Every finding on record at Baptist Homes, Tri-County

Based on observation, interview, and record review, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety. The facility census was 58.Review of the facility policy, Sanitization, revised November 2022, showed the following:-The food service area is maintained in a clean and sanitary manner;-All kitchens, kitchen areas and dining areas are kept clean;-All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 1. Observations in the kitchen on 3/2/26 between 10:45 A.M. and 3:30 P.M., and on 3/3/26 between 8:30 A.M. and 3:40 A.M., showed the following:-A ceiling-mounted air unit, located above the coffee machine and clean cups, had a heavy buildup of oily substance, dust and debris on the bottom vent area;-A ceiling-mounted air vent, located between the clean coffee cup area and clean side of dishwasher area, had a moderate buildup of dust and debris;-A ceiling-mounted air vent, located above the dishwasher, had a heavy buildup of dust and debris;-A ceiling-mounted air unit, located above a preparation table, food processor, and blender, had a moderate buildup of oily substance, dust and debris on the bottom vent area;-A ceiling-mounted air unit in the preparation sink area, had a heavy buildup of oily substance, dust and debris on the bottom vent area;-A ceiling-mounted air unit to the left side of the K-fire extinguisher, had a heavy buildup of oily substance, dust and debris on the bottom vent area;-The sprinkler system drain piping, located next to the coffee maker, had a moderate buildup of dust and debris;-The electrical box, located behind the coffee maker, had a heavy buildup of oily substance, dust and debris;-The wall-mounted exhaust fan, located between the tea dispenser and coffee maker, had a moderate buildup of dust and debris;-The steamer oven, positioned between the white upright freezer and meat slicer, had a moderate buildup of oily substance, dust and debris on the top surface;-The top surface of the white upright freezer had a moderate buildup of dust and debris;-Two wall-mounted fire suppression control boxes and piping systems, located above a food preparation table containing clean Styrofoam plates, foil wrap box and floor mixer, had a moderate to heavy buildup of oily substance, dust and debris;-The front and the left side of the deep fryer had a heavy buildup of oily substance, brown and yellow crusted material, and liquid runs;-The front and sides of the four-burner stovetop/oven had a moderate buildup of an oily substance, food runs and debris;-The top and sides of the four-door upright oven had a moderate to heavy buildup of oily substance, dust and debris;-The top of the two-door upright refrigerator had a moderate to heavy buildup of dust and debris. During an interview on 3/2/26 at 2:20 P.M., Dietary Aide I said dietary staff did not have any specific daily, weekly, or cleaning duties. Everyone was supposed to clean as they go. If staff are using something or an area, they should clean it. Everyone should work as a team. A sheet was kept on the preparation table of things evening staff were to complete before the shift ended. Some examples of things to complete were sweeping and mopping the kitchen, wipe down the counters, change the steam table water, and sweet and mop both dining rooms. During an interview on 3/3/26 at 10:30 A.M., the Dietary Manager said the following:-She was not aware of the condition of the identified areas. She expected the identified areas to be in a clean and sanitized condition;-Staff cleaned these areas at least once a month; -When staff used an item, they should clean it or take care of the situation;-Staff completed general cleaning daily and between meals;-When staff noticed unclean items, they should clean the item and notify her. -The dietary department had no set daily, weekly and monthly cleaning lists or logs.

Based on observation, interview and record review, the facility failed to have an adequate audible system for residents to signal nursing staff for assistance and failed to ensure staff responded to call lights timely for two residents (Resident #19 and Resident #2) in a review of 19 sampled residents and two additional residents (Resident #39 and Resident #32). The facility census was 58. Review of the facility policy titled Resident Call System dated [DATE] showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation;-Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor;-Call system communication may be audible or visual. The system may be wired or wireless;-The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional;-If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan;-The resident call system is routinely maintained and tested by the maintenance department;-Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately. 1.Review of the facility's exception for a wireless call light system, granted by the state agency on [DATE], showed an exception regarding the omission of indicator lights at the corridor entrance of each bedroom, and audible signals and indicating panels in each utility room which expired on [DATE]. Observation on [DATE] at the [NAME] Nurses' Station showed the following:-At 12:33 P.M. room [ROOM NUMBER] and room [ROOM NUMBER] were lit up green on the kiosk (signaling the call light was activated). The kiosk indicated the call lights were activated at 12:13 P.M. There was no light on outside room [ROOM NUMBER] and room [ROOM NUMBER];-At 12:37 P.M. room [ROOM NUMBER] and room [ROOM NUMBER] were lit up red on the kiosk (signaling the call light was activated). At 12:37 P.M. the call lights were answered by staff (24 minutes after the call light was activated);-At 12:39 P.M. room [ROOM NUMBER] was lit up green on the kiosk (signaling the call light was activated). There was no light on outside room [ROOM NUMBER];-At 12:49 P.M. room [ROOM NUMBER] was lit up red on the kiosk (signaling the call light was activated).There was no light on outside room [ROOM NUMBER];-At 12:55 P.M. Licensed Practical Nurse (LPN) E told Certified Nurse Aide (CAN) K that room [ROOM NUMBER] was lit up red on the kiosk and the call light needed to be answered;-At 12:55 P.M. the Assistant Director of Nurses (ADON) answered the call light in room [ROOM NUMBER] (16 minutes after the call light was activated);-A pager sat on the [NAME] Nurses' Station. It intermittently softly beeped three times in a row. 2. During an interview on [DATE] at 1:40 P.M. Resident #19's family member said the following:-The resident had lived at the facility approximately six months and previously lived at another facility;-The resident has a history of falls prior to admission to this facility;-The resident was on hospice and needed more help with activities of daily living;-The resident pushes his/her call light and must wait 30-35 minutes for staff to respond;-One day the resident called him/her because the resident had pushed his/her call light, and no staff came. He/She told the resident not to get up without help until he/she got to the facility. When he/she got to the facility, the resident's call light was still on, and no staff had come in to help. The resident still needed assistance;-He/She has talked to the Administrator about the prolonged call light response time and the Administrator told him/her to have the resident push the call light every five minutes until staff responded. 3. During an interview on [DATE] at 2:05 P.M. Resident #33 said sometimes it takes a very long time for staff to answer call lights. 4. During a group interview on [DATE] at 10:04 A.M. Resident #32 said he/she has waited two hours for his/her call light to be answered by staff. 5. During an interview on [DATE] at 12:28 P.M., Certified Nurse Assistant (CNA) L said the following:-The call lights made an audible chime at the nurses station, and there was a monitor at the nurses station that showed the room where the call light was activated. The indicator lights outside the resident rooms above the doors did not work;-Staff were to carry pagers, but no one carried them. Staff listened for the audible chime at the nurses station or check the call light monitors. This was the only way to know if a call light was activated. During an interview on [DATE] at 8:10 P.M. CNA C said the following:-There was only one pager for the [NAME] Wing, and it stayed at the nurses' station;-The pager beeps three times when a call light is activated;-The call lights do not sound down the hallway;-Staff know a call light is activated if they hear the pager sound or look at the kiosk at the nurses station;-No light comes on outside the resident's room when a call light is activated;-Staff don't carry pagers with them when on duty;-If he/she was in a room with a door shut and a call light activated, he/she could not hear the call light. 6. Review of Resident #2's care plan, last reviewed [DATE], showed the following: -The resident had an ADL self-care performance deficit related to hemiplegia (loss of motor function on one-half side of the body, usually after a stroke), and impaired balance; -The resident required a mechanical lift with two staff for assistance with transfers. Review of the resident's quarterly MDS, completed by facility staff on [DATE], showed the following: -Cognitively intact; -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Dependent for toileting; -Diagnosis of stroke. Observation on [DATE] at 9:01 A.M. showed the resident's room number highlighted in green (indicating the resident requested nursing assistance) on the kiosk positioned and secured to the wall in the 200-hall, no sound was emitted from the kiosk. During an interview on [DATE] at 9:01 A.M. the resident said he/she put the call light on because he/she needed to use the bathroom. Observation on [DATE] at 09:40 A.M. showed the resident's room number highlighted in red (indicating the resident had waited greater than 15 minutes for nursing staff) on the kiosk that positioned and secured to the wall in the 200-hall, no sound was emitted from the kiosk. Observation on [DATE] at 09:40 A.M. showed Certified Nurse Aide (CAN) O and another unidentified staff entered the resident's room and asked him/her what he/she needed, then closed the resident's door behind them. Continuous observation showed the resident's call light was on for 40 minutes before facility staff responded. During an interview on [DATE] at 9:55 A.M., the resident said the following: -This morning, he/she had to use the bathroom when he/she put the call light on; -He/She has had to wait for nursing staff for a long time; -It was very frustrating to have to wait that long. During an interview on [DATE] at 4:04 P.M., the Assistant Director of Nursing (ADON) said the following:-The call light system was wireless;-The lights above the doors did not work and staff do not carry pagers;-There were pagers for the call light system, and they were mounted at the nurses station. Staff did not carry the pagers anymore because staff kept losing them or took them home. The pagers were too expensive for the facility to replace;-There were call light monitors mounted at the nurses station and down the hallway. Staff were trained to check the monitors every time they exited a resident room. During an interview on [DATE] at 5:47 P.M. the Director of Nursing (DON) said the following:-The facility did not have enough pagers for all staff to carry;-She did not monitor call light response times but does look at the kiosks when she was on the hall. If it was red, she directed staff to answer the call light;-She has not seen any call light logs showing call light response times;-She thought staff could hear the call lights and check the kiosks;-Call lights should be answered quickly;-It was not appropriate for staff to answer a call light and shut it off without providing the care needed unless staff needed to get additional help. During an interview on [DATE] at 12:35 P.M. the Administrator said the following:-It would not be appropriate for residents to have to wait 30 minutes or more for their call light to be answered and needs to be met;-The facility does not do any active monitoring of call light response time;-Information was obtained from resident council meeting regarding prolonged call light response time and that was taken to the Quality Assurance (QA) department;-He does not have access to the call light logs;-He was unaware the facility's exception for the wireless call light system was expired.

Based on observation, interview, and record review, the facility failed to ensure staff served food that was palatable and served at a safe and appetizing temperature. The facility census was 58.Review of the facility policy, Food Preparation and Services, revised November 2022, showed the following:-Proper hot and cold temperatures are maintained during food distribution and service; -Food and nutrition services staff are to monitor the temperatures of foods held in the steam tables throughout the meal service. 1. Review of the Resident Council Minutes, dated 01/08/26, showed the following:-The vegetables were cooked too long;-The food on the west hall was cold. Staff explained to the residents the plate warmer broke, and they were working on getting a new one. During an interview on 03/02/26 at 2:33 P.M., Resident #3 said the following:-Saturday night there was some kind of casserole on his/her plate that was unrecognizable. It didn't look appetizing, and he/she couldn't eat it;-The food was horrid and didn't taste good;-The meat was tough and hard to chew;-The residents complained to the facility about the food and nothing was done. The food was still bad. During an interview on 03/02/26 at 1:25 P.M., Resident #32 said the following: -He/She ate all meals in the dining room; -The food was often served cold;-He/She reported this during resident council meetings, but nothing was ever done. During a resident council meeting on 03/04/26 at 10:00 A.M., several residents in attendance reported the food was often served cold. 2. Review of lunch menu for 03/03/26 showed the lunch meal included meatloaf, mashed potatoes, and mixed vegetables. Observation on 3/3/26 at 11:17 A.M., showed staff took serving temperatures of the following food items at the steam serving table prior to beginning the meal service: -Meatloaf, 190 degrees Fahrenheit;-Mashed potatoes, 185 degrees Fahrenheit;-Mixed vegetables, 190 degrees Fahrenheit. Observation on 3/3/26 at 11:19 A.M., showed the following:-Dietary staff began serving the lunch meal from the steam table;-Staff placed the prepared plates on trays in the electric temperature-controlled, insulated food cart;-The temperature in the food cart was 153 degrees Fahrenheit. Observation on 3/3/26 at 11:41 A.M. showed dietary staff prepared the final lunch plate (test tray), placed it in the food cart, and transported the cart to the west dining room. Observation on 3/3/26 at 11:45 A.M., showed dietary staff arrived at the west dining room with the food cart. Staff plugged in the cart. The temperature in the cart was 137 degrees Fahrenheit. Observation on 3/3/26 at 11:47 A.M., showed staff began serving lunch trays to the residents in the west dining room. Staff served the last tray in the dining room at 11:58 A.M. The temperature in the cart was 116 degrees Fahrenheit. Observation on 3/3/26 at 12:04 P.M., showed the temperature in the cart was 130 degrees Fahrenheit. Staff unplugged the cart and began serving room trays beginning with room [ROOM NUMBER] and ending with room [ROOM NUMBER] (eight trays). Observation of the test tray on 3/3/26 at 12:18 P.M., after staff served the last resident, showed the following: -The meatloaf was cool to the taste, and the temperature was 111.7 degrees Fahrenheit;-The mashed potatoes and gravy were cool to the taste, and the temperature was 107.4 degrees Fahrenheit;-The mixed vegetables were cool to the taste, and the temperature was 112.2 degrees Fahrenheit. 3. Observation on 03/04/26 at 12:15 P.M. of a test tray at the lunch meal showed the following:-The turkey crunch was very salty, and the turkey pieces were hard to chew;-The stuffing was dry and had minimal flavor;-The chocolate cake was dry. During an interview on 03/04/26 at 12:02 P.M., Resident #37 said the following:-He/She didn't eat all his/her lunch;-The turkey was too hard to chew, so he/she didn't eat it. During an interview on 03/02/26 at 2:29 P.M. and 03/04/26 at 12:08 P.M., Resident #41 said the following:-The food was awful;-The turkey crunch tasted awful, so he/she only ate a bite of it;-The food was bland and had no taste;-The meat was too tough to chew. 4. During an interview on 3/4/26 at 3:40 P.M., the Dietary Manager said the following:-She was not aware the food temperatures for the 03/03/26 lunch meal was below 120 degrees Fahrenheit;-The cooks took the temperature of the food before moving the food items to the steam table and before meal service began; -The residents occasionally reported the food was cool and had concerns with the texture of foods;-The dietary department received a heated hall cart a few weeks ago, and she had only received a couple concerns with the food temperatures since implementing the new cart;-Dietary staff should prepare meals by methods that conserve nutritive value, flavor, and appearance. However, if a resident had a concern during a meal service with the temperature or texture of the food, staff was to prepare a new plate if the resident wanted one;-She expected the meals to be palatable and served at safe and appetizing temperatures. Hot foods should be served hot, and cold foods should be cold.

