an order for [REDACTED]., 11:00 A.M., 4:00 P.M., and 8:00 P.M.; -An order to call physician if 4:00 P.M. blood sugar was above 400 and offer snack if blood sugar less than 80; -an order for [REDACTED]., 11:30 A.M., and 4:00 P.M. Review of the resident's nurses notes dated [DATE], showed CMT (Certified Medication Technician) U noted the following: -At 3:50 A.M., resident found with large emesis in bed during bed check, undigested food, resident awakened and cleaned and changed, denied nausea at that time but did remember having upset stomach earlier, not sure what time, no diarrhea, vital signs temperature 97.4 (normal 98.6), pulse 56 (normal ,[DATE]), respirations 16 (normal 12 to 20), blood pressure ,[DATE] (normal range ,[DATE]), oxygen saturation 94 per cent (normal ,[DATE] per cent) in room air, stated stomach felt fine now; (the note did not show whether CMT U notified the charge nurse and/or the resident's physician regarding the resident's emesis and vital signs); -At 5:45 A.M. (next note almost two hours later), FBS (fasting blood sugar) 256 (normal ,[DATE]), resident alert and talkative, said feeling better; (the note did not show whether CMT U checked the resident's vital signs or notified the charge nurse and/or the resident's physician regarding the emesis and high blood sugar or whether CMT U administered the prescribed insulin according to the sliding scale). (The notes did not show whether a licensed nurse made an assessment of the resident's condition during the night or notified the physician of the resident's vomiting and abnormally high blood sugar.) Review of the facility's policy and procedure for [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (high blood sugar and low blood sugar), dated [DATE], showed it was facility policy for staff to notify physician if a resident's blood glucose (sugar) is below 60 or above 200. (The policy did not include procedure(s) for staff to follow regarding the administration of sliding scale insulin.) Review of the resident's MAR (Medication Administration Record) for January, 2012, showed the following: -On [DATE] at 8:00 P.M., staff failed to record if accucheck was done or result; -On [DATE] at 8:00 P.M., staff failed to record if accucheck was done or result; -On [DATE], the accucheck scheduled for 6:00 A.M. was 256; -On [DATE], the sliding scale insulin was scheduled for 7:00 A.M. (one hour later) and not marked as administered. (Note the nurses notes above for [DATE] showed the accucheck was done at 5:45 A.M., one hour and 15 minutes ahead of schedule for the sliding scale insulin.) During interview on [DATE] at 3:05 P.M., CNA Z said the following: -The resident had an episode of vomiting brown, undigested food at about 2:00 A.M. bedcheck; -The resident had another episode of vomiting around 4:00 A.M. bedcheck, which was worse, thew up more, same color and consistency, which he/she reported to CMT U; -At about 4:30 A.M., two other aides cleaned the resident after another episode of vomiting; -When he/she went to get the resident out of bed a little after 6:00 A.M., the resident had thrown up and just enough to be on upper part of gown and kind of in the mouth; -The resident was not breathing; -The resident's eyes were closed, his/her skin did not look different; -He/she reported this to LPN D. Review of a written statement dated [DATE], showed CNA Z said the following: -At around 2 AM (on [DATE]), went to do bed check and found the resident had vomited; -The resident vomited again a little before 4 AM; -After break, at about 4:30 A.M., two other CNAs were cleaning the resident again; -A little after 6:00 A.M., he/she went to the resident's room to get him/her out of bed and saw he/she had vomited and was not breathing; -The resident looked as though he/she was sleeping, had head elevated; -He/she went and reported to the day shift charge nurse, LPN D. During interview on [DATE] at 2:40 P.M., LPN BB said the following: -He/she is usually the charge nurse for the entire building on night shift (10 P.M. to 6 A.M.); -He/she usually stayed on A wing, and went to B wing for emergencies; -A CMT (Certified Medication Technician) usually stayed on B wing; -The resident had appeared fine and felt fine the evening before; -He/she learned the resident was sick close to 5:00 A.M. (on [DATE]), and did not do an assessment; -He/she did not recall whether CMT U had described the resident's emesis and was not concerned about it because many residents were sick with the flu; -CMT U did not tell LPN BB that the resident's blood sugar was high that morning; -The facility's protocol was for night shift staff to check the residents' blood sugars and the day shift staff to administer the insulin, including those with sliding scale insulin prescribed. Review of a written statement dated [DATE], showed LPN BB said the following: -He/she was informed that the resident had become ill at approximately 5 A.M. (on [DATE]), and was informed the resident had vomited; -He/she had seen the resident earlier in the shift and he/she awakened easily and conversed appropriately; -He/she did not see the resident again that shift; -At approximately 6:20 A.M., he/she was informed that the resident had expired. Review of LPN BB's personnel file showed he/she had a current CPR/AED certification through the AHA. During interview on [DATE], CMT U said the following: -The resident had two emesis during the night, which he/she reported to LPN BB; -He/she heard the resident wretching the second time, with emesis of moderate amount yellow, undigested food; -The resident was responsive both times; -Staff checked the resident's vital signs; -At 5:30 A.M., the resident's blood sugar was above 200, which was high for him/her, which he/she reported to the charge nurse at 6:00 A.M.; -Staff did not administer the resident any insulin at that time; -While he/she was giving report to the next shift, an aide told them he/she thought the resident was not breathing; -He/she followed LPN D into the resident's room; -The resident was cold and gray and "gone"; -LPN D called RN B who came over; -The resident was full code. Review of a written statement dated [DATE], showed CMT U said the following: -The resident had been ill two times between 2:00 A.M. and 4:30 A.M., during their shift (10 PM to 6 AM on [DATE]); -CMT U notified the charge nurse; -The next time CMT U saw the resident was at 5:30 A.M. while getting blood sugars, when resident was awake, alert, oriented times three (person, place, time), denied pain or nausea, color was normal; -The resident's blood sugar was over 200 which was high for him/her, which CMT U recorded for report to the oncoming charge nurse at 6:00 A.M.; -During report, a night shift CNA went to desk and reported the resident was not breathing; -The charge nurse went immediately to the room and CMT U followed; -The resident was gray and cold; -The charge nurse attempted to get vital signs; -CMT U felt no radial (at wrist) pulse; -The charge nurse contacted the RN on the other wing. Review of CMT U's personnel file showed he/she had a current CPR/AED certification through the American Heart Association (AHA). Review of the resident's nurses notes dated [DATE], showed the following: -At 6:45 A.M., LPN (Licensed Practical Nurse) D noted that at 6:15 A.M., CNA reported (to LPN D) resident did not appear alive, observed resident gray in color and cold (arms, legs, trunk), auscultation (listening usually with a stethoscope) of lungs and heart revealed "no life", RN (Registered Nurse) B called and had same findings (the note did not show whether the nurses called [DATE] or began CPR (cardiopulmonary resuscitation). DON called at approximately 6:20 A.M., physician notified at 6:25 A.M., and family, funeral home called while CNAs (Certified Nurse Aides) performed postmortem care; -At 8:50 A.M., funeral home picked up resident's body. During interview on [DATE] at 12:15 P.M., RN B said the following: -(On the morning of [DATE]), the resident was cold and gray, and looked like he/she had been dead for quite some time; there was no heartbeat and no respirations, the eyes were closed; -RN B listened to the resident for respirations and heartbeat and felt for carotid (side of neck) pulse, felt the skin temperature and determined he/she was deceased ; -Residents who were full