Based on observation, interview and record review, the facility failed to provide appropriate infection control practices for six residents (Resident #59, #47, #1, #2, #9 and #36), in a review of 19 sampled residents, and for four additional residents (Residents #46, #60, #48 and #44). Facility staff failed to change gloves or perform appropriate hand hygiene during personal care and assistance with eating for Residents #59, #46, #47 and #60, failed to properly clean a multi-use glucometer (device used to obtain a blood sugar reading after obtaining a drop of blood from the resident that is then placed on a test strip and placed in the device), failed to maintain infection control when a barrier was not used during blood glucose checks for Residents #1, #2, #48 and #44, failed to maintain catheter bags and tubing to prevent infection for Resident #9, and failed to properly clean and store a nebulizer mask for Resident #36. The facility failed to develop written policies and procedures as required to outline the facility's infection prevention and control program to prevent the development and transmission of communicable diseases and infections and failed to maintain a system to consistently track infections to prevent transmission. The facility census was 58. Review of the facility policy, Handwashing/Hand Hygiene, revised August 2019, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections;-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections;-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies;-Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:-When hands are visibly soiled, and:-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 residents; -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 (e.g. medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Before and after eating or handling food; -Before and after assisting a resident with meals; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff), dated 11/20/25, showed the following:-Dependent on staff for dressing, toileting hygiene and personal hygiene;-Always incontinent of bladder and bowel. Review of the resident's Care Plan, revised 12/01/25, showed the following:-The resident was totally dependent on one staff for repositioning, turning in bed and personal hygiene;-The resident has bladder incontinence related to impaired mobility and physical limitations;-The resident has bowel incontinence related to immobility;-Provide pericare after each incontinent episode. Observation on 3/3/26 at 7:27 P.M. showed the following:-Certified Nurse Assistant (CNA) C used alcohol-based hand rub (ABHR) and put on gloves;-CNA C transferred the resident from his/her Broda chair (specialized wheelchair) to bed;-CNA C removed the resident's pants; -The resident's incontinence brief was saturated with urine and feces;-CNA C performed front peri care and rolled the resident to his/her right side;-CNA C performed rectal peri care and removed the soiled incontinence brief from under the resident;-Without changing gloves or washing his/her hands, CNA C placed a clean incontinence brief under the resident's hips, rolled the resident back in forth in bed, fastened the clean incontinence brief, pulled the resident's gown down, and covered the resident with a blanket;-CNA C removed his/her gloves, and without performing hand hygiene, placed his/her hands under the resident's head, straightened the resident's pillow, picked up the bed control and lowered the resident's bed. 2. Review of Resident #46's quarterly MDS, dated [DATE], showed the following: -Dependent on staff for toileting; -Always incontinent of bladder and bowel. Observation on 03/04/26 at 1:10 P.M. showed the following: -The resident lay on his/her bed; -Nurse Aide (NA) D and CNA L wore gloves and stood on either side of the resident's bed and prepared to perform peri-care; -NA D and CNA L pulled down the resident's pants; -NA D and CNA L unfastened the resident's incontinence brief and pushed the urine-soiled incontinence brief down and in between the resident's upper thighs; -NA D and CNA L did not remove their gloves after touching the soiled incontinence brief; -CNA L cleaned the resident's perineum from front to back with disposable wipes;-CNA L did not remove his/her gloves; -CNA L rolled the resident to his/her left side by touching the resident's right shoulder and right hip with his/her soiled gloved hands; -NA D supported the resident on his/her left side by touching the resident's right shoulder and right hip; -CNA L cleaned the resident's rectal area with disposable wipes;-The resident was soiled with a small amount of feces; -CNA L removed his/her gloves, did not wash his/her hands or use a hand sanitizer, and donned new gloves; -Both CNA L and NA D repositioned the resident to his/her right side, and CNA L supported the resident by touching his/her left shoulder and left hip; -NA D pulled the wet incontinence brief from under the resident and placed it in the bag on the bed; -NA D cleaned feces from the resident's bottom with disposable wipes; -NA D did not remove his/her gloves, wash his/her hands, or use a hand sanitizer; -NA D placed a clean incontinence brief under the resident; -NA D and CNA L repositioned the resident onto his/her back; -NA D and CNA L pulled the clean incontinence brief up and around the resident, fastened it, and then pulled up the resident's pants; -CNA L removed his/her gloves but did not use hand sanitizer or wash his/her hands; -NA D, without removing his/her gloves, pulled up the resident's blankets and placed the resident's call light across the resident's lap; -NA D removed his/her gloves, gathered the trash bag, tied it shut, and left the room; -NA D did not use a hand sanitizer or wash his/her hands after removing his/her gloves. During an interview on 03/04/26 at 1:20 P.M., NA D said the following:-He/She should change gloves and wash hands or use ABHR if his/her gloves were soiled, after pericare and prior to touching clean items in the room;-He/She did not think his/her gloves were soiled when he/she changed the resident. During an interview on 03/05/26 at 5:57 P.M., the Director of Nursing (DON) said staff should change their gloves when they moved from a dirty area to a clean area when providing incontinence care. 3. Review of the facility policy, Glucometer Maintenance and Calibrating Glucometer, dated 7/6/25, showed the following:-To ensure that all glucometers are clean and disinfected prior to each use;-All staff who perform glucometer checks on our residents will follow the guidelines put forth in this policy to ensure that glucometers are calibrated and to prevent cross contamination from one resident to another;-Each glucometer is to be disinfected prior to and after each use, using an approved disinfectant;-Cleaning and disinfecting are to be completed by using a commercially available Environmental Protection Agency (EPA) registered disinfectant detergent or germicidal wipe;-Remove the wipe from the container and follow product label instructions to disinfect the glucometer. Review of the Arkray Technical Brief for Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System (BGMS), updated September 2024, showed the following;-To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below;-The Assure Platinum BGMS may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed;-The meter should be cleaned and disinfected after use on each patient;-The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure;-The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens;-Option 1: -Obtain a commercially available EPA-registered disinfectant detergent or germicide wipe; -Carefully review the manufacturer's instructions; -Remove wipe from the container and squeeze out any excess liquid; -Clean and disinfect the meter following step-by-step instructions in the reference manual;-Option 2: -Clean the outside of the blood glucose meter with a lint-free cloth dampened with soapy water or isopropyl alcohol (70-80%); -Disinfect the meter by diluting 1 milliliter (mL) of household bleach (5-6% sodium hypochlorite solution) in 9 mL water to achieve a 1:10 dilution; -Use a lint-free cloth dampened with the solution to thoroughly wipe down the meter. Review of [NAME] Germicidal Surface Wipes Brochure, revised March 2026, showed the following:-[NAME] disposable germicidal surface wipes are an ideal cleaning and disinfection solution for hard, non-porous surfaces;-Wipes: hospital and general disinfection or bactericidal. This product kills the following bacteria in two minutes on pre-cleaned hard, non-porous surfaces at room temperature when used as directed: Acinetobacter baumannii, Escherichia coli, Enterobacter aerogenes, carbapenem-resistant klebsiella pneumoniae, listeria monocytogenes, methicillin-resistant staphylococcus aureus, mycobacterium bovis, pseudomonas aeruginosa, salmonella enterica, serratia marcescens, staphylococcus aureus, and vancomycin-resistant enterococcus faecium;-Wipes: virucidal. This product kills the following viruses in two minutes on pre-cleaned hard, non-porous surfaces at room temperature when used as directed: SARS-related coronavirus, avian influenza A reassortant virus, rotavirus, hepatitis B virus (HBV), Hepatitis C virus (HCV), Herpes simplex II virus, human immunodeficiency virus (HIV), influenza A virus-H1N1, influenza A virus-strain A2/[NAME] kong, and rhinovirus;-This product kills HIV, HBV and HCV pre-cleaned hard, non-porous surfaces/objections previously soiled with blood/body fluids in health care or other setting in which there is an expected likelihood of soiling of hard, non-porous surfaces/objects with blood/body fluids, and in which the surfaces/objects can be associated with the potential for transmission of HIV, HBV and HCV;-Special instructions for cleaning against HIV, HBV, and HCV on surfaces/objects soiled with blood/body fluids: blood and other body fluids must be thoroughly cleaned from surfaces/objects before disinfection, allow hard, non-porous surfaces to remain wet for 2 minutes to kill HIV, HBV, and HCV. Review of the Centers for Disease Control and Prevention (CDC) website, showed the following:-Proper Protocol: For cleaning blood or other potentially infectious materials, the CDC recommend using an EPA-registered tuberculocidal disinfectant or a 1:10 to 1:100 dilution of bleach and water;-If you are dealing with blood in a professional or healthcare setting, it is recommended to use specialized germicidal wipes (such as Sani-Cloth) or a bleach solution rather than standard consumer disinfecting wipes. Review of the undated American Health Care Association, Tips for Meeting the Cleaning and Disinfection of Blood Glucose Meters Requirements in Skilled Nursing Facilities, showed the following: -Place barrier under blood glucose meter when in resident's room or placed on top of medication cart to avoid spread of microorganisms and contamination of surfaces and other equipment or supplies;-Tip: Place clean and dry paper towel(s) under blood glucose meter before placing on resident table or on top of medication cart. 4. Observation on 03/04/26 at 10:48 A.M. showed the following:-Certified Medication Technician (CMT) H obtained a blood sample from Resident #1's finger and collected a drop of blood onto a test strip in the glucometer (a portable medical device that measure the concentration of sugar in the blood) to check the resident's blood glucose level; -CMT H removed the test strip from the glucometer and placed the glucometer directly on the medication cart without a barrier;-CMT H did not clean or sanitize the glucometer and proceeded to Resident #2's room. Observation on 03/04/26 at 10:54 A.M. showed the following:-CMT H gathered blood glucose testing supplies and the glucometer he/she used to obtain Resident #1's blood glucose level and sat them on a barrier on Resident #2's lap. CMT H did not clean or sanitize the glucometer before he/she used it to check Resident #2's blood glucose level; -CMT H obtained a blood sample from Resident 2's finger. He/She collected a drop of blood onto a test strip in the glucometer to check the resident's blood glucose level;-He/She sat the glucometer directly onto the medication cart without a barrier.-CMT H did not clean or sanitize the glucometer and proceeded to Resident #48's room. During an interview on 03/04/26 at 11:04 A.M., CMT H said the following:-Each resident did not have their own glucometer; -He/She forgot to clean the glucometer between residents;-He/She typically cleaned the surface of the medication cart with the germicidal surface wipes after each resident;-He/She typically cleaned the glucometer quickly with germicidal surface wipes after every use and ensured the glucometer was dry before using it on the next resident;-He/She was not aware the glucometer needed to stay wet for two minutes, according to the wipe manufacturer directions. Observation on 03/04/26 at 11:13 A.M. showed the following:-CMT H retrieved the glucometer, he/she used to obtain Resident #2's blood glucose level, from the medication cart drawer and put it on a barrier on the medication cart. He/She did not clean or sanitize the glucometer prior to taking it into Resident #48's room;-He/She placed blood glucose testing supplies and the glucometer on a barrier on Resident #48's bedside table;-He/She obtained a blood sample from Resident #48's finger. He/She collected a drop of blood onto a test strip in the glucometer to check the resident's blood glucose level;-He/She sat the glucometer on the medication cart on the same barrier he/she used in the resident's room;-He/She wiped the glucometer with a germicidal surface wipe for approximately five seconds;-He/She folded the barrier in half (the bottom side that touched the resident's bedside table and the top of the medication cart now faced up) and sat the glucometer on the barrier. 5. Observation on 03/03/26 at 7:50 P.M. showed the following: -CMT M lay an Assure glucometer and bottle of lancets on top of the medication cart without placing a barrier under the equipment; -CMT M did not wash his/her hands or use a hand sanitizer before he/she donned gloves; -CMT M wiped the front and back of the glucometer with an 80% isopropyl alcohol pad; -CMT M obtained a blood sample from Resident #44's finger. He/She collected a drop of blood onto a test strip in the glucometer to check the resident's blood glucose level; -CMT M place the glucometer directly on top of the medication cart without a barrier and wiped the front and back of the glucometer with an 80% isopropyl alcohol pad;-CMT M lay the glucometer back on top of the medication cart without a barrier; -CMT M removed his/her gloves and did not wash or sanitize his/her hands;-CMT M did not use an Environmental Protection Agency (EPA) registered disinfectant detergent or germicidal wipe as instructed per the facility policy. During an interview on 03/03/26 at 8:55 P.M., CMT M said the following: -Residents did not have individual glucometers; -He/She always used prepackaged 80% isopropyl alcohol wipes to clean glucometers between each resident; -He/She was not sure if, once it was cleaned, the glucometer needed to dry for any specific length of time before staff could use it again; -He/She was not sure when he/she should use a disinfectant wipe;-He/She was not sure the glucose manufacturer indicated if 80% isopropyl alcohol wipes were appropriate to clean the glucometer. During an interview on 03/05/26 at 5:47 P.M., the DON said the following:-Staff should clean the glucometer between each resident; -She did not think it was appropriate for staff to only clean the glucometer with alcohol wipes; -Staff should clean the glucometer with the facility provided germicidal wipes, and the glucometer should remain wet for the required amount of time. During an interview on 3/18/26 at 8:51 A.M., the Infection Preventionist said the following:-Staff should clean glucometers prior to and after each use; -Staff should always clean the glucometer between residents; -Staff should clean the glucometer with the facility provided germicidal wipes;-An alcohol wipe would not be an acceptable way to clean the glucometer; -Staff should always place the glucometer on a clean barrier. 6. The facility did not provide a policy related to caring for a resident with a urinary catheter. Review of Resident #9's care plan, updated 12/24/25, showed the following:-He/She had a urinary catheter;-Monitor/record/report to physician for signs/symptoms of urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns;-Monitor for signs/symptoms of UTI. Review of the resident's physician's orders, dated 1/31/26, showed an order for Macrobid (an antibiotic) oral capsule 100 mg, give by mouth two times a day for culture and sensitivity (C&S) urine culture for five days. Observation on 03/04/26 at 1:31 P.M., showed the resident's urinary catheter bag hung under the wheelchair and dragged on the floor as Nurse Aide (NA) A pushed the resident in the wheelchair from the resident's room to the shower room, approximately 100 feet. Observations on 03/05/26 at 8:33 A.M., 9:52 A.M., and 10:58 A.M., showed the resident asleep in his/her room in his/her wheelchair. The urinary catheter bag hung under the wheelchair and touched the floor. The urinary catheter bag and tubing contained urine. The floor under the catheter bag was sticky. Observation on 03/05/26 at 1:27 P.M. showed the resident sat in his/her wheelchair in his/her room. The catheter tubing was looped up and around the catheter bag hook under the wheelchair which prevented the urine in the tubing from draining into the catheter bag. The urine in the catheter tubing was dark yellow and had mild sediment. During an interview on 3/18/26 at 8:51 A.M., the Infection Preventionist said the following:-Catheter bags and tubing should never touch or drag on the floor;-Catheter tubing should never be looped (to prevent the flow of urine);-Doing either of these things increased the risk for infection. 7. Review of the undated facility policy, Nebulizer Storage and Cleaning, showed the following:-To ensure safe storage, cleaning, disinfection, and maintenance of nebulizer equipment to prevent healthcare-associated respiratory infections, following current Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), Association for Professionals in Infection Control and Epidemiology (APIC), and respiratory-therapy clinical standards;-The policy applies to all staff who use, clean, store, transport, or provide nebulizer equipment;-CMS 42 CFR 483.80 requires facilities to maintain an infection prevention and control program with written policies for equipment cleaning and disinfection;-CMS respiratory care pathway requires nebulizers be used, cleaned, and stored per manufacturer instructions, with sterile water rinsing and air-drying between uses;-Store nebulizers in clean, dry, closed containers or covered bins labeled with resident name;-Tubing must not be rinsed or submerged, store in a clean sealed bag between uses;-Reusable nebulizer components (mask, mouthpiece, cup) must be stored only after full air-dried to prevent microbial growth;-After each use (required): -Disconnect tubing from nebulizer components, tubing should never be washed; -Wash nebulizer mask/mouthpiece/cup with warm water and mild detergent; -Rinse under running warm water for at least 30 seconds; -Perform a final rinse using sterile or distilled water, not tap water; -Shake off excess water and place on clean, lint-free towel to air-dry completely; -Once dry, store components in clean sealable bag or closed container with tubing stored separately;-Staff must perform hand hygiene before and after handling nebulizer equipment;-Between treatments, clean and disinfect components after each use, tubing check for moisture, drying by running compressor 10-20 seconds, never rinse;-Store only fully dry components in a closed, clean container;-Label with resident name, date last disinfected;-Maintain separation from dirty equipment areas;-All nursing and respiratory care staff must receive annual education on cleaning, disinfection, and storage protocols for nebulizers. Review of Resident #36's undated face sheet showed the following:-Diagnoses of chronic obstructive pulmonary disease (COPD; lung disease), acute respiratory failure (a sudden-onset emergency where the lungs cannot adequately exchange oxygen for carbon dioxide) with hypoxia (low oxygen levels), asthma (a chronic lung disease), pneumonia (infection and inflammation of the lung) due to COVID-19, and bronchiectasis (a chronic lung disease). Review of the resident's quarterly MDS, dated [DATE], showed moderate cognitive impairment. Review of the resident's Physician Orders, dated 2/20/26, showed the following:-Ipratropium-Albuterol inhalation solution (an inhaled medication to treat COPD) 0.5-2.5 3 milligram (mg)/3 milliliter (mL), one vial inhale orally every four hours as needed for shortness of breath or wheezing;-Ipratropium-Albuterol inhalation solution 0.5-2.5 3 mg/3 mL, one vial inhale orally every morning and at bedtime for chronic cough. Observation on 3/2/26 at 1:19 P.M. showed a nebulizer machine, mask, and tubing sat directly on the resident's bedside table and were not stored in a bag. There was no bag to store the nebulizer and components in the room. The mask and tubing were still connected to the nebulizer machine. Observation on 3/3/26 at 9:17 A.M. showed the resident sat on the edge of his/her bed and received his/her nebulizer treatment. There was no staff in the room. Observation on 3/3/26 at 11:04 A.M. and 3:57 P.M. showed the resident asleep in his/her bed. The nebulizer mask and tubing were still connected to the nebulizer machine and lay directly on the resident's bedside table. The nebulizer, mask and tubing were not stored in a bag. Observation on 3/3/26 at 10:00 A.M. showed Certified Medication Technician (CMT) H exited the resident's room after he/she started the resident's nebulizer treatment. Observations on 3/4/26 at 11:41 A.M. and 1:04 P.M. showed the resident rested in bed. The resident's nebulizer mask and tubing sat directly on the resident's nightstand. The nebulizer, mask, and tubing were not stored in a bag, and no bag was available in the room. Observations on 3/5/26 at 8:30 A.M. and 9:52 A.M. showed the resident's nebulizer mask and tubing sat on the resident's bedside table. The nebulizer, mask, and tubing were not stored in a bag, and no bag was available in the room. During an interview on 3/5/26 at 5:18 P.M., Licensed Practical Nurse (LPN) A said the following:-Staff should rinse the nebulizer masks and canisters after every use; -Staff should lay the masks, canisters, and tubing out to dry, then store them in a bag when not in use; -He/She was unsure if the bag used to store the nebulizer should be dated or labeled;-He/She was unsure if staff should regularly change the mask, tubing, or bag. He/She did not change them. During an interview on 03/05/26 at 5:23 P.M., CMT H said the following:-Staff should rinse the nebulizer masks and canisters and lay them out to dry after every use; -The nebulizer parts should be stored in a bag when not in use;-He/She was unsure about changing out parts, he/she has never done this, it usually falls on nightshift duties. During an interview on 03/05/26 at 5:47 P.M., the DON said the following:-Staff should date, label and store nebulizer parts in a bag when not in use;-Whoever performed the treatment was responsible to clean the nebulizer components and to store them in a bag. During an interview on 3/18/26 at 8:51 A.M., the Infection Preventionist said staff should clean nebulizer masks and canisters with warm soapy water, allow them to air dry, and them place them in a bag after every use. 8. Review of the facility's undated policy, Infection Prevention and Control Program (IPCP) showed it only addressed COVID-19. A policy related to the facility's overall plan for preventing, identifying, reporting, investigating, and controlling all potential infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, was requested, but none provided. During an interview on 3/18/26 at 8:51 A.M., the Infection Preventionist (IP) said the following:-She had been the IP for approximately 2.5 years;-She was part time and worked three weekends per month for a total of six shifts per month;-She ran a weekly report for new infections and used the report to update her infection tracking;-On the weekend each month she didn't work, no one ran the report with new infections, so she ran a two week report the following weekend;-If she was sick or took extra time off, no other staff tracked or monitored infections. During an interview on 3/5/26 at 4:04 P.M., the Assistant Director of Nursing (ADON) said the following:-She offered to help the IP with tracking, but the facility told her she could not help because there was already someone tracking infections;-She did not know if the IP was tracking infections. During an interview on 3/5/26 at 3:24 P.M., the DON said the following:-The IP worked part-time and only on the weekends;-The IP was the only staff who tracked and mapped infections; -She did not help with the infection tracking when the IP was not working. 9. Observation on 03/02/26 from 11:47 A.M. to 11:55 A.M., in the [NAME] Dining Room, showed the following:-NA D handed Resident #47 a glass of apple juice with a straw;-Without performing hand hygiene, NA D opened Resident #60's can of soda, picked up the resident's spoon and gave Resident #60 a bite of ham and potatoes;-Without performing hand hygiene, NA D picked up Resident #47's spoon and gave the resident multiple bites of pureed ham and potatoes;-Without performing hand hygiene, NA D picked up Resident #59's spoon and gave the resident bites of pureed ham and potatoes;-Without performing hand hygiene, NA D picked up Resident #60's fork and gave the resident bites of pickled beets;-Another unknown staff member entered the dining room and began feeding Resident #47;-NA D continued to sit between Resident #59 and Resident #60 and alternated back and forth giving bites of food to both residents. During interviews on 03/04/26 at 1:20 P.M. and 03/13/26 at 3:31 P.M., NA D said he/she usually kept alcohol based hand rub (ABHR) in his/her pocket and used it while feeding multiple residents, but he/she didn't have any ABHR with him/her. During an interview on 03/18/26 at 8:51 P.M., the Infection Preventionist said the following:-Staff should perform hand hygiene between residents while assisting multiple residents with eating;-At the very least, staff should use ABHR in between residents;-She was aware there were a few staff who fed multiple residents and didn't use ABHR between residents.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) the Infection Preventionist attended QAPI meetings as required. The facility census was 58. Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Plan, dated 06/23/25, showed the following:-QAPI Committee Members:-Administrator;-Medical Director;-Director of Nursing;-Pharmacy Consultant;-Infection Preventionist (IP);-MDS Coordinator;-Social Services Director;-The QAPI Committee meets quarterly. 1. Review of the Quarterly QAPI Meeting Attendance, dated 04/29/25, showed documentation the IP was absent. Review of the Quarterly QAPI Meeting Attendance, dated 07/24/25, showed documentation the IP was absent. Review of the Quarterly QAPI Meeting Attendance, dated 10/27/25, showed documentation the IP was absent. The facility did not provide evidence of a fourth quarter QAPI meeting in 2025. 2. During an interview on 03/18/26 at 8:51 A.M., the IP said the following:-She works six shifts per month, all on the weekends;-She was a part of the QAPI team;-She does not attend the meetings in person because they are during the week;-She creates a three-month report of all infections, antibiotics, and culture results as well as any interventions, like training, that occurred during those three-months;-The Director of Nursing presents the report to the QAPI team. 3. During an interview on 03/05/26 at 5:47 P.M., the Director of Nursing said the IP has not attended the QAPI meetings. The IP sends information to the meeting for the committee to review. During an interview on 03/05/26 at 7:00 P.M. and 03/16/26 at 12:30 P.M. the Administrator said the IP had not attended the QAPI meetings. The IP was part-time and sends information to the meeting. Prior to the survey, he was not aware the IP was required to attend the QAPI meetings. He felt like the IP had always provided a comprehensive report. The facility did not have a fourth quarter QAPI meeting in 2025 due to a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak in the facility.