code each had a tool box sticker near their picture on doorway, and a toolbox on their chart, and there was a list of full code residents in the dining room and at each nurses station. Review of a written statement dated [DATE], showed RN B said the following regarding the resident's death on [DATE]: -RN B received a phone call from LPN D on the other wing who said he/she needed to go to the resident's room; -Upon entering the resident's room, RN B observed the resident was gray and had no pulse, hearbeat or respirations, and body was cold and he/she appeared to have expired quite some time earlier; -RN B discussed the events with LPN D, and the events leading to then, asking when the blood sugar had been checked, who had been in the room after that, and when to try to get a timeline; -RN B instructed LPN D to call the DON, the physician, and the family; -The resident had no audible heartbeat, no palpable carotid pulse, and skin was cold. Review of RN B's personnel file showed he/she had a current CPR/AED certification through the AHA (American Heart Association). Review of a document dated [DATE] and signed by the DON on [DATE], showed the following: -LPN called and informed DON of resident's passing and DON asked LPN why CPR was not performed; -LPN said he/she and RN B had determined the resident was already very cold and gray and appeared to have been gone quite some time, so they did not feel CPR would have been successful; -DON spoke with the RN who also said the resident looked like he/she had been gone awhile and cold to touch and gray in color, and not a candidate for CPR. -On [DATE], DON and administrator advised LPN D and RN B that all residents designated a full code should be coded regardless of the condition they are found in, and that in the future, under the same circumstances, they should proceed with a "code blue" and call the ambulance; -On [DATE], DON discussed with resident's physician who advised that in the future, nurses proceed with CPR on any full code resident deemed to be pulseless, regardless of the amount of time they may have already been in that condition. During interview on [DATE] at about 2:15 P.M., LPN D confirmed he/she had not begun a full code or CPR for the resident because the resident was cold and gray and his/her eyes were not normal. During interview on [DATE] at 2:50 P.M., LPN D said the following: -He/she was the charge nurse on day shift [DATE], which began at 6:00 A.M.; -The night shift CMT had seen the resident at about 5:30 A.M.; -After 6:00 A.M., a CNA told LPN D that the resident had passed; -Resident #15 did not have heart rate or respirations; -He/she discussed the resident with RN B; -They agreed tht CPR was not warranted; -The resident was cold and had no signs of life; -The resident's color was bluish/gray; -The resident's eyes were "hazy". Review of a written statement dated [DATE], showed LPN D said the following: -A CNA went to desk and reported the resident did not look alive; -LPN D and CMT U went to the resident's room and checked for lung sounds, pulse, etc; -There was no audible heartbeat and no air movement; -LPN D called RN B from the other wing; -RN B auscultated (listened to) lungs and heart; -They discussed code status; -The resident's feet and hands were cold; -RN B advised CPR would not be beneficial; -LPN D agreed with RN B; -They notified the DON and physician of the resident's death. Review of LPN D's personnel file showed he/she had a current CPR/AED certification through the AHA. During interview on [DATE] at 3:00 P.M., the resident's physician said the following; -The facility staff notified him/her on [DATE] of the resident's death; -The facility staff had not notified him/her that the resident had vomiting that morning; -The facility staff had not notified him/her that the resident's blood sugar was 256 that morning; -He/she did not recall at that time (when staff called him/her) whether or not the resident was a full code; -He/she expected all his/her orders to be followed; -He/she believed the resident's death was due to [MEDICAL CONDITION]. Review of the resident's certification of death filed [DATE], showed the resident's date of death was [DATE], and the underlying causes were [MEDICAL CONDITION] and [MEDICAL CONDITION]. During interview on [DATE] at 2:10 P.M., the resident's physician said the following: -He/she expected staff to administer residents' sliding scale insulin soon after the accuchecks were done; -He/she expected facility staff to know each resident's code status; -He/she doubted whether performing CPR on the resident would have changed the outcome; -The resident had been clinically stable since he/she assumed the resident's care in the fall of 2009; -The cause of death was [MEDICAL CONDITION]. Review of a note posted at the B wing nurses station on [DATE] at 11:45 A.M., showed the following: -Residents who have this symbol (symbol of a toolbox with handle) by their picture and on the spine of their charts are full code residents; -This means we do everything in our power should their heart stop beating or they stop breathing; -It is important for staff to know this and call a code when needed; -The number of code residents varies, we currently have a high number; -Code review is done each June, but can be changed at any time; -If you notice someone is a code and their symbol is missing, please slide, not stick, a new one in by their picture, if in their chart, then stick one on the spine. -Code list included 19 residents' names; -Code list did not include two residents who had current physician orders [REDACTED].#21), which were added to the list provided by the DON at 7:45 P.M., so that the list included 21 residents. Review of the facility's B wing code box check provided by the DON (Director of Nursing) on [DATE], showed the contents were checked on [DATE] and on [DATE], and no record that contents were checked between [DATE] and [DATE] (about two years). Review of a statement signed b the DON on [DATE], showed there was not a current policy for checking the contents of the code boxes, and the AED was checked annually for mechanical problems and for battery strength. Review of Code Box contents sheet (undated), showed the following contents for the Code Boxes: -Stethoscope; -Blood pressure cuff; -Mouth shield; -Ambu bag; -IV catheter; -IV (through vein) tubing and extension sets; -IV Solutions (A-wing box) -1000 ml (milliliters) sodium chloride; -1000 ml D5W([MEDICATION NAME] in water); -Bandage supplies; -Non sterile gauze 2 x 2 8-ply; -Scissors; -Tape (1 roll cloth, 1 roll silk) -Gloves; -Sterile gloves; -Biohazard Bag Kit; -Alcohol wipes; -Iodine wipes; -Tourniquet; -IV [MEDICATION NAME] (clear protectant for skin); -Notepad and pen. Observation on [DATE] at 11:18 A.M., showed the following contents in the Code Box on B wing: -Stethoscope; -Blood pressure cuff; -Mouth Shield; -Alcohol wipes; -Ambu bag (expiration date 2009); -IV tubing (expiration date [DATE]); -[MEDICATION NAME]; -Tourniquet; -(No note pad or pen); -Scissors; -Sterile gloves; -Gauze; -2 x 2 gauze; -No IV extension tubing; -Tape. Observation on [DATE] at 11:24 A.M., showed the following contents in the Code Box on A wing: -2 x 2 gauze sponges; -Stethoscope; -Blood pressure cuff; -Paper (no pen); -Tape; -Sugar; -Mouthshield; -22 gauge IV needle (expiration date ,[DATE]); -Alcohol wipes; -[MEDICATION NAME] wipes; -Biohazard kit (broken); -Four 18 gauge IV needles (expiration date ,[DATE]) -(No IV tubing); -Ambu bag; -Two 24 gauge IV needles (expiration date ,[DATE]) -IV fluid 1000 ml D5W (expiration date ,[DATE]). 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 measures to address and lower the violation at the time. During the onsite visit, the facility had provided inservice to all licensed nurses and had begun providing inservice to all staff regarding procedures for full code residents. The facility had yet to complete inservice all facility staff as to their responsibilities when a resident showed no signs of life. The facility had yet to ensure the contents of the two code boxes for emergency use contained all necessary supplies that were not outdated. At the time of the 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 the Class I violation.