Based on observation, interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for two residents (Resident #01 and Resident #03), in a review of 18 sampled residents, and for two additional residents, (Resident #32 and Resident #39), who participated in a group interview and reported bedtime snacks were not offered on a routine basis at the facility. The facility census was 58. Review of the facility policy Frequency of Meals, dated July 2017, showed the following:-Nourishing snacks will be available for residents who need or desire additional food between meals;-Evening snacks will be offered routinely to all residents;-Residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast excessed 14 hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other;-A substantial evening meal is an offering of two or more menu items at one time, one of which includes a high-quality protein such as meat, fish, eggs or cheese. The meal represents no less than 20% of the day's total nutritional requirements;-The facility will choose the snacks that are served at bedtime. However, the dietitian and food services manager will solicit input from the residents and/or the resident council. 1.During a resident council meeting on 03/04/26 at 10:04 A.M., four of nine residents (Resident #01, Resident #03, Resident #32, and Resident #39) said staff did not pass bedtime snacks and they would take a bedtime snack if offered. 2. Review of Resident #01's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 12/19/25, showed the following: -He/She was cognitively intact; -He/She considered it very important to have snacks available between meals; -Diagnosis of diabetes mellitus (DM, a group of diseases that affect how the body uses blood sugar). 3. Review of Resident #03's annual MDS, completed by facility staff, dated 01/15/26, showed the following: -He/She was cognitively intact;-He/She considered it very important to have snacks available between meals; -Diagnosis of diabetes mellitus. 4. Review of Resident #32's annual MDS, completed by facility staff on 02/19/26, showed the following: -He/She was cognitively intact; -He/She considered it very important to have snacks available between meals. 5. Review of Resident #39's quarterly MDS, completed by facility staff on 02/02/26, showed the following: -He/She was cognitively intact; -He/She considered it very important to have snacks available between meals; -Diagnosis of diabetes mellitus. 6. Observation on 03/03/26 at 8:20 P.M., in the [NAME] Dining Room, showed the following:-Bags of chips and cookies on the counter;-Boxes of snack cakes in the cabinet;-Pudding cups and juices in the refrigerator. 7. During an interview on 03/03/26 at 8:20 P.M., Certified Nurse Aide (CNA) C said the following:-Staff pass bedtime snacks to residents only if the residents ask for a snack;-They have cookies, pudding, chips and drinks available if a resident wants a snack;-There were no fruit or nutritious snacks available. During an interview on 03/05/26 at 3:40 P.M., the Dietary Manager said the following:-Dietary staff prepare and leave a snack cart in the kitchen for nursing staff to have available for the residents' evening/bedtime snacks before leaving at 6:30 P.M. to 7:00 P.M.;-Available items are snack cakes, vanilla and chocolate pudding (sweetened and unsweetened), peanut butter and crackers and unsweetened apple sauce;-The kitchen is left unlocked, and nursing staff can go in and get the cart. The walk-in cooler and freezer are also unlocked;-Sandwich meats, cheeses and bread are available. Ice cream and gelato for thickened resident orders. Flavors include butter pecan, chocolate, and vanilla; -Approximately six months ago, sandwiches were made available for the cart. However, residents were not taking them, and the sandwiches were wasted and were discontinued. During an interview on 03/05/25 at 5:47 P.M., the Director of Nursing (DON) said the following:-She thought staff brought out a bedtime snack cart, but she did not know if staff offered bedtime snacks to all residents;-Ideally she wanted staff to offer bedtime snacks to all residents, and there should be something of some substance, not just sweets, available. During an interview on 03/16/26 at 12:35 P.M., the Administrator said the following:-He would expect staff to offer bedtime snacks to all residents;-Nutritious options should be available for bedtime snacks if desired. During an interview on 03/18/26 at 3:01 P.M., the Medical Director said he would expect staff to offer residents nutritious bedtime snacks, especially a diabetic resident, if awake, should be offered a snack.