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident #3) who entered the facility without pressure sores did not develop pressure sores; and one resident (Resident #2) with a Stage IV pressure sore (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) received the necessary treatment and services to promote healing and prevent infection; and for two residents (Residents #5, and #10) out of 18 sampled residents,who were at high risk for developing pressure sores, were turned and repositioned frequently to prevent pressure sores and that one resident (Resident #5) was cleansed in a manner to prevent potential contamination of his/her pressure sore with feces. The facility census was 78. 1. Review of Resident #2's Minimum Data Set (MDS), (a federally mandated assessment instrument required to be completed by facility staff), dated 4/18/11, showed the following: -admitted was 4/16/11; -Skin conditions showed the resident at risk for pressure ulcers; -No pressure ulcers present. Review of the resident's MDS dated [DATE], showed the following: -Skin conditions showed the resident at risk for pressure ulcers; -No pressure ulcers present. Review of nursing admission notes (skin assessment) dated 4/28/11, showed the following: -Had two open areas on coccyx (tail bone) measuring 1.6 x 1.2 cm and 0.7 x 0.5 cm; -Had minimal amount of serous drainage; -The area to the right buttock was pink, soft, and labeled as a concern area. Review of the resident's MDS discharge assessment, dated 5/2/11, showed the following: -At risk for pressure ulcer development; -A stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open lucer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) was present. Review of hospital discharge summary dated 5/24/11, showed the following: -admitted d 5/02/11; -discharge date d 5/23/11; -Stage II pressure ulcer to sacrum (tailbone) with some surrounding redness but no discharge noted upon admission and upon discharge with no documented change in ulcer; -Open area to coccyx (tailbone) which was treated in the nursing home facility with hydrogel and gauze daily. Review of nurse's notes, dated 6/1/11, showed wound measurements of 3 x 1 cm with a depth of 0.5 cm and no drainage. Edges of wound rolled with a white center of 0.2 x 0.4 cm. Surrounding skin excoriated. Review of nurse's notes dated 6/3/11 at 9:00 A.M., showed dressing changed to coccyx and described as deeper with full thickness deep through the tissue to underlying white area appearing as bone. At 11:30 A.M., showed dressing orders for coccyx wound of calcium alginate with [MEDICATION NAME] in the wound base due to sacral pressure ulcer being unstageable and covered with slough. At 3:20 P.M., showed the following DON (Director of Nursing) assessment of the pressure ulcer: -Viewed wound due to charge nurse reported possible bone in base of coccyx wound -Measurement: 2.9 x 1.9 cm with depth of 0.8 cm; -0.4 cm tunnel to distal portion of wound; -Scant amount of serous drainage on old dressing; -Wound bed white with slight soft layer over top of bone; - "Now stage IV due to visible wound bed" ; - "Proximal portion of wound continues to have an area of 2 cm of white tissue where wound is not as deep" ; -Wound edges contained [MEDICATION NAME] tissue. Review of the resident's MDS dated [DATE], showed the following: -At risk for pressure ulcer development; -Stage IV pressure ulcer with slough present; -Pressure ulcer depth= 0.8cm (centimeters); -Pressure ulcer length= 2.9cm; -Pressure ulcer width= 1.9cm; -Turning and repositioning section left blank; -Extensive assistance with bed mobility; -Extensive assistance with transfers; -Extensive assistance with ambulation (walking) in room; -Nonambulatory; -Total dependence with ADLs (activities of daily living); -Total dependence with wheelchair navigation; -Two person assistance with dressing, bathroom use, and bathing; -One to one assistance with eating; -Impaired range of motion in upper and lower extremities (both arms and both legs); -Functional rehabilitation potential nonexistent; -No potential to increase ADLs. Review of nurse's notes dated 6/4/11 at 1:15 A.M., showed the resident was on his/her call light every one to two minutes due to pressure ulcer pain and unable to rest except for short intervals. At 10:30 A.M.the resident's physician came for a visit and wrote new orders for a wound clinic specialist. At 4:30 P.M. another physician assessed the resident's pain level and spoke with the resident about his/her level of pain. an order for [REDACTED]. Review of nurse's notes on 6/6/11 at 9:50 A.M., showed the resident's oncologist to look at stage IV wound while the resident was there for [MEDICAL CONDITION] treatment. No further documentation about appearance, size, depth, drainage or pain to wound. Review of nurse's notes on 6/7/11 at 1:!5 P.M., showed all physicians were unavailable to view wound that day as well as wound nurse. DON documented that an appointment with the wound nurse was made for the following Friday between the resident's other two appointments that day. DON also documented discussing appearance of wound with the resident's family member. Review of the resident's care plan dated 6/21/11, showed the following: -Stage IV sacral wound [MEDICAL CONDITION]; -Skin is in poor condition, assess and monitor skin status; -Weak and unable to " do for self " , with need of extensive to total assistance for ADL ' s (activities of daily living); -Bed mobility per extensive assist of two, routine positioning, head of bed to be elevated at all times with recommended elevation of 45 degrees; -Transfers per extensive assist of two, using gait belt with contact guard assist; -Ambulation per extensive assist of two using gait belt for a few steps only; -Dressing per extensive assist of two, allow to assist as able, has some left shoulder limitations; -Toileting per extensive assist of two, do not leave alone while on toilet, incontinent of bowel and bladder, offer bedpan at request, implement a scheduled toileting plan, wears briefs for protection; -Personal hygiene per extensive assist of two; -Bathing per extensive assist of two; -Examine skin during bathing for signs and symptoms of breakdown; -Leave up at least 20 minutes after eating. -Stage IV pressure ulcer to sacrum (tailbone); -Air mattress to bed with adequate air at all times; -Gel cushion to wheelchair; -Routine incontinence checks; -Assess size, depth, and color of wound every week using PUSH tool and document; -Routine positioning; -Body/skin audit two times weekly; -Use precautions for wound care due [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staph aureus) present in wound; -Position off affected areas; -Follow treatment as directed. Review of nurse's notes on 6/29/11 at 11:00 A.M., showed edges of pressure ulcer rolled, no draingage and no odor. Silvacel and gauze with foam dressing placed at that time. No wound measurements accompanied nurse's notes, no depth recorded. Review of nurse's notes on 7/13/11 at 11:00 A.M., showed the following pressure ulcer to sacral area measurements: -3.0 cm x 1.3 cm x 1.0 cm, did not specify which measurement was depth measurement; -Moderate amount of drainage; -necrotic tissue; -Dressing changed twice per day. Review of nurse's notes on 7/19/11 at 8:20 A.M., showed dressing removed from scaral pressure ulcer revealing wound which measured 3 cm x 2.2 cm x 1.5 cm (0.5 cm increase from previous week recorded); -Visible bone in the base of the wound; -Undermining from three o'clock to nine o'clock positions. Review of nurse's notes on 7/19/11 at 2:30 P.M., showed the resident had been seen by a wound nurse, who made the suggestion to change dressing to [MEDICATION NAME] silver daily and PRN (as needed) and cover with foam and tape. No wound measurements or assessment recorded. Review of nurse's notes on 7/21/11 at 1:30 P.M., showed RN B notified the resident's family member of wound and treatment. No measurements or assessments of wound documented. Review of nurse's notes on 7/27/11 at 9:45 A.M., showed wound measurements of 3 cm x 2.5 cm x 1.5 cmn (increased from wound measurements on 7/19/11), heavy drainage, slough, visible bone at the base of the wound, and undermining from 3 o'clock to 9 o'clock position. Review of nurse's notes on 7/31/11 at 9:30 A.M., showed pressure ulcer dressing change with no odor, less tunneling, and no drainage, and "area seems slightly improved since first of month with tunneling less". No measurements of wound recorded. Review of nurse's notes on 8/3/11 at 10:10 A.M., showed pressure ulcer measurements of 2.5 cm x 1.5 cm x 1.5 cm to the bone, heavy drainage, slough and undermining. (Drainage increased since previous assessment recorded). Review of nurse's notes on 8/6/11 at 1:00 P.M., showed dressing was changed. No assessment or measurement of wound recorded. Review of nurse's notes on 8/10/11 at 10:40 A.M., showed wound measurements of 3 cm x 2 cm (increase of 0.5 cm to both height and width since previous measurement). No assessment of depth, drainage, slough, bone, tunneling or odor recorded. Review of nurse's notes on 8/17/11 at 9:00 A.M., showed wound measurements of 3 cm x 2 cm, visible bone, "does not seem to be undermining on sides". No depth measurement or assessment of drainage, slough or pain documented. Review of nurse's notes on 9/7/11 at 11:25 A.M., showed wound measurements of 3.25 cm x 2.5 cm, bone visible, heavy drainage and slough tissue (increase in size since previous wound measurements). No depth recorded. Review of nurse's notes on 9/14/11 at 8:00 A.M., showed wound measurements of 3.5 cm x 1.5 cm, bone visible, heavy drainage, and slough tissue. (increase of 0.5 cm since previous measurements). No depth recorded. Review of nurse's notes on 9/21/11 at 8:35 A.M., showed wound measurements of 3 cm x 1.5 cm, visible bone, heavy drainage and slough tissue. No depth measurement documented. At 2:00 P.M., DON spoke with the resident's family member regarding the resident's amount of pain while sitting upright. Review of nurse's notes on 10/14/11 at 9:20 A.M., showed culture results all positive [MEDICAL CONDITION] to wound. No wound measurements or assessment recorded. Review of nurse's notes on 10/24/11 at 11:10 A.M., showed wound measurements of 1.3 cm x 2.7 cm with a depth of "about 1 cm deep", visible bone in wound bed covered by "slimy substance", and granulation tissue present along edges of wound bed. Old dressing removed had moderate amount of serous drainage. Review of nurse's notes on 11/24/11 at 2:00 P.M., showed wound dressing was changed. No measurements or assessment of wound documented. Review of the resident's MDS dated [DATE], showed the following: -Cognition was intact for daily decision making; -Total dependence with bed mobility; -Total dependence with transfers; -Nonambulatory (did not walk); -Total dependence with ADLs (activities of daily living); -Assist of two people; -Range of motion impairment to upper and lower extremities (both arms and both legs); -At risk for pressure ulcer with one existing stage IV pressure ulcer; -[DIAGNOSES REDACTED]. Review of nurse's notes dated 12/22/11, showed dressing change completed with large amount of red drainage and foul odor. No depth of wound documented. Review of the physician's orders [REDACTED]. -[MEDICATION NAME] to pack wound loosely daily and PRN (as needed); -Cover with foam dressing. Review of nurse's noted dated 1/4/12, showed wound measurements of 1.5 cm x 1cm (centimeter), heavy exudate (drainage), and granulation tissue. No depth of wound documented. Review of nurse's notes dated 1/11/12, at 6:30 A.M., showed the following pressure ulcer measurements: -1.5 x 1 cm; -Heavy drainage; -Granulation tissue; -No depth of wound recorded. Review of PUSH (a wound assessment tool used to measure pressure ulcers), tool showed the following definitions: - Length x width- do not guess, measure from head to toe and side to side using a centimeter ruler; -Exudate amount- estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudates as none, light, moderate, or heavy; -Necrotic Tissue (eschar)- black, brown, or tan tissue that adheres firmly to the would bed or ulcer edges and may be either firmer or softer than surrounding skin; -Slough- yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous; - Granulation Tissue- pink or beefy red tissue with a shiny, moist, granular appearance; - [MEDICATION NAME] Tissue- for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface; - Closed/Resurfaced- the wound is completely covered with epithelium (new skin); -Total Score- Sum of the scores on the three elements of the tool to derive a total PUSH score. Changes in the score over time provide an indication of the changing status of the ulcer. If the score goes down, the wound is healing. If it gets larger, the wound is deteriorating. Review of pressure ulcer healing chart (using the PUSH tool approach), from 10/12/11 to 1/18/12, showed the following: -10/12/11: Length and width=3 x 1 cm, Exudate Amount=heavy, Tissue Type=slough; -10/19/11: Length and width=3 x 1.5 cm, Exudate Amount=heavy, Tissue Type=slough; -10/24/11: Length and width=2.7 x 1.3 cm, Exudate Amount= moderate amount, Tissue Type= granulation tissue, Total Score= 11; -11/3/11: Length and width=2.6 x 1.2 cm, Exudate Amount= moderate, Tissue Type= granulation tissue, Total Score= 13; -11/6/11: Length and width= not recorded, Exudate Amount= moderate, Tissue Type= granulation tissue, Total Score= 10; -11/16/11: Length and width= not recorded, Exudate Amount= moderate, Tissue Type= granulation tissue, Total Score= 10; -11/23/11: Length and width= 2 x 1.5 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score= 10; -11/30/11: Length and width= 2 x 2 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score= 11; -12/7/11: Length and width= 2 x 2 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score= 11; -12/14/11: Length and width= 2 x 2 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score= 11; -1/4/12: Length and width= 1 x 1.5 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score=9; -1/11/12: Length and width= 1 x 1.5 cm, Exudate Amount= heavy, Tissue Type= granulation tissue, Total Score= 9; -1/18/12: Length and width= 0.8 x 1.0 cm, Exudate Amount= moderate, Tissue Type= granulation tissue, Total Score= 7. Review of PUSH ulcer healing chart dated from 10/12/11 to 1/18/12, showed no measurement of depth of wound. Review of the pressure ulcer tracking form dated 1/19/12, showed a stage IV pressure ulcer to coccyx sacral area measuring 0.8 x 1 cm. Depth was not recorded. Drainage was not recorded. Surrounding tissue assessment was not recorded. Observation on 1/23/12 at 6:08 P.M., showed the resident had a pressure ulcer to the coccyx sacral area (tailbone) with dressing saturated with copious (large) amount of serosanguineous drainage (containing blood and serum), malodorous (strong odor), and soiled with bowel movement. LPN K said that the pressure ulcer was a Stage IV. LPN K said the dressing was only changed once daily and had already been changed that day. LPN K removed soiled, odorous dressing to coccxy sacral (tailbone) pressure ulcer. Dressing noted to be odorous, saturated with serosangenious (containing blood and serum) drainage and BM (bowel movement), and becoming detached from body on upper portion of dressing. LPN K turned the resident onto his/her left side with the assistance of CNA G and NA H, and removed dressing. LPN K layed soiled dressing and soiled gloves on bed near the resident's head. CNA G picked up the soiled items and threw them into the trash bin on floor. LPN K left room. Pressure ulcer remained open to air. LPN K returned to the room at 6:19 P.M. Cleansed pressure ulcer with normal saline wound spray and took a wash cloth off of the resident's towel rack to pat exposed wound dry. CNA L placed trash bin from floor onto bed beside the resident's exposed pressure ulcer. Pressure ulcer packed with [MEDICATION NAME] tightly, covered with gauze and Island dressing (adhesive bandage with holes throughout). Soiled items were disposed of in the trash bin on the bed. Observation of repositioning on 1/24/12 beginning at 7:01 A.M. and ending at 10:23 A.M., showed the following: -At 7:01 A.M., assisted to dining room. Ate 100% peach yogurt and drinking water. Awaited breakfast tray; -At 7:10 A.M., ate fruit, whole sausage patty, scrambled eggs, breat and butter sandwich, and cheerios. Drank ice tea and water. Also given a carton of 2% milk to drink. -At 7:20 A.M., ate and drank 100% of breakfast; -At 8:10 A.M., sat at dining room table waiting to be returned to room; -At 8:55 A.M., still sat at dining room table. No staff beside resident; -At 10:23 A.M., assisted to room. Bathroom privileges (BRP) provided with peri care (washing of genital area). Placed on left side on high-low airflow bed with bedside mat. Country music television turned on, as requested by resident. Staff failed to reposition the resident for almost three and a half hours. 