Based on interview and record review, the facility failed to ensure residents knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. The facility census was 58. Review of the facility's undated admission packet, Resident Rights, showed the following: -Each resident shall be encouraged and assisted throughout his/her stay to exercise their rights as a resident and citizen and may voice grievances and recommend changes in policies and services to the facility staff or outside representatives of his/her choice; -A staff person shall be designated to receive grievances and residents may voice their complaints and recommendations to staff designee, an ombudsman, or any person outside the facility; -Residents shall be informed of and provided with a viable format for recommending changes in policy and services. Review of the facility policy, Grievances/Complaint, Filing, revised April 2017, showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; -All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response;-Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board;-Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously;-The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is the Social Services Designees through the grievance form or in person; -Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint; -The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law; -The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated;-The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken; -The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems; -The administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility'-A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office; -If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The grievance officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected; -The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision; -This policy will be provided to the resident or the resident's representative upon request;The policy did not address where forms were located or available to file a written grievance. 1. During the resident council group interview on 03/04/26 at 10:00 A.M., Resident #3, Resident #32, and Resident #39 said the following: -They did not know how to file a grievance, and they were not sure if there were grievance forms available to residents; -If they had a problem or a complaint, they would just tell the nursing staff;-Resident #3 said if he/she had a concern, he/she would just verbally have to tell the Social Service Designee (SSD);-They do not receive a quick response from staff regarding their concerns. -They do not receive in writing a rationale for the response of their verbal grievance. 2. Observation on 03/05/26 at 11:21 A.M. of the resident bulletin board, just inside the facility entrance showed no evidence of a copy of the facility grievance/complaint procedure posted and no forms were available for anyone to complete a written grievance. 3. During an interview on 3/03/26 at 12:22 P.M., the Activity Director (AD) said the following:-She takes concerns from resident council to the Administrator and the individual departments to be addressed;-She does not fill out a grievance form and was not aware of any specific grievance form. During an interview on 03/12/26 at 2:01 P.M., the SSD said the following:-She has been the facility's Grievance Official since August 2024;-She has had no training regarding how to handle a grievance or that there should be a paper grievance form or log of grievances;-She does not have a grievance log;-The AD reports concerns from resident council and takes those concerns to the individual departments to be addressed. During an interview on 03/05/26 at 3:00 P.M. the Assistant Director of Nurses (ADON) said the following: -She was not aware if there were grievance forms available to the residents in the facility, unless the SSD had them; -When made aware of resident concerns from the resident council meetings, she followed up with the residents and reported the resolutions to the group. During an interview on 03/05/26 at 5:47 P.M., the Director of Nurses (DON) said the following: -The facility did not have grievance forms that she was aware of;-The SSD would be responsible for keeping and handling grievances, a paper trail would be the SSD responsibility as well. During an interview on 03/04/26 at 3:05 P.M. and 03/16/26 at 12:35 P.M. the Administrator said the SSD was responsible for grievances. The SSD does not have a grievance log. Prior to the survey, there was no process in place for residents to file grievances anonymously.

Based on interview and record review the facility failed to ensure residents received mail on regular mail delivery days as identified by the United States Postal Service (USPS), including Saturdays. The facility census was 58. Review of the facility's undated admission Packet showed a Patient [NAME] of Rights (page 33), which included the right of each resident to send and receive unopened mail. Review of the facility policy, Mail and Electronic Communication, revised May 2017, showed the following: -Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email, and other electronic forms of communication confidentially; -Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). 1. During a group interview on 03/04/26 at 10:00 A.M., Resident #3, Resident #32, and Resident #39 said residents did not receive mail on Saturdays. 2. During an interview on 03/05/26 at 2:50 P.M., Licensed Practical Nurse (LPN) A said the following: -Occasionally the (United States Postal Service) mail carrier delivered mail on Saturdays, but facility staff did not pass out the mail to the residents and were never told to do so; -He/She placed any delivered mail on Saturday in the medication room and the mail, which could include resident mail, stayed there until Monday. During an interview on 03/05/26 at 3:00 P.M., the Assistant Director of Nurses (ADON) said the following: -About a year ago the facility stopped the post office from delivering mail to the facility because the mail carrier would leave the mail at the nurses' station unattended; -The mail was no longer delivered to the facility on Saturdays, it was held at the post office and no facility staff went to the post office to check for mail and deliver it. During an interview on 03/05/26 at 5:47 P.M., the Director of Nurses (DON) said the following: -Per facility request, the post office held residents' mail on Saturdays because the facility did not have administrative staff available to pick it up and deliver it to the residents; -The Saturday mail was picked up on Monday and delivered to the residents at that time. During an interview on 03/05/26 at 3:14 P.M., the administrator said he would expect that mail should come to the facility on Saturdays, and that he had no idea that mail was not being delivered to the residents on Saturdays.