2. Review of #3's Care Plan dated 01/19/12, showed the following: -Braden scale of 17 indicating mild risk for developing pressure ulcers; -To turn and reposition routinely; -Had history of weight loss; -Monitor for pain control. Review of the resident's Physician order [REDACTED]. Review of the resident's Admission assessment dated [DATE], showed no open areas. Review of the resident's shower sheet dated, 01/23/12, 6:00A.M.-2:30 P.M., showed no skin problems. Observation on 01/24/12 at 6:35 A.M., showed the following: -Pressure sore above the coccyx; -Pressure sore inside left inner buttock; -Both were Stage II Pressure sores. (Stage II- partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact of open/ruptured blister.) During interview on 01/24/12 at 6:40 A.M., CNA C said had not seen any open areas on the resident 's buttocks. During interview on 01/24/12 at 6:45 A.M., the resident said he/she had pain on his/her tailbone. Observation on 01/24/12 at 6:48 A.M., showed the following: -He/she sat up in bedside chair; -There was no pressure relief device in the bedside chair. During interview on 01/24/12 at 6:50 A.M., LPN D said the following: -Every Wednesday the charge nurse measured wounds; -There was not a wound nurse; -The charge nurse was responsible for treatments and dressing changes each shift. Observation on 01/24/12 of the resident showed the following: -At 7:50 A.M., he/she sat up in the bedside chair; -At 8:10 A.M., he/she sat up in the bedside chair; -At 8:25 A.M., he/she sat in the bedside chair; -At 8:40 A.M., he/she sat in the bedside chair; -At 9:05 A.M., he /she sat in the bedside chair; -At 9:30 A.M., he/she sat in the bedside chair; -At 9:45 A.M., he/she sat in the bedside chair; -At 10:05 A.M., he/she sat in the bedside chair; -At 10:30 A.M., he/she sat in the bedside chair; -At 10:45 A.M., he/she sat in the bedside chair. (The resident sat in the same position for 2 hours and 55 minutes without staff repositioning him/her.) During interview on 01/24/12 at 10:35 A.M., LPN D said the following: -There were no reports of open areas on the resident's buttocks; -He/she had some problems with reddened areas. During interview on 01/24/12 at 10:40 A.M., CNA E said the following: -When the resident stands up after shower and dried off, they were to look at the skin; -If notice any areas, would call charge nurse to check the skin. During interview on 01/24/12 at 10:45 A.M., the resident said his/her bottom hurt all of the time. Observation on 01/24/12 at 10:50 A.M. showed the following: -LPN D went to the resident's room to look at his/her skin; -Pressure sore to left inner buttock measured 1.6 cm x 1 cm Stage II. -Pressure sore above the coccyx measured 1.0 cm x 0.3 cm Stage II. During interview on 01/24/12 at 11:15 A.M., the Director of Nursing (DON) said the following: -Shower sheet is to be filled out each time resident is in the shower; -Expect non licensed staff to report any open areas, bruises, or redness to the charge nurse. During interview on 01/24/12 at 11:20 A.M., the DON said the following: -Licensed nurses are to note any new areas; -Document on the area; -Notify physician; -Notify family or durable power of attorney; -Sign the shower sheet daily; -Turn it in to the DON for review. Observation on 01/24/12 of the Resident showed the following: -At 12:05 P.M., he/she sat in the bedside chair; -At 12:20 P.M., he/she sat in the bedside chair; -At 12:45 P.M., he/she sat in the bedside chair; -At 1:00 P.M., he/she sat in the bedside chair; -At 1:20 P.M., he/she sat in the bedside chair; -At 1:35 P.M., he/she sat in the bedside chair; -At 1:50 P.M., he/she sat in the bedside chair; -At 2:05 P.M., he/she sat in the bedside chair; -At 2:15 P.M., he/she sat in the bedside chair; (The resident sat in the same position for 2 hours and 10 minutes without the staff repositioning him/her.) 3. Review of Resident #5's MDS dated [DATE], showed the following: -BIMS score (a way of testing cognition) showed the resident was moderately impaired; -Required extensive assistance with one person physical assist with bed mobility; -Required extensive assistance with two person physical assist with transfers and toileting; -Was occasionally incontinent of bowel and bladder; -Was at risk for pressure sores; -No pressure sores. Review of the resident's physician's orders [REDACTED]. Observation on 01/23/12, at 7:25 A.M., showed the following: -Certified Nurse Aide (CNA) E and CNA W were in the resident's room preparing to get the resident up; -Staff checked the resident who was incontinent of urine; -Staff provided front peri care and turned the resident to his/her side; -The resident had a dressing on his/her right buttock; -CNA W removed the dressing from the site, which revealed an open Stage II pressure sore; -CNA W then washed the resident's buttocks and used back and forth and circular motions and washed over the open pressure sore with the same surface of the washcloth; -CNA W then wiped inside the buttock fold and up and over the open pressure sore with the same surface of the washcloth. Observation on 01/24/12, at 9:15 A.M., showed the following: -CNA W and Licensed Practical Nurse (LPN) X transferred the resident to his/her bed; -Staff checked the resident and said he/she was incontinent of urine; -CNA W wiped all around the resident's buttocks and buttock fold and wiped over the resident's open pressure sore (the dressing was off the pressure sore); -The resident was observed to urinate again on the incontinence pad; -CNA W then wiped the resident's buttocks and buttock fold, wiped up and down and all around and wiped over the open pressure sore, then wiped and had a smear of bowel movement on the disposable wipes. During interview on 01/25/12 at 9:20 A.M., CNA W said the following: -Peri care: Staff should wipe front to back; -Never wipe more than twice with the same wipe; -Cleanse in between labia; -Always use gloves; -Never wipe back to front; -Never continuously wipe with a soiled wipe; -Try to wipe once and fold then wipe again; -Use no back and forth or all around motion. 4. Review of Resident #10's MDS, dated [DATE], showed the following: -The resident's cognition was severely impaired; -Required extensive assistance with one person physical assist with bed mobility, transfer and toileting; -Frequently incontinent of bowel and bladder; -Was at risk for developing pressure sores; -No unhealed pressure sores; -No previous ulcers on prior assessment. Review of the resident's care plan reviewed 01/16/12, showed the following: -Category: ADL's (activities of daily living); -Problem: I need extensive assist with all my ADL's; -Approaches: Bed mobility is extensive assist of 1-2, see that I reposition at least every 2 hours; -Toileting assist of 1-2, I am occasionally incontinent if not toileted on schedule; Category: Pressure sores; -Problem: I have occasional bowel and bladder incontinence plus decreased mobility and at risk for skin breakdown; -Approaches: Assist me to reposition routinely; -Encourage intake of adequate fluids on all shifts; -Sometimes I wiggle a lot in my chair and this could cause sores. Observation showed the following: -On 01/23/12, at 3:10 P.M., to 5:03 P.M., the resident was observed in the sitting room area, lying in the recliner chair covered with a blanket asleep; -At 5:03 P.M., staff assisted the resident into his/her wheelchair and took to the dining room; -At 5:15 P.M., the resident received his/her food tray, and staff assisted him/her with eating his/her meal; -At 5:45 P.M., the resident remained eating his/her meal in his/her wheelchair. (The resident remained positioned on his/her buttocks for at least 2 hours and 35 minutes). Observation on 01/24/12, showed the following: -At 5:40 A.M., the resident sat in his/her wheelchair, in the dining room at the table, no fluids offered; -At 6:00 A.M., the resident remained in the dining room in his/her wheelchair; -At 6:35 A.M., the resident remained in the dining room in