Based on observation, interview and record review, the facility failed to provide services that met professional standards of practice for two residents (Resident #10 and #56), in a review of 19 sampled residents. The facility failed to administer bolus tube feedings according to physician orders and per manufacturer guidelines and failed to properly administer medications via a feeding tube for Resident #10. The facility failed to obtain a lithium level (a laboratory test to monitor the concentration of lithium in the blood - a mood stabilizing medication to treat mental illness) for Resident #56. The facility census was 58. Review of the facility policy, Enteral Feedings (nutrition delivered directly into the gastrointestinal tract) - Safety Precautions, revised November 2018, showed the following:-All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities;-All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities;-The facility will remain current in and follow accepted best practices in enteral nutrition;-Use only sterile or purified water for formula reconstitution, medication dilution and flushed before and after medication administration;-Administer only full-strength formulas, do not add water or dilute liquid or reconstituted enteral nutrition formulas;-Check enteral tube placement every shift and prior to feeding or administration of medication;-Check gastric residual volume as ordered;-Elevated the head of the bed at least 30 degrees during tube feeding and at least one hour after feeding. Review of the [NAME] Nutrition Osmolite 1.5 Cal manufacturer guide, updated 2025, showed the following:-Follow physician's instructions;-Additional fluid requirements should be met by giving water. Review of the American Society of Parenteral and Enteral Nutrition (ASPEN) Safe Practices of Enteral Nutrition Therapy, dated January 2017, showed the following:-The administration of enteral therapy is a step in the process with significant potential for error;-Feeding tubes are prone to clogging for a variety of reasons, including insufficient water flushes and incorrect medication preparation and administration;-Flush feeding tubes immediately before and after feeding with intermittent feedings;-Flush feeding tubes before and after medication administration and follow appropriate medication administration practices;-In adult patient, flush feeding tubes with a minimum volume of 30 milliliters (mL) of water before and after intermittent feedings;-Administer each medication separately;-Avoid mixing different medications intended for administration through the feeding tube given the risks for incompatibilities and altered therapeutic drug responses;-Provide appropriate tube irrigation around the timing of drug administration: -Prior to administering medication, flush the tube with at least 15 mL of water; -Administer the medication using a clean enteral syringe; -Flush the tube again with at least 15 mL of water; -Repeat with each medication; -Flush the tube one final time with at least 15 mL of water. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/23/26, showed the following:-Had a feeding tube;-Received 51 percent or more of his/her total calories through tube feeding;-Received 501 milliliters (mL) or more of his/her average fluid intake per day by tube feeding. Review of the resident's Care Plan, updated 3/3/26, showed the following:-Nutritional status general NPO (nothing by mouth) tube feeding;-Feedings will be given as ordered;-Give fluids as ordered via G-tube;-The resident had dehydration or potential fluid deficit related to poor intake and G-tube use;-The resident requires tube feeding related to dysphagia (swallowing disorder);-The resident needed the head of his/her bed elevated 45 degrees during and 30 minutes after tube feeding;-Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold if greater than 200 mL aspirate. Review of the resident's Physician Orders, dated 3/4/26, showed the following:-Nothing by mouth (NPO) diet;-May crush medications: tablets may be crushed, capsules may be opened, unless contraindicated, to be administered individually with water and administered via G-tube due to NPO status, every day and night shift;-Osmolite 1.5 Cal oral liquid (nutritional supplement), give 120 mL via G-tube two times a day for nutritional supplement with 125 mL water flush before and after bolus feeding. Observation on 3/4/26 at 10:26 A.M. showed the following:-The MDS/Care Plan Coordinator filled a water graduate with 150 mL of tap water. (He/She did not use sterile or purified water as directed by facility policy); -He/She drew up 60 mL of Osmolite 1.5 Cal into a syringe and added it to the graduate of water;-He/She drew up another 60 mL of Osmolite 1.5 Cal into the syringe and added it to the graduate of water; -The MDS/Care Plan Coordinator did not check the positioning of the resident's G-tube;-He/She flushed the tube with 20 mL of the water and Osmolite 1.5 Cal mixture;-He/She removed the plunger from the syringe and administered the remainder of the water and Osmolite 1.5 Cal mixture (230 ml) via gravity. (He/She diluted the Osmolite formula with water and did not follow facility policy to not dilute the formula);-He/She flushed the tube with 30 mL of water after the gravity feeding was completed.(The MDS/Care Plan Coordinator administered 180 ml of water, not 250 ml of water as ordered.) During an interview on 3/4/26 at 10:45 A.M., the MDS/Care Plan Coordinator said the following:-The order was for 120 mL of Osmolite and a total of 125 mL water flush;-He/She mixed the water and Osmolite to help thin the Osmolite and prevent clogging;-He/She flushed a small amount of the mixture first to ensure the G-tube was not clogged;-He/She flushed with water after the feeding to ensure no mixture was left in the tube to decrease the risk of clogging. Observation on 3/5/26 at 10:05 A.M. showed the following:-Licensed Practical Nurse (LPN) A entered the resident's room to administer the resident's scheduled Osmolite 1.5 Cal;-He/She poured the Osmolite 1.5 Cal formula into a disposable cup. (The cup did not contain any measurements to identify the amount of formula in the cup); -He/She filled a graduate with approximately 200 mL of tap water. (He/She did not use sterile or purified water as directed by facility policy);-He/She checked the placement of the G-tube by pushing approximately 10 mL of air and water through the G-tube and listened to the abdomen by the G-tube;-He/She administered a 60 mL water flush via gravity. (He/She did not flush the G-tube with 125 ml of water as ordered); -He/She added approximately 50 mL of the Osmolite 1.5 Cal to the syringe when the water flush had approximately 10 mL left, filling the 60 mL syringe;-He/She added approximately 40 mL of Osmolite 1.5 Cal to the syringe when the feeding was at approximately 20 mL, filling the 60 mL syringe;-He/She added more water, approximately 30 mL, to the syringe when the feeding was at approximately 30 mL, filling the 60 mL syringe;-He/She added the remaining Osmolite 1.5 Cal, approximately 30 mL, when the feeding was at approximately 20 mL, not quite filling the 60 mL syringe;-He/She added 60 mL of water to the syringe after the feeding was complete; -The graduate of water still contained approximately 50 mL;(LPN A flushed the G-tube with approximately 150 ml of water. He/She did not follow orders to flush with 125 mL of water before and after the bolus feeding.) During an interview on 3/5/26 at 10:47 A.M., LPN A said the following:-The resident should receive a total of 175 mL of water with each bolus feed; -He/She used the disposable cup to measure the Osmolite 1.5 Cal formula because the cup was 120 mL; -He/She always flushed before giving the bolus feeding to ensure there wasn't any blockage of the G-tube;-He/She added a little water to the Osmolite 1.5 Cal to help the feeding go a little quicker and to lessen the chance of clogging;-When administering medications via G-tube, he/she crushed and mixed all the medications together with water;-When administering crushed medications, he/she flushed the G-tube first, then administered the crushed medication solution, added water as needed to clear the syringe, and finished with a final flush. During an interview on 03/05/26 at 5:47 P.M., the Director of Nursing (DON) said staff were to follow physician orders for administering medications and tube feedings. During an interview on 03/18/26 at 3:01 P.M., the resident's physician said the following:-Staff should always check placement of the feeding tube prior to administering a feeding; -If the physician order specified to give a specific amount of water with a flush, staff should follow the order;-It is important for staff to flush the G-tube with the ordered amount of water as the hydration status of the resident requiring tube feedings was very important;-Staff should be administer medications per G-tube individually unless the facility had it approved/confirmed by the pharmacy then received his approval and an order to combine the medications for administration through the tube. 2. Review of the undated facility policy, Obtaining Lab Orders, showed the facility will accept and act on lab orders signed or electronically authenticated by physicians (MD/DO), physician assistants, nurse practitioners, or clinical nurse specialists acting within Missouri scope of practice. Review of Resident #56's diagnosis list showed the resident had diagnosis of multiple sclerosis (a nervous system disease that affects the brain and spinal cord), major depressive disorder, stroke and dysphagia (difficulty swallowing). Review of the resident's November 2025 physician's orders showed the following:-Lithium level every three months;-Lithium Carbonate 150 mg, give two capsules by mouth once daily;-Lithium Carbonate 150 mg, give four capsules once daily. Review of the resident's EHR, dated 11/03/25, showed staff obtained the resident's lithium level as ordered and it resulted 0.5 mmol/L (below normal range). (Review showed no documentation staff notified the resident's physician of the resident's lab results Review of the resident's December 2025 physician's orders showed the following:-Lithium level every three months;-Lithium Carbonate 150 mg, give two capsules by mouth once daily;-Lithium Carbonate 150 mg, give four capsules once daily. Review of the resident's January 2026 physician's orders showed the following:-Lithium level every three months;-Lithium Carbonate 150 mg, give two capsules by mouth once daily;-Lithium Carbonate 150 mg, give four capsules once daily. Review of the resident's February 2026 physician's orders showed the following:-Lithium level every three months;-Lithium Carbonate 150 mg, give two capsules by mouth once daily (end 02/19/26);-Lithium Carbonate 150 mg, give four capsules once daily (end 02/19/26). Review of the resident's EHR, dated 02/19/26, showed the resident admitted to hospice. Review of the resident's progress notes, dated 02/20/26 at 2:11 P.M., showed the following:-The resident admitted last night to hospice;-Hospice nurse here and gave new orders to start Lithium Carbonate 300 mg twice daily per tube. Review of the resident's February 2026 physician's orders showed the following:-Lithium level every three months;-Lithium Carbonate 300 mg one capsule per tube twice daily (start 02/20/26). Review of the resident's February 2026 EHR showed no documentation staff obtained a lithium level due since the last level was drawn 11/03/25. Review of the resident's March 2026 EHR showed no documentation a lithium level was obtained through the review date of 03/03/26. 3. During an interview on 03/04/26 at 11:30 A.M., the DON said the resident's lithium level should have been obtained in February but was not. The nurse who took the order for the lithium level was new and did not fill out a lab requisition for the level to be drawn. During an interview on 03/18/26 at 3:01 P.M., the resident's physician said the following:-He would expect staff to obtain labs as ordered or notify him if there were issues or a delay and why;-It is important to obtain lithium levels; -He may not adjust the lithium dosage, but he won't know to adjust the dosage if the lithium levels are not monitored;-If he placed the order to monitor lithium levels, it was not a suggestion, it must be done.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund petty cash account and by not reconciling each month. The facility managed funds for 37 residents. The facility census was 58. Review of the facility's monthly bank statements and resident trust fund records for December 2025, January 2026 and February 2026, showed no documentation the facility reconciled the monthly bank statements with the month ending resident trust fund records, to include outstanding checks and petty cash, to ensure an accurate accounting of all resident finds. During an interview on 3/5/26 at 1:00 P.M., the Business Office Manager (BOM), said the following: -She was responsible for managing the resident trust fund account and the resident petty cash; -The resident petty cash account was maintained from money withdrawn monthly from the resident trust account; -She typically kept $400.00 from the resident trust account in the resident petty cash account; -She issued a voucher to each resident who withdrew cash from the resident petty cash account when the withdrawal occurred and filed these monthly; -She counted the resident petty cash each month, then withdrew from the resident trust account what was needed to ensure there was $400.00 in the resident petty cash account for the next month; -She did not maintain a written record of the monthly reconciliation of the resident petty cash but would just figure it in my head and use some sticky notes to determine how much she would need to withdraw from the resident trust account to put in the resident petty cash account. During an interview on 03/16/26 at 12:35 P.M., the administrator said he would expect the BOM to reconcile the residents' petty cash fund to the resident trust fund statements monthly.

Based on observation, interview and record review, the facility failed to ensure stock medications (a limited supply of non-prescription, over-the-counter [OTC] or emergency drugs stored on-site for immediate use) were labeled with the date they were opened and removed and/or replaced when expired. This had the potential to affect all residents. The facility census was 58. Review of the facility policy, Storage of Medications, last revised November 2020, showed the following: -The facility stores all drugs and biologicals (specialized medications used to treat specific conditions) in a safe, secure, and orderly manner; -Discontinued, outdated, or deteriorated drugs or biologicals are destroyed; -OTC medication will be available for use until the manufacturer expiration date unless there are signs of deterioration; -OTC will have an open date label when the container is opened; -OTCs that have been opened will be stored from a separate area from those that are unopened. 1. Observation on 03/05/26 at 9:45 A.M. of the 200-hall medication cart showed the following: -A previously opened stock bottle of acetaminophen (a non-narcotic pain reliever) 500 milligram (mg) tablets in the first drawer with no open date; -A previously opened stock bottle of ibuprofen (a non-narcotic pain reliever) 200 mg tablets in the first drawer with no open date; -A previously opened stock bottle of cetirizine (an OTC allergy medication) 10 mg tablets in the first drawer with no open date; -A previously opened stock bottle of vitamin B1 (a supplement) 250 mg tablets in the first drawer with no open date. Observation on 03/05/26 at 10:20 A.M. of the facility's east medication room showed the following: -A previously opened bottle of Refresh Tears (an OTC eye drop used for dry eyes) sat on the countertop, did not have an open date and had expired 07/2025; -A previously opened stock bottle of Azo Urinary Pain Relief tabs sat in the overhead cabinet above the countertop, did not have an open date and had expired on 12/2025; -A previously opened stock bottle of Benadryl (an allergy medication) 25 mg sat in the overhead cabinet above the countertop, did not have an open date and expired on 02/2026; -A previously opened 16-ounce (oz) stock bottle of Geri-Tussin (a non-narcotic cough suppressant syrup) sat in the cabinet below the countertop, opened on 05/13/25, and expired on 11/2025; -A previously opened card of stock Compazine Suppositories (a rectal suppository used for nausea and vomiting) 10 mg was in the refrigerator, did not have an open date and expired on 01/2026. 3. During an interview on 03/05/26 at 10:30 A.M., Certified Medication Technician (CMT) H said the following:-All stock medications should be labeled when they are opened, and any expired medications should be removed and/or replaced; -He/She was not sure who the Refresh Tears eye drops belonged to or how long the bottle had been on the counter, it should have been labeled with an open date and resident's name;-All the medications in the east medication room were in-use medications and not medications that were to be destroyed. During an interview on 03/05/26 at 5:47 P.M., the Director of Nurses (DON) said the following: -The facility used to have a system in place for checking medications for labeling and expiration dates and this was done every Monday and Tuesday by the charge nurse; -This had not been done.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%), when staff made two medications errors out of a total of 30 opportunities for error, resulting in a 6.67% error rate. Staff did not ensure Resident #2 received the full dose of ordered insulin and did not administer the ordered dose of Tramadol (a narcotic pain medication) to Resident #44. The facility census was 58. Review of the facility policy, Administering Medications, revised April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility policy, Insulin Pens, showed the following:-Priming an insulin pen (an air shot) is essential before each injection to remove air bubbles from the cartridge and needle, ensuring the resident receive the full, accurate dose of insulin. It also confirms the pen is working correctly, checks for blockages in the needle, and prevents under-dosing;-Release air out of the insulin pen, turn the dial to 2 units, with the needle pointing up, push the plunger of the pen all the way in, until you see a drop of insulin;-Inject the insulin by slowly pushing in the plunger all the way, leave the needle in and slowly count to five, this will keep insulin from leaking out of the injection site. 1. Review of Resident #2's Physician Orders, dated March 2026, showed an order for NovoLog FlexPen subcutaneous solution pen-injector (a rapid-acting, injectable insulin used to manage high blood sugar)100 unit/milliliter (mL), inject as per sliding scale: if 150-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-500=10 units, subcutaneously with meals. Review of the NovoLog FlexPen manufacturer instructions for use, revised February 2023, showed the following:-Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injections air and to ensure proper dosing:-Turn the dose selector to select 2 units;-Hold your NovoLog FlexPen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way in and the dose selector returns to 0;-A drop of insulin should appear at the needle tip;-NovoLog can be injected under the skin (subcutaneously);-Insert the needle into your skin, inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer;-Keep the needle in the skin for at least six seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin, this will make sure that the full dose has been given. Observation on 3/4/26 at 10:54 A.M. showed the following:-Certified Medication Technician (CMT) H checked the resident's blood glucose;-The resident's blood glucose was 218;-CMT H applied a needle into the insulin pen;-He/She did not prime the insulin pen; -He/She dialed up 4 units of NovoLog insulin in the pen as ordered;-He/She injected the insulin into the resident's right upper arm and held for three seconds;-He/She removed the needle from the resident's arm. During an interview on 3/4/26 at 11:04 A.M., CMT H said the following:-He/She had never primed an insulin pen before he/she administered insulin to residents; -He/She usually held the insulin pen against a resident's skin for a couple seconds after he/she administered the insulin; -He/She had not received any additional education or training regarding insulin administration, including priming the insulin pen needle and holding the needle in the skin when administering. 2. Review of Resident #44's Physician Order Sheet (POS), dated March 2026, showed an order for Tramadol 50 milligrams (mg), two tablets daily at bedtime. Observation on 03/03/26 at 8:32 P.M. showed the following: -CMT M pulled the prefilled packet of Tramadol 50 mg tabs from the narcotic lock box on the medication cart and pushed one tablet into a medication cup to administer to the resident; -CMT M returned the prefilled packet of Tramadol 50 mg into the narcotic lock box on the medication cart; -CMT M documented he/she administered Tramadol 50 mg, two tablets at bedtime, on the resident's electronic medical record (EMR); -CMT M took the medication to the resident and prepared to give the resident one tablet of Tramadol 50 mg.-The survey agency asked CMT M to verify the medication with the resident's medication order. During an interview on 93/03/26 at 8:45 P.M., CMT M said he/she did not read the resident's medication order correctly when he/she started to administer one Tramadol 50 mg tablet to the resident. 3. During an interview on 3/5/26 at 5:47 P.M., the Director of Nursing (DON) said the following:-She expected staff to follow physician's orders and to give medications as ordered;-When administering insulin, she expected staff to follow the manufacturer recommendations, including priming the insulin pen needle and holding pressure for the appropriate amount of time. During an interview on 03/16/26 at 12:35 P.M., the Administrator said he expected staff to follow physician's orders.

Based on interview and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews for two Certified Nurse Aides (CNA F and CNA G), in a review of two CNA employee files. The facility census was 58. Review of the Facility Assessment, revised 04/01/2025, showed the following:-The facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for the resident population;-Required in-service training for nurse aides. In-service training must:-Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. 1.Review of Certified Nurse Aide (CNA) F's employee file showed the following:-Date of hire: 09/26/24;-No documentation of nurse aide evaluation/competencies or annual performance review. 2. Review of CNA G's employee filed showed the following:-Date of hire: 04/02/24;-No documentation of nurse aide evaluation/competencies or annual performance review. 3. During an interview on 03/05/26 at 5:47 P.M., the Director of Nursing (DON) said she had not done any nurse aide evaluations/competencies or annual performance reviews.During an interview on 03/16/26 at 12:35 P.M. the Administrator said the DON was responsible for annual CNA performance evaluations and he would expect CNAs employed greater than 12 months to have a performance evaluation completed and for that staff to receive additional education as needed based on the results of the evaluation.

Based on observation, interview, and record review, the facility failed to ensure the physician provided his/her rationale for not making a medication change as recommended by the pharmacist during the monthly drug regimen review for one resident (Resident #9), in a review of 19 sampled residents. The facility census was 58.Review of the facility policy, Antipsychotic Medication Use, revised July 2022, showed the following:-All antipsychotic medications will be used within the clinically recommended dosage guidelines or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours;-The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of the facility policy, Psychotropic Medication Use, revised July 2022, showed the following:-Residents on psychotropic medications received gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications;-If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued and document the rationale for this decision. 1. Review of Resident #9's undated face sheet showed the following:-admitted [DATE];-Diagnosis of insomnia. Review of the resident's physician orders, dated 12/18/25, showed an order for melatonin (a hormone that regulates sleep) 3 milligrams (mg), give on tablet by mouth every 24 hours as needed for 14 days (stop on 12/30/25). Review of the resident's Physician Orders, dated 1/8/26, showed an order for melatonin 10 mg, give one tablet by mouth at bedtime. Review of the resident's progress notes, dated 1/28/26 at 9:24 P.M., showed the resident was sleeping in his/her wheelchair. Review of the resident's Pharmacist's Recommendation to Prescriber, dated 1/28/26, showed the following:-Medication management recommendation, melatonin dose greater than 6 mg per day;-High doses (greater than 6 mg) of exogenous melatonin can cause prolongation of elevated melatonin levels and desensitization. Large doses have been shown to produce supra-physiological levels in older adults which may result in drowsiness, somnolence, or unsteady feeling when waking up and may result in loss of efficacy for sleep. Multiple studies have shown some efficacy in regard to decreased sleep latency and improved sleep efficiency in doses ranging from 1 to 6 mg;-Recommendation section gave two options: reduce melatonin to 5 mg daily, one hour before bedtime, or continue current dose, no change is indicated at this time;-The physician selected the no change is indicated at this time;-No prescriber comments were provided as to why the change was not indicated;-The provider signed on 2/10/26. Review of the resident's physician orders, dated February 2026, showed an order for melatonin 10 mg, give one tablet by mouth at bedtime (original order dated 01/08/26). Review of the resident's progress notes, dated 2/1/26 at 11:51 A.M., showed the resident was up in his/her wheelchair all night. Review of the resident's progress notes, dated 2/4/26 at 1:15 P.M., showed the resident took his/her morning medications, then slept through breakfast, waking for lunch at 12:30 P.M. Review of the resident's progress notes, dated 2/10/26 at 10:44 A.M., showed the resident's physician reviewed the pharmacy recommendation to prescriber, related to the melatonin dose, the physician marked to continue current dose no change was indicated at this time. Review of the resident's progress notes, dated 2/17/26 at 8:58 A.M., showed the resident did not sleep the previous two nights. Review of the resident's progress notes, dated 2/18/26 at 5:10 A.M., showed the resident hollered out around 1:38 A.M. and was found on the floor in front of his/her wheelchair. Review of the resident's progress notes, dated 12/18/26 at 12:50 P.M., showed the resident was sleeping in his/her wheelchair. Review of the resident's physician orders, dated March 2026, showed an order for melatonin 10 mg, give one tablet by mouth at bedtime (original order dated 01/08/26). Observation on 03/02/26 at 1:55 P.M. showed the resident was asleep in his/her wheelchair in his/her room. Observations on 03/03/26 at 11:08 A.M. and 7:59 P.M. showed the resident was asleep in his/her wheelchair in his/her room. Observation on 03/04/26 at 1:01 P.M. showed the resident was asleep in his/her wheelchair in his/her room. Observation on 3/5/26 at 8:33 A.M. showed the resident was asleep in his/her wheelchair in his/her room. Observation on 3/5/26 at 9:52 A.M. showed the resident was asleep in his/her wheelchair in his/her room. During an interview on 3/5/26 at 5:47 P.M., the Director of Nursing said the following:-The pharmacy completed the monthly drug regimen reviews and made recommendations;-She sent the recommendation to the physician who reviewed and made a decision regarding the medication;-She documented the physician's decision in the medical record and made any changes if ordered. During an interview on 3/18/26 at 3:01 P.M., the resident's primary care physician said the following:-He was aware CMS expected him to give a rationale for continuing an abnormal dose or not completing a GDR;-He did not have the time to review every resident's medical record, including medications and behaviors, when reviewing the pharmacy recommendation;-When the facility gave updates on the resident, based on the pharmacy recommendations, it made it easier for him to give a rationale as to why he was or was not making the recommended changes.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan that included services to maintain the residents' highest practicable physical, mental, and psychosocial well-being, when the facility failed to include skin breakdown and pressure ulcers for one resident (Resident #9), and the use of a nebulizer due to chronic health conditions for one resident (Resident #36), in a review of 19 sampled residents. The facility census was 58.Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident;-The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission;-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment;-The comprehensive, person-centered care plan:-Includes measurable objectives and timeframes;-Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment or any specialized services to be provided as a result of PASARR recommendations and which professional services are responsible for each element of care;-Includes the resident's stated goals upon admission and desired outcomes;-Builds on the resident's strengths;-Reflects currently recognized standards of practice for problem areas and conditions;-Services provided for or arranged by the facility and outlined in the comprehensive care plan are provided by qualified persons, culturally competent, and trauma-informed;-Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making;-When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers;-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change;-The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome is 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 assessment. 1. Review of Resident #9's baseline care plan, dated 12/16/25, showed the resident had lesions to the scalp and had a history of skin integrity issues. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/1/26, showed the following:-Moderately impaired cognition;-The resident did not have any pressure ulcers or injuries;-The resident was at risk of developing pressure ulcers or injuries;-The resident did not have any open lesions, other than ulcers, rashes or cuts;-The resident had moisture-associated skin damage. Review of the resident's skin check, dated 2/1/26, showed the following:-New skin tear to the right elbow;-Old open lesion to the frontal scalp; -New moisture-associated skin damage to the right buttock;-New moisture-associated skin damage to the left buttock;-New open lesion to the genitalia. Review of the resident's Physician Orders, dated 02/01/26, showed an order for Calmoseptine (an over-the-counter moisture barrier designed to protect, soothe, and promote healing of skin irritations) to open/excoriated areas to genitalia and right and left buttocks every shift, until healed. Review of the resident's skin check, dated 2/11/26, showed the following:-Old skin tear to the right elbow, improving;-Old open lesion to the frontal scalp, improving;-New moisture-associated skin damage to the right buttock;-New open lesion to the genitalia;-New moisture-associated skin damage to the left buttock. Review of the resident's Care Plan, updated 2/17/26, showed the resident required skin inspection weekly. (There was nothing documented indicating any active skin concerns, breakdowns, or interventions.) Review of the resident's skin check, dated 2/21/26, showed the following:-New moisture-associated skin damage to the right buttock;-New open lesion to the genitalia;-Old open lesion to the frontal scalp, improving;-New moisture-associated skin damage to the left buttock;-Old skin tear to the right elbow. Review of the resident's Skin and Wound note by Healing Partners (wound care provider), dated 2/24/26, showed the following:-The resident presented with open skin injury to coccyx (tailbone), etiology consistent with pressure;-Wound #1: coccyx, pressure ulcer/injury, stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) status is new, size is 1 centimeter (cm) by 0.5 cm by 0.1 cm, wound base was 50% epithelial (outer layer of the skin) and 50% granulation (new connective tissue and blood vessels that form on the surfaces of a wound);-Surgical wound debridement (medical removal of dead, damaged, or infected tissue from a wound to promote healing) was performed;-Wound #1: coccyx treatment recommendations: cleanse with normal saline, apply hydrogel to base of wound, secure with bordered dressing, change daily;-Follow treatment plan for wound, frequent repositioning and offloading cushion to wheelchair. Review of the resident's Physician Orders, dated 2/24/26, showed an order to cleanse the coccyx with normal saline, pat dry, apply hydrogel, cover with bordered dressing and change daily until healed. Review of the resident's skin check, dated 2/28/26, showed the following:-Old moisture-associated skin damage to the right buttock;-Old open lesions to the genitalia;-Old open lesion to the frontal scalp;-Old moisture-associated skin damage to the left buttock;-Old skin tear to the right elbow. Observation on 03/05/26 at 1:27 P.M. showed the resident had a pressure ulcer on his/her coccyx. Review of the resident's current Care Plan showed no documentation the resident had any skin concerns or pressure ulcers. 2. Review of Resident #36's undated face sheet showed his/her diagnoses included chronic obstructive pulmonary disease (COPD; a lung disease that restricts breathing), acute respiratory failure (a condition where the lungs cannot adequately exchange oxygen for carbon dioxide) with hypoxia (low oxygen levels), asthma (a chronic lung disease that causes inflammation, swelling, and narrowing of the airways, making it difficult to breathe), pneumonia (a lung infection) due to COVID-19, and bronchiectasis (a chronic lung disease where the airways become permanently widened, damaged, and inflamed). Review of the resident's Physician Orders, dated 2/20/26, showed the following:-Ipratropium-Albuterol inhalation solution (an inhaled medication to treat COPD) 0.5-2.5 3 milligram (mg)/3 milliliter (mL), one vial inhale orally every four hours as needed for shortness of breath or wheezing;-Ipratropium-Albuterol inhalation solution 0.5-2.5 3 mg/3 mL, one vial inhale orally every morning and at bedtime for chronic cough. Review of the resident's care plan, updated 2/20/26, showed no documentation the resident had COPD or required nebulizer treatments. During an interview on 3/5/26 at 5:47 P.M., the Director of Nursing (DON) said she expected care plans to be up to date, resident specific and revised with changes to the resident.