his/her wheelchair; -At 6:55 A.M., the resident remained in the dining room in his/her wheelchair and staff served the resident his/her fluids; -At 7:15 A.M., the resident remained up in his/her wheelchair at the dining room table; -At 7:30 A.M., the resident remained up in his/her wheelchair asleep at the dining room table; -At 7:45 A.M., the resident remained up in his/her wheelchair asleep at the dining room table; -At 7:55 A.M., Certified Nurse Aide (CNA) E served the resident his/her breakfast food tray; -At 8:30 A.M., the resident remained sitting in his/her wheelchair at the dining room table asleep, staff remained at the table; (The resident had not been repositioned for at least two hours and 50 minutes); -At 9:00 A.M., the resident remained sitting in his/her wheelchair at the dining room table asleep; -At 9:15 A.M., the resident remained sitting in his/her wheelchair at the dining room table asleep; -At 9:45 A.M., the resident was sitting in the recliner chair asleep; -At 10:05 A.M., the resident remained sitting in the recliner chair asleep; -At 10:30 A.M., the resident remained sitting in the recliner chair asleep; -At 11:00 A.M., the resident remained sitting in the recliner chair asleep; -At 11:30 A.M., the resident remained sitting in the recliner chair asleep; -At 11:45 A.M., the resident was sitting in the wheelchair at the dining room table and staff had served the resident his/her fluids; -At 12:20 P.M., the resident was served his/her food tray; -At 12:45 P.M., the resident remained sitting in his/her wheelchair at the dining room table. (The resident had not been repositioned for at least 3 hours and 45 minutes). During interview on 01/25/12 at 10:00 A.M., CNA E said he/she had worked with the resident quite a bit; -He/she said the night shift gets the resident dressed and up; -When he/she comes on duty at 6:00 A.M., the resident is up in the recliner chair; -Out of the recliner chair shortly 7:00 A.M., to his/her wheelchair and ask to go to bathroom, sometimes says yes and sometimes says no; -Staff checks the resident every two hours for incontinence, and usually incontinent of bowel and bladder; -Then taken to dining room table for meal; -Assist with feeding him/her if needed; -Take him/her to bathroom; gets back in the wheelchair and then goes to the recliner chair and takes naps there; -Resident stays in the recliner chair; -He/she said the resident was never in bed during the day. He/she said repositioning was to stand up or transfer, to get the resident off the skin area he/she had been on. He/she said residents are to be turned and repositioned every 2 hours. If on buttocks or back, staff should either reposition them on their right or left side. Observation on 01/25/12 at 10:55 A.M., showed the following: -CNA E put the resident to bed; -CNA E checked the resident who was incontinent of urine; -There was no redness to the resident's front peri area; -The resident was turned to his/her side, the resident's coccyx (tailbone) and lower right buttock was red. 5. During interview on 02/03/12, at 8:35 A.M., LPN K said residents should be turned and repositioned at least every 2 hours or more often depending on the resident. If a resident had a pressure sore or bed bound, staff should check every hour and if needed repositioned do so. He/she said repositioning means from side to side, side to back, to get off the body part was on to relieve pressure. He/she said during peri care, staff should wipe front to back and start at the front genitalia area and then turn the resident for back peri care. Staff are to wipe one wipe and change the cloth or cloth site. He/she said there should not be any back and forth, up or down or circular motion. He/she said staff are to use a clean cloth site after each wipe. He/she said the CNA's are absolutely not to remove dressings off pressure sores and are not to wipe over an open pressure sore during peri care. He/she said the pressure sores were to be cleansed ny the nurse. He/she said by wiping over open pressure sores during peri care can contaminate it and cause infection.

Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision to prevent falls to two of 18 sampled residents (Residents #5 and #7) and adequate assistance during transfer of one resident (Resident #4) who required a mechanical lift. The facility failed to ensure the environment remained free of accident hazards by having hot water temperature exceeding 120 degrees Fahrenheit (F.) for one sink outside the kitchen entrance which was accessible to all residents in the dining room. The facility census was 78. 1. Review of Resident #5's fall risk profile dated 09/18/11, showed the following: Fall history: Had a fall in the past 30 days and had one fall in the past 31-180 days; -He/she had a score of 9, a score of 6 or more represents high risk. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/19/11, showed the following: -BIMS (an assessment to evaluate cognition) score was 10, which was assessed as moderately impaired; -Cognitive decision-making was severely impaired; -Needed extensive assist with one person physical assistance with bed mobility; -Needed extensive assistance of two people with transfers and toileting; -The lower extremity had impairment with ROM (range of motion) on one side; -The resident was occasionally incontinent of bowel and bladder; -Had one fall since prior assessment. Review of the resident's Care Plan reviewed 12/21/11, showed the following: Category: ADL's (Activities of Daily Living); Problems: Needed limited to extensive assist to maintain ADL's; Approaches: My mental function varies day to day and hour to hour, staff to adjust care to meet my needs; -Transfers are extensive assist of 1- 2, use a gait belt with contact guard assist. Verbal cueing needed with task; -Ambulation extensive assist of 2, using wheeled walker, gait belt with contact guard assist; -Toileting extensive assist of 2, I am occasionally incontinent of bowel and bladder. I wear medium pull-ups daytime and medium briefs at night. Do not leave me alone while on the toilet. Category: Cognition; Problem: I have dementia my level of understanding fluctuates day to day, hour to hour, and minute to minute; Approaches: Assess my mental status quarterly; -Explain tasks as you are doing them step by step. Category: Falls; Problem: My last fall risk profile placed me at high risk to fall d/t (due to) my need for assist with tasks. I have had 7 falls this last year; Approaches: Assess my footwear for proper fit and non-skid soles; Cueing reminders to use call light to seek assist with tasks, keep call light in reach; -Observe me for gait unsteadiness during transfers, turns, etc; -Observe my routine in my personal environment; -Consistent reminders needed for proper use of assistive devices, (walker, w/c) (wheelchair); -Assess my medication use routinely; -Keep my bed in low position with a mat beside while I am in bed; -Do not leave me alone when I am on the toilet/commode; -Place pad alarm in my wheelchair and bed for safety, answer alarm promptly when sounding; -See ADL section for staff assist with tasks. Category: Urinary; Problem: I am toileted on schedule, but still occasionally incontinent of bowel and bladder; Approaches: Implement a scheduled toileting plan; -Do not leave me alone while on toilet. Review of the resident's nurses notes showed the following: -On 01/13/12 at 12:30 P.M., resident found lying on the bathroom floor; - He/she had been placed on the bathroom stool and left alone for a few minutes; -He/she had large hematoma developing on left forehead; -Ice applied; -After standing and returning to bed, he/she complained of pain when proximal femur (long bone in upper leg) was touched; -The left leg is possibly a tiny bit shorter, but no external rotation; -On 01/13/12 at 1:00 P.M., the physician was notified and order received for hip x-ray. Review of the physician's orders [REDACTED]. -On 01/13/12, at 1:15 P.M., a nurse received an order for [REDACTED]. Review of the resident's Mobile Diagnostics (mobile x-ray) dated 01/13/12, showed the following: -Pelvis/Hip; -History fall/pain; -Two views of left hip were obtained; -Findings: Suspicious for possible left subcapital (below the capsule) femoral neck fracture. Suggest clinical correlation and strongly