Based on interview and record review, the facility failed to monitor the drug regimen for unnecessary medications by not ensuring the as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #19 and #14), in a review of 19 sampled residents. The facility census was 58. Review of the facility policy, Antipsychotic Medication Usage, dated July 2022, showed the following:-Residents will not receive medications that are not clinically indicated to treat a specific condition;-Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review;-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order;-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(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions):-Schizophrenia;-Schizoaffective disorder;-Schizophreniform disorder;-Delusional disorder; -Mood disorders (e.g., 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 (e.g., high-dose steroids); -Tourette's Disorder; -Huntington Disease; -Hiccups (not induced by other medications); or -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 (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or behavioral interventions have been attempted and included in the plan of care, except in an emergency (see below);-In the case of an emergency (that is, an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others) related to one or more of the above conditions or diagnoses, the use of antipsychotic medications must meet following additional requirements:-The acute treatment period is limited to seven days or less; and-A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication; and-Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. 1. Review of Resident #19's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/01/26 showed the following:-Moderately impaired cognition;-Diagnoses of malnutrition and anxiety;-Hospice care;-Takes antipsychotic medication. Review of the resident's Care Plan, revised 01/09/26, showed the following:-The resident uses psychotropic medications related to disease process;-Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift;-The resident was at risk for adverse reactions related to polypharmacy. Review of the resident's Physician's Orders, dated 02/17/26, showed an order for Haldol (antipsychotic medication) 2 milligrams (mg)/milliliter (ml) give 0.5 ml by mouth every six hours PRN agitation/hallucinations (open ended order/no stop date). Review of the resident's February 2026 Medication Administration Record (MAR) showed no documentation staff administered PRN Haldol to the resident between 02/17/26 and 02/28/26. Review of the resident's March 2026 Physician's Orders showed an order for Haldol 2 mg/ml, give 0.5 ml by mouth every six hours PRN agitation/hallucinations (start date 02/17/26, open ended order/no stop date). Review of the resident's March 2026 MAR, for review dates of 03/01/26 through 03/04/26, showed the following: -On 03/02/26 at 2:38 A.M., staff documented the resident received Haldol 0.5 ml by mouth. Staff documented the medication was effective;-On 03/02/26 at 10:10 P.M., staff documented the resident received Haldol 0.5 ml by mouth. Staff documented the medication was effective;-On 03/04/26 (16 days after the medication start date) at 1:00 A.M., staff documented the resident received Haldol 0.5 ml by mouth. Staff documented the medication was ineffective;-On 03/04/26 (16 days after the medication start date) at 4:34 P.M., staff documented the resident received Haldol 0.5 ml by mouth. Staff documented the medication was ineffective. Review of the resident's medical record, dated 02/01/26 through 03/04/26, showed no documentation of a pharmacy recommendation regarding the PRN Haldol and no documentation the resident's physician evaluated the resident for the appropriateness of PRN Haldol and documented the rationale for continued use. 2. Review of Resident #14's Significant Change MDS, dated [DATE], showed the following:-Cognitively intact;-No behaviors;-Diagnosis of stroke, dementia, anxiety and depression;-Hospice care;-Receives antianxiety medication. Review of the resident's Care Plan, revised 12/01/25, showed the following:-The resident has impaired cognitive function or impaired thought processes related to dementia;-The resident was at risk for falls related to psychoactive medication use and the potential side effects;-The resident used antianxiety medications related to anxiety disorder;-Administer antianxiety medications as ordered by the physician. Monitor for side effects and effectiveness as needed;-The resident was at risk for adverse reaction related to polypharmacy.Review of the resident's Physician's Orders, dated 01/24/26, showed an order for alprazolam (antianxiety medication) 0.25 mg, give one tablet PRN anxiety twice daily (open ended order/no stop date). Review of the resident's January 2026 MAR showed on 01/31/26 at 4:11 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective. Review of the resident's February 2026 Physician's Orders showed an order for alprazolam 0.25 mg, give one tablet PRN anxiety twice daily (open ended order/no stop date). Review of the resident's Quarterly MDS, dated [DATE], showed the following:-Moderately impaired cognition;-No behaviors;-Receives antianxiety medication. Review of the resident's February 2026 MAR showed the following:-On 02/04/26 at 9:47 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/06/26 at 7:05 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/07/26 (15 days after the medication start date) at 3:40 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/12/26 (20 days after the medication start date) at 5:15 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/14/26 (22 days after the medication start date) at 5:09 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/15/26 (23 days after the medication start date) at 11:30 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/17/26 (25 days after the medication start date) at 10:31 A.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective;-On 02/21/26 (29 days after the medication start date) at 7:03 P.M., staff administered alprazolam 0.25 mg by mouth. Staff documented the medication was effective. Review of the resident's March 2026 Physician's Orders showed an order for alprazolam 0.25 mg, give one tablet PRN anxiety twice daily (open ended order/no stop date). Review of the resident's March 2026 MAR showed no documentation the resident received PRN alprazolam. Review of the resident's Care Plan, revised 03/02/26, showed the following:-The resident used psychotropic medications;-Administer psychotropic medications as ordered by the physician;-Monitor for side effects and effectiveness every shift. Review of the resident's medical record dated 01/01/26 through 03/04/26 showed no documentation of a pharmacy recommendation regarding the PRN alprazolam and no documentation the resident's physician evaluated the resident for the appropriateness of PRN alprazolam and documented the rationale for continued use. 3. During an interview on 3/5/26 at 5:47 P.M. the Director of Nursing said the following:-PRN antipsychotic medications should have 14 day stop dates;-Other PRN psychotropic medications, like antianxiety medications, can be ordered by the physician for six months;-PRN psychotropic medications are mostly monitored by pharmacy;-She tried to monitor the PRN psychotropic medication as well, but it sometimes slips through the cracks.

Based on observation, interview, and record review, the facility failed to adequately address strong and pervasive urine odor at its source. The facility census was 58. No policy regarding addressing odors was received from the facility upon request. 1. Observation on 03/02/26 at 11:50 A.M. showed the following: A strong, urine odor in the hallway outside of Resident #28's room and adjoining resident rooms on the hall; -Resident #28's door was partially open; -The resident appeared to be sleeping and lay on his/her bed, unclothed, with his/her private area covered by a towel;-The fitted sheet beneath the resident had a dark, circular ring just beneath the resident's buttocks that appeared wet. Observation on 03/02/26 at 4:15 P.M. showed the following: -A strong urine odor noted in the hallway outside of the resident's room, and adjoining resident rooms in the hall; -The resident's door was partially open; -The resident sat on the side of his/her bed; -The fitted sheet beneath the resident had a dark, circular ring just beneath the resident's buttocks that appeared wet; -A partially filled urinal, with no lid, sat on the floor beside the resident's legs. Observation on 03/03/26 at 09:00 A.M. showed a strong, urine odor noted in the hallway outside of the resident's room and adjoining resident rooms on the hall. Observation on 03/03/26 at 07:50 P.M. showed a strong, urine odor noted in the hallway outside of the resident's room adjoining resident rooms on the hall. Observation on 03/04/26 at 10:55 A.M. showed a strong, urine odor noted in the hallway outside of the resident's room and adjoining resident rooms on the hall. 2. During an interview on 03/04/26 at 11:00 A.M., Resident #32, who resided on the same hall and next door to Resident #28, said he/she noticed a terrible smell in the hallway outside of his/her room at times. 3. During an interview on 03/04/26 at 10:00 A.M., a family member of another resident, two rooms down from Resident #28's room, said he/she always noticed a bad smell in the hall when he/she visited daily. 4. During an interview on 03/03/26 at 10:50 A.M., Housekeeper B said the following: -Housekeeping tried to clean Resident #28's room every day, but sometimes the resident would holler at staff and tell them to get out of the room; -Sometimes housekeeping would go back to the resident's room when he/she was sleeping and at least mop the floor. During an interview on 03/03/26 at 7:15 P.M., Certified Nurse Aide (CNA) N said the following: -The resident was independent with using the bathroom; -Nursing staff attempted to help the resident with bathing/hygiene, but the resident would often refuse and yell at staff to get out; -Staff could not force the resident to clean up as that was his/her right. During an interview on 03/05/26 at 3:25 P.M., the Director of Therapy said the following: -The facility's therapy room was located around the corner and a short distance from Resident #28's room; -The therapy room was accessed by all residents on skilled services;-There was always a strong urine odor in the hallway outside Resident #28's room, sometimes it could be detected in the therapy room. During an interview on 03/05/26 at 05:47 P.M., the Director of Nurses (DON) said the following: -She was aware of the strong odors from Resident #28's room that permeated the hallway; -The resident refused assistance with hygiene/bathing; -Housekeeping tried to mop daily, and all staff tried to clean the room as best as they could, especially when the resident was asleep. During an interview on 03/16/26 at 12:35 P.M., the administrator said he would expect housekeeping staff to make additional efforts as needed/warranted to keep the facility free from odors when a resident refused housekeeping services.

Based on observation, interview and record review, the facility failed to ensure staff transferred one resident (Resident #59), in a review of 19 sampled residents, using appropriate technique, consistent with the resident's abilities and condition, to ensure the resident's safety. The facility census was 58. Review of the facility policy, Safe Lifting and Movement of Residents, revised July 2017, showed the following:-In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents;-Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Manual lifting of residents shall be eliminated when feasible;-Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following;-Resident's preferences for assistance; -Resident's mobility (degree of dependency); -Resident's size; -Weight-bearing ability; -Cognitive status; -Whether the resident is usually cooperative with staff; and -The resident's goals for rehabilitation, including restoring or maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 1. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/20/25, showed the following:-Severe cognitive impairment;-Dependent on staff for dressing, toileting hygiene and personal hygiene;-Dependent on staff for roll left and right, sit to stand, sit to lying, chair/bed to chair transfer, and toilet transfer;-Walking not attempted due to medical condition or safety concerns;-Always incontinent of bladder and bowel;-Diagnoses of stroke;-Weight 113 pounds;-Hospice care. Review of the resident's Care Plan, revised 12/01/25, showed the following:-The resident has activity of daily living (ADL) self-care performance deficit related to stroke;-The resident is totally dependent on one staff for repositioning, turning in bed, personal hygiene and eating;-The resident is totally dependent on two staff for transferring. Use Hoyer lift (full body mechanical lift) as needed (PRN). Up in Broda chair (specialized, highly adjustable medical wheelchair or positioning chair designed for superior comfort, safety, and pressure management in long-term care, nursing homes, and rehab centers);-The resident is non-weight bearing;-The resident has bladder incontinence related to impaired mobility and physical limitations;-The resident has bowel incontinence related to immobility. Observation on 03/03/26 at 7:27 P.M., in the resident's room, showed the following:-The resident sat in his/her Broda chair;-Certified Nurse Assistant (CNA) C removed the resident's shirt and placed a gown over the resident's head;-CNA C told the resident to give him/her a hug;-CNA C put his/her arms under the resident's arm pit area;-CNA C lifted the resident up out of the chair and moved the resident to his/her bed;-CNA C did not use a gait belt or mechanical lift during the transfer;-The resident's knees were bent during the transfer and he/she did not bear weight;-CNA C provided peri care and dressed the resident. During an interview on 03/03/26 at 8:38 P.M., CNA C said the following:-The resident can't stand on his/her own;-He/She was not sure if a gait belt would be appropriate to transfer the resident as he/she likes to have the resident hold onto him/her during the transfer;-He/She feels like the resident wouldn't be close enough to staff during a gait belt transfer;-The resident does not take steps and needs help standing up;-He/She feels like the resident tries to bear weight; -He/She can see the resident's care plan on the computer. Observation on 03/04/26 at 1:37 P.M., in the shower room, showed the following:-The resident sat in his/her Broda chair;-The resident was incontinent of urine;-Certified Medication Technician (CMT) J pushed the resident's chair close to the toilet;-CMT J stood in front of the resident on the left side and CNA G stood in front of the resident on the right side;-CMT J placed his/her arm under the resident's arm pit and CNA G placed his/her arm under the resident's arm pit and lifted the resident up out of his/her chair;-The resident's feet slid across the floor while CNA G and CMT J lifted the resident onto the toilet;-The resident was unable to stand, and his/her knees were bent during the transfer;-The resident urinated in the toilet;-CMT J placed his/her arms under the resident's arm pits, lifted upward and stood the resident while CNA G performed peri care;-The resident's knees were bent and the resident did not stand upright;-CNA G applied a clean disposable brief and pants;-CMT J pivoted the resident to his/her Broda chair;-The resident's feed slid across the floor while CMT J transferred the resident;-The resident did not bear weight during the transfer.-CMT J and CNA G did not utilize a gait belt, and did not use a mechanical lift for the resident who did not bear weight. During an interview on 03/04/26 at 1:42 P.M., CMT J said the following:-He/She doesn't usually work on the floor;-He/She was unsure if staff usually used a gait belt when transferring the resident;-The resident did not stand well and did not fully bear weight. During an interview on 03/04/26 at 3:30 P.M., CNA G said the following:-He/She usually transferred the resident without a gait belt but sometimes he/she used a gait belt when moving the resident from his/her chair to the bed;-Today (03/04/26), the resident did not bear weight well at all; he/she was very unsteady. During an interview on 03/05/26 at 3:25 P.M., the director of therapy said staff should use a mechanical lift for transfers if a resident was unable to bear weight. Staff should not pull up under a resident's arms during transfers. During an interview on 03/05/26 at 5:47 P.M., the Director of Nursing said if the resident was not bearing weight, staff should use the mechanical lift for transfers.