advise further evaluation with CT (computed tomography)/MRI (magnetic resonance imaging) of the left hip. Review of the hospital report dated 01/16/12, showed the following: History of present illness: The patient actually had a fall this past Friday (01/13/12). He/she hit his/her head and just has not been walking. He/she normally does not walk much, he/she just stands and pivots and has made complaints of pain; -HEENT (head, ears, eyes, nose and throat): He/she had two contusions (bruise) on his/her head; Ancillary: X-rays were reviewed. CT reviewed. There is an impacted left femoral neck fracture; -Impression and plan: Percutaneous (through the skin) screw fixation; -Postoperative Diagnosis: [REDACTED]. During interview on 01/25/11 at 9:05 A.M., Certified Nurse Aide (CNA) A said he/she was the CNA working with Resident #5 on 01/13/12. He/she said at 12:30 P.M., he/she went to toilet the resident and the resident needed assistance of one or two persons to toilet. He/she said someone asked him/her to go do something and he/she left the resident on the commode and was gone 10 to 15 minutes and when he/she returned, the resident was on the floor. He/she said the resident was on the floor on his/her left side, and had hit his/her head. He/she said there was a bump on his/her left side of forehead above the eye. He/she said he/she did not move the resident and got the nurse. 2. Review of Resident #7's Fall Risk Profile with admitted [DATE], showed the following "Risk Elements": -Uses assistive devices (i.e., wheelchair, walker, cane); -Three or more room transfers; -Primary [DIAGNOSES REDACTED]. -Fall history was not marked; -Total score was not recorded (Staff did not complete the assessment ). Review of the resident's admission MDS dated [DATE], showed the following: -admitted on [DATE] from the hospital; -Had moderately impaired cognition; -Had moderate depression; -Transferred and walked with minimal assistance of one staff. Review of the November, 2011 physician orders [REDACTED]. - [DIAGNOSES REDACTED]. -Medications included: -Coreg (for high blood pressure) 3.125 milligrams (mg) one twice a day. To hold if pulse less than 60 or SBP (systolic blood pressure less than 110); -Celexa (for depression) 20 mg one every day (increased to two tablets or 40 mg every day on 11/21/11); -Xanax (for anxiety) 0.25 mg one tablet every 8 hours as needed for anxiety; -Norco 5-235 mg one tablet every 4 hours PRN (as needed) for pain; -Physical Therapy (PT) five times a week to include gait training. Review of the December, 2011 physician orders, signed by physician 12/08/11, showed the following: -Added [DIAGNOSES REDACTED]. -On 12/10/11, the resident may be up ad lib (on own) in facility with wheeled walker. Review of the resident's care plan for Falls dated 12/06/11, showed the following: -Problem: Getting stronger but still have some weakness due to post/op surgery and at risk to fall; -Approaches included: Have been transferring, walking, and toileting independently in room. Staff to encourage assistance of one for safety; -Assess footwear for proper fit and non-skid soles; -Keep call light within reach; -Keep room clutter free; -Encourage use of walker and wheelchair for safety; -Monitor for shortness of breath on exertion and provide oxygen at 2 liters N/C continuous and wean off as able; -Give breathing medications as directed Advair, Spiriva, Duonebs; -Observe for gait unsteadiness; -Encourage to participate and follow PT/OT (Physical Therapy/Occupational Therapy) recommendations for strengthening; -Teach proper use of walker and wheelchair; -Teach to identify own physical limitations; -Encourage hand rails and grips in bathroom; -Assess for pain and treat as directed. (Facility did not address the fall on 12/18/11 and include interventions to prevent another fall.) Review of the Daily Nursing Assessment notes dated 12/11/11, showed the following: -At 3:25 A.M., the resident's blood pressure was 210/100 (normal blood pressure is 120/80); -At 3:35 A.M., the physician was notified and staff received an order for [REDACTED]. -At 5:00 A.M., blood pressure in the left arm was 160/96 and in the right arm, the blood pressure was 176/98. Review of the Daily Nursing Assessment notes dated 12/11/11, showed the following: -The blood pressure for the 10 pm- 6:00 A.M. shift was 160/100 (high blood pressure); -At 8:45 A.M., staff documented the resident's blood pressure was elevated last night and the resident was complaining of feeling weak and slightly dizzy. The resident's temperature was 99.3 degrees. (Staff failed to document if this was an oral temperature); -Staff instructed the resident to call for assistance today prior to getting up. Review of the Daily Nursing Assessment notes dated 12/12/11, showed the following: -At 10:30 A.M., the resident's sitting blood pressure was 84/64 and standing blood pressure was 80/60 and becomes weak and faint when up. (low blood pressure as readings lower than 90 systolic or 60 diastolic - you need to have only one number in the low range for your blood pressure to be considered lower than normal); -At 11:30 A.M., staff rechecked the blood pressure which was 150/98 (high blood pressure), and resident complained of things swirling around; -The resident had been walking in the hallway and then returned to bed, and complained of a headache. The blood pressure was 170/110 (high blood pressure); -At 2:00 P.M., staff notified the physician of the blood pressure fluctuations and the physician ordered hydrochlorothiazide in attempt to normalize the blood pressure. Review of a physician order [REDACTED]. Review of the laboratory report dated 12/13/11 showed the resident's potassium (an electrolyte) was 3.4 Low (normal range was 3.5-5.4 mEq/L). Review of the Daily Nursing assessment dated [DATE], showed the following: -On the 6 A.M.-2:00 P.M. shift, the blood pressure was 164/100 (high blood pressure); -At 10:00 A.M., the resident continued to ambulate around in room by him/herself quickly becomes weakened and tired and has to sit down, return to bed, or lay down. --- -The resident continued to be tearful; -On the 2 P.M.-10:00 P.M. shift, the blood pressure was 140/80; -On the 10 P.M.-6:00 A.M. shift, the blood pressure was 186/92 (high blood pressure); -At 1:15 A.M., the resident complained of headache and Norco (for pain) given. Review of the Daily Nursing assessment dated [DATE], showed the following: - On the 10 P.M.-6:00 A.M. shift, the blood pressure was 140/70; -At 2:00 A.M., staff assisted the resident to the bathroom. The resident's gait was unsteady and he/she complained of feeling lightheaded. The resident required assistance of lifting feet into bed. Review of the physician order [REDACTED]. Review of the Daily Nursing assessment dated [DATE], showed the following: -On the 6 A.M.-2:00 P.M. shift, the blood pressure was 100/82; -At 1:00 P.M., the resident had been more sedated and somewhat lethargic today since dose of Xanax has been increased. Family visited and concerned about the increased dose of Xanax as it had caused the resident to be very dizzy before and made him/her a fall risk; -At 1:40 P.M. spouse called and requested that the resident's medication be changed back to Xanax 0.25 mg PRN; -At 1:50 P.M., staff received order for above change; -At 4:00 P.M., the resident rested in bed and complained of a headache. Staff encouraged the resident to get out of the bed; -On the 2 P.M.-10:00 P.M. shift, the blood pressure was 142/76; -On the 10 P.M.-6:00 A.M. shift, the blood pressure was 160/70 (high blood pressure). Review of the Daily Nursing assessment dated [DATE] showed the following: -On the 6 A.M.-2:00 P.M. shift, the blood pressure was 154/60 (high blood pressure); -At 9:15 A.M., the resident was resting in bed with eyes open. Staff encouraged the resident to get out of bed with no success; -At 4:05 P.M., the resident's blood pressure was 144/100 (high blood pressure) and pulse was 92 (normal ranges 60-100 beats per minute). The resident was up to therapy and using the "pedals" with his/her arms. The resident complained of dizziness and therapy brought him/her back laid him/her down. Staff notified the physician's office and left a message; -At 4:20 P.M., the blood pressure was 190/120 (high blood pressure); -At 4:25 P.M., the blood pressure was 190/118. The physician called back and discussed condition, including decreased appetite and continued signs of depression. The physician gave a new order to give Coreg 3.125 mg times one now and check blood pressure in 30 minutes ; -At 5:15 P.M., the physician called back. Blood pressure was 190/110. The physician advised to give a 6:00 P.M. Coreg at 5:45 P.M. if blood pressure was still up, call him back if it did not go down; -At 5:45 P.M., blood pressure was 160/80(high blood pressure). The resident complained of headache and staff administered Tylenol along with Coreg; -Staff rechecked blood pressure at 8:35 P.M. and blood pressure was 158/62; -At 11:30 P.M., the resident was awake and complained of severe frontal headache and crying. Blood pressure was 180/100 (extremely high blood pressure). The resident wanted the nurse to stay with him/her. Xanax given for anxiety; -At 12:30 P.M., the resident was sleeping. Blood pressure was 138/100 ( blood pressure was high); -At 4:50 A.M., the resident awake with complaint of headache. Blood pressure was 180/100(high blood pressure) and physician notified. New orders to give Coreg 3.125 mg one now and Vicodin (for pain) one now; -On the 10 P.M.-6 A.M. shift, staff documented blood pressure was 138/100 (blood pressure was elevated). Review of the Daily Nursing Assessment Report dated 12/17/11, showed the following: -At 9:00 A.M., staff recorded the resident was cheerful and smiling and had no complaints; -On the 6 A.M.-2 P.M. shift, the resident's blood pressure was 120/70; -At 4 P.M., the resident laid down in the bed with lights off and door shut. The resident spoke, very shaky, and slow but had no complaints; -At 6:10 P.M., the resident's blood pressure was 170/100 (high blood pressure). The resident was upset and crying. Staff notified the physician who gave new order for blood pressure medications and to start now. Review of the unsigned physician order [REDACTED]. Staff was to hold the medication if pulse was less than 60 or SBP (systolic blood pressure) was less than 110. Review of the MAR for 12/17/11 at 6:30 P.M., showed staff administered one extra Coreg 3.125 mg to the resident (At 6:10 P.M. the resident's blood pressure was 170/100). Review of the Daily Nursing Assessment form dated 12/17/11, showed the following: -At 9:35 P.M., the resident's blood pressure was 150/88.( high blood pressure); -At 10:40 P.M., the resident requested a Tylenol for headache and staff administered; -At 2:30 A.M., the resident complained of a headache and said the Tylenol did not help the pain. Staff administered a Norco (narcotic pain reliever) one tablet. Review of the MAR dated 12/18/11 at 9:00 A.M. showed LPN Y checked the resident's blood pressure which was 118/72 and pulse was 35 (low), and did not administer the Coreg 3.125 mg two tablets to equal 6.25 mg (Staff failed to increase supervision after his/her blood pressure dropped and pulse was below normal). Review of the CDC (Centers for Disease Center) website showed the following: - A sudden fall in blood pressure can also be dangerous. A change of just 20 mm Hg - a drop from 110 systolic to 90 systolic, for example - can cause dizziness and fainting when the brain fails to receive an adequate supply of blood. Review of the Daily Nursing assessment dated [DATE], showed the following: -At 9:55 A.M., staff found the resident lying on his/her back on the floor; -When staff attempted to assist him/her to stand, the resident complained of severe low back pain and would not let staff stand him/her up; -Staff laid the resident flat on floor and used a transfer board to lift resident on to the bed; -Vital signs checked and pulse rate was 33 (low pulse rate) but then came up to 73; -Blood pressure was 204/102 (extremely high blood pressure); -Staff notified the physician to send to the emergency room ; -At 10:15 A.M., the resident's blood pressure was 190/102; -At 10:30 A.M., the resident's blood pressure was 176/60; -At 10:45 A.M., ambulance arrived and transported to emergency room . Review of the Patient Transfer Form dated 12/18/11, showed the following: -The resident had surgery in November, 2011 for aneurysm repairs and had been having problems with blood pressure since then, worse lately; -Blood pressures will fluctuate from very high to normal and then have severe postural hypotension (low blood pressure); -Pulse rate varies today from 33 to 73; -The resident was found on the floor this a.m. at 9:55 A.M. and complained of severe low back pain. Review of the lab report dated 12/18/11 showed the potassium level was 2.9 Low.(Normal range 3.5-5.4). Review of the Daily Nursing assessment dated [DATE] showed the following: -At 4:00 P.M., LPN K spoke with the nurse about resident coming back to facility. The nurse reported a low potassium level at 2.9; -At 4:20 P.M., the family brought the resident back to facility with new order for potassium and Xanax. Vital signs were 47 AHR (a low apical heart rate), a 50 radial pulse (low pulse), and blood pressure was 160/88 (high blood pressure) , heart beat very slow, 2 beats with a long pause followed by 2 beats and repeated; -At 7:00 P.M., the resident's blood pressure was 122/82 and heart rate 62. During interview on 01/23/12 at 10:20 A.M., the DON (Director of Nursing) said the following: -Resident had aneurysm repair before coming to facility; -Had fluid loss; -The resident to see a physician today about his/her blood pressure. During interview on 01/23/12 at 10:20 A.M., the resident said the following: -He/she was on two medications for blood pressure and would like to be off these medications; -Was not in pain but was weak. 3. Review of Resident #4's MDS, dated [DATE], showed the following: -The resident had short term and long term memory problems; -Required total assistance with 2 person physical assist with bed mobility, transfers, and toileting. Observation on 01/23/12, at 4:45 P.M., showed the following: -Certified Nurse Aides (CNA's) Q and R placed the lift sling under the resident; -Attached the sling to the mechanical lift; -CNA Q operated the mechanical lift; -When the resident was off the bed staff did not widen the base of the lift, turned the resident around to face the wheelchair, moved the lift with the resident over to the wheelchair before the base of the lift was widened. Staff widened the base of the lift to get it around the wheelchair. Observation on 01/24/12 at 6:40 A.M. showed the following: -CNA S and CNA T were in the resident's room; -CNA T hooked the sling to the mechanical lift and operated the lift; -CNA T moved the lift away from the bed, did not widen the base of the lift, turned the resident with the lift around to face the wheelchair, moved the lift over to the wheelchair before the base of the lift was widened. Staff widened the base of the lift to get it around the wheelchair. During interview on 01/24/12, at 6:50 A.M., CNA T said he/she was supposed to widen the mechanical lift legs, but he/she just forgot to during the transfer. Review of the manufacturers manual for the Invacare Reliant 450 mechanical lift, showed the following: -Category: Number 6 operation under 6.1 Introduction, warning; -The legs of the lift must be in the maximum open position for optimum stability and safety; -If it is necessary to close the legs of the lift to maneuver the lift under the bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed; -When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. 4. Observation on 01/23/12 at 5:11 P.M. showed the following: -Two staff washed hands at small sink next to the kitchen door in the dining room. One nurses aide told another nurses aide that the water was hot and burning and to be careful when washing hands. Observation on 01/24/12 at 10:25 A.M., at the small sink showed the hot water was 147.3 degrees F. when measured with a digital thermometer. During interview on 01/24/12 at 10:25 A.M., the Dietary Supervisor said that he/she had never saw any residents using the sink but that staff dumped coffee into the sink and used it for washing their hands. During interview on 01/24/12 at 11:40 A.M., the Administrator said she was unaware of any residents that used this sink. Observation on 1/24/12 at 11:50 A.M., showed staff had shut off the hot water to the sink until the temperature was safely regulated. Complaint MO