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two residents (Resident #2 and #8) in a review of nine residents when staff failed to provide incontinence care timely and maintain good personal hygiene and failed to ensure resident clinical assessments were completed and documented for Resident #2. The facility failed to provide sufficient staff on the memory care unit to ensure supervision of Resident #8. The facility also and failed to consistently have Certified Nurse Assistant (CNA) staff as identified in the facility assessment. The facility census was 54. Review of the facility policy Staffing, Sufficient and Competent Nursing, dated 8/2022 showed the following: -The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses and certified nurse assistants are available 24 hours a day, seven days a week to provide competent resident care services including assuring resident safety, attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident, assessing, evaluating, planning and implementing resident care plans, and responding to resident needs; -Licensed nurses are required to supervise nurse assistants and are scheduled in such a way that permits adequate time to do so; -Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment; -Factors considered in determining appropriate staffing ratios and skills include an evaluation of the disease, conditions, physical or cognitive limitations of the resident population and acuity. 1 Review of the facility Assessment Tool, revised 8/5/24, showed the following: -Use of the facility assessment will demonstrate a good faith effort by the facility to evaluate necessary resources to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies; -Based on our resident population and their needs for care and support, the facility had made a good faith effort and approach to ensure sufficient staff to meet the needs of the resident at any given time; -Average daily census was 55 residents; -Average 20 residents with behavioral health needs; -Nursing services hours per day listed by shift (day and night); -Registered Nurse eight hours per day; -Licensed Practical Nurse (LPN) 24 hours per day shift and 24 hours per night shift; -Certified Nurse Assistant (CNA) 72 hours per day shift and 60 hours per night shift; -Certified Medication Technician (CMT) 24 hours per day shift. Review of the facility December 2024 daily nursing assignment sheets showed the following CNA hours documented as worked per day shift (6:00 A.M. to 6:00 P.M.) and night shift (6:00 P.M. to 6:00 A.M.): -On 12/1/24 day shift 52 hours and night shift 36 hours, 20 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/3/24 day shift 37 hours, 23 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/4/24 day shift 39 hours, 33 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/5/24 day shift 35 hours, 37 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/6/24 day shift 67 hours and night shift 42 hours, five CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/7/24 day shift 48 hours, 24 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/9/24 day shift 64 hours and night shift 32 hours, eight CNA hours less on day shift and 28 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/10/24 day shift 47 hours and night shift 51 hours, 25 CNA hours less on day shift and six CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/11/24 day shift 52 hours, 20 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/13/24 night shift 44 hours, 16 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/14/24 day shift 55 hours and night shift 51 hours, 17 CNA hours less on day shift and nine CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/15/24 day shift 64 hours, 18 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/16/24 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/17/24 night shift 39 hours, 21 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/18/24 day shift 29 hours, 43 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/19/24 day shift 32 hours, 40 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/20/24 day shift 52 hours and night shift 34 hours, 20 CNA hours less on day shift and 26 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/21/24 day shift 58 hours, 24 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/23/24 day shift 48 hours and night shift 32 hours, 24 CNA hours less on day shift and 28 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/24/24 day shift 63 hours, nine CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/25/24 day shift 43 hours, 29 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/26/24 day shift 66 hours and night shift 48 hours, 16 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/27/24 day shift 52 hours and night shift 48 hours, 20 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/28/24 day shift 36 hours, 35 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/29/24 day shift 60 hours and night shift 48 hours, 12 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/31/24 day shift 44 hours and night shift 44 hours, 28 CNA hours less on day shift and 16 CNA hours less on night shift than indicated as needed on the facility assessment. Review of the facility January 2025 daily nursing assignment sheets showed the following CNA hours scheduled per day shift and night shift: -On 1/1/25 day shift 58 hours, 14 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/2/25 day shift 56 hours and night shift 36 hours, 16 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/3/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/5/25 day shift 48 hours and night shift 24 hours, 24 CNA hours less on day shift and 36 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/6/25 day shift 40 hours and night shift 36 hours, 32 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/7/25 day shift 42 hours, 30 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/10/25 day shift 45 hours, 27 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/11/25 day shift 60 hours and night shift 42 hours, 12 CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/12/25 day shift 60 hours and night shift 36 hours, 12 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/13/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/14/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/16/25 day shift 48 hours and night shift 42 hours, 24 CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/17/25 night shift 24 hours, 36 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/18/25 night shift 48 hours, 12 CNA hours less on night shift than indicated as needed on the facility assessment. 2. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24, showed the following: -Severely impaired cognition; -Frequently incontinent of urine; -Always incontinent of bowel; -Required substantial/maximum staff assistance (helper does more than half the effort) with toileting, dressing lower body and personal hygiene; -Dependent on staff for transfers to and from the toilet. Review of the resident's Care Plan, dated 10/20/24, showed the following: -Diagnoses of dementia, anxiety, urinary incontinence, abnormal gait and mobility, unsteadiness on feet, kidney disease, stroke and urinary tract infection; -Impaired physical mobility and risk for self-care deficit. Staff should determine the level of assistance needed, provide assistance with Activities of Daily Living (ADL) as needed, determine residents ability to transfer, educate resident on exercise and safe transfer techniques, encourage resident to increase activity as indicated, evaluate skin for areas of redness, evaluate functional abilities; -ADL self-care performance deficit related to stroke. Staff should provide assistance with ADLs, transfers, dressing and personal hygiene and total assistance with toileting. Review of the resident's Nurses Note, dated 12/29/24, showed staff documented the following: -At 12:48 P.M. the resident was not acting right. The resident sat in the wheelchair with head tilted back, no response to verbal stimuli and slight response to sternal rub (act of forcefully rubbing the sternum) Blood pressure 186/116 (normal 120/80), heart rate 128 (normal 60-80) beats per minute and bounding, respirations 16 (normal 12-18) breaths per minute and slow. Covid-19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2(SARS-CoV-2) test was positive. Staff called the ambulance and transferred the resident to the emergency room for evaluation and treatment; -At 4:20 P.M. the resident was admitted to the hospital with acute CVA (cardiovascular accident or stroke). Review of the resident's Hospital Discharge Physician Orders, dated 12/31/24, showed the following: -Hospital admission diagnosis of acute stroke; -Physical therapy, occupational therapy and speech therapy evaluation and treat; -Check weights and record; -Check vital signs and record; -COVID-19 precautions; -Follow up with cardiology physician in 30 days related to Zio heart monitor (a heart monitor patch applied to the skin that records the heart rhythm for up to two weeks). Review of the resident's Nurses Note, dated 12/31/24 at 6:33 P.M., showed staff documented the resident returned to the facility by medical transport. The resident was on isolation precautions due to positive COVID-19 status. Review of the resident's medical record showed no documentation staff completed an admission clinical assessment or assessed the resident's vital signs (blood pressure, heart rate, respirations, temperature and oxygen saturation level) on 12/31/24. Review of the resident's medical record showed no updated and current MDS assessment since the admission MDS assessment completed on 9/27/24. Review of the resident's vital signs record dated 1/1/25 showed staff documented the resident's heart rate was 91 beats per minute. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs other than heart rate (blood pressure, respirations, temperature, oxygen saturation level) on 1/1/25. Review of the resident's Physician Order Sheet (POS), dated 1/2/25, showed the following: -Admit to the facility, the resident needed continuous care due to inability to live independently and the need for 24-hour assistance, observation and planning; -Vital signs and weigh monthly. Review of the resident's medical record dated 1/2/25 showed staff documented heart rate 83 beats per minute. No documentation staff completed a clinical assessment or updated the resident's care plan regarding recent hospitalization for stroke and presence of a heart monitor or assessed the resident vital signs other than heart rate. Review of the resident's Nurses' Note, dated 1/3/25, showed staff documented the following: -At 1:21 A.M. the resident was readmitted and was positive for COVID-19. The resident was isolated in his/her room and monitored for any worsening of symptoms; -At 12:05 P.M. the resident remained COVID-19 positive and in isolation. The resident was up in the wheelchair in room for meals, no complaints noted. Vital signs within normal limits, medications administered. Review of the resident's medical record dated 1/3/25 showed staff documented heart rate 77 beats per minute and oxygen saturation level of 94 percent (normal greater than 92 percent). No documentation staff completed a clinical assessment or assessed the resident vital signs other than heart rate and oxygen saturation level. Review of the resident's Nurses' Note, dated 1/4/25, showed staff documented the following: -At 1:47 A.M. the resident continued isolation due to positive COVID-19. No cough noted and no adverse reactions; -At 5:18 P.M. the resident continued isolation due to positive COVID-19. No cough noted. The resident ate well for meals while staff set up food and offered limited assistance. Review of the resident's medical record dated 1/4/25 showed staff documented blood pressure was 144/86, heart rate was 79 beats per minute, respirations 20 breaths per minute, and temperature was 98.7 degrees (normal 98.6 degrees).and oxygen saturation level of 94 percent (normal greater than 92 percent). No documentation staff completed a clinical assessment or assessed the resident's oxygen saturation level. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs from 1/5/25 through 1/18/25. Review of the resident's Nurses Note, dated 1/19/25, showed the following: -At 12:41 P.M. staff documented around breakfast time the cardiology physician's staff requested the nurse press on the heart monitor to obtain a reading. At 11:00 A.M. the cardiology physician's staff instructed the facility to send the resident to the emergency room due to abnormal readings obtained from the heart monitor. Staff transferred the resident to the emergency room by ambulance. Vital signs at the time of transfer were blood pressure 102/64, heart rate 62 beats per minute, respirations 18 breaths per minute, temperature 98.2 degrees, oxygen saturation 98 percent; -At 8:46 P.M. the resident was admitted to the hospital with bradycardia (abnormal slow heart rate). Review of the resident's Hospital Discharge Physician Orders, dated 1/20/25, showed the following: -Diagnoses of heart pause lasting seven seconds per cardiac monitor, recent stroke, bradycardia; -Zio heart monitor patch remained in place; -Check and record weights; -Check and record vital signs. Review of the resident's Nurses' Note, dated 1/20/25 at 5:29 P.M., showed the resident returned to the facility, alert and responded verbally to questions. Blood pressure 130/90, heart rate 96 beats per minute, respirations 18 breaths per minute, temperature 98.7 degrees, oxygen saturation 98 percent. Review of the resident's medical record dated 1/20/25 showed no documentation staff completed a clinical assessment or updated the resident's care plan regarding the recent hospitalization for bradycardia and heart pause or the present of the a heart monitor and no updated MDS assessment since the admission MDS assessment completed on 9/27/24. Observation on 1/22/25 showed the following: -At 10:05 A.M. the resident sat in a wheelchair, a heart monitor was noted attached to the resident's left chest wall just below the collar bone. Four square foam dressings dated 1/19/25 covered the resident's inside and outside ankle areas. A strong urine odor was noted coming from the resident; -At 11:00 A.M. the resident remained in the wheelchair with no change in position. A strong urine odor was noted coming from the resident; -At 11:45 A.M. Certified Nurse Assistant (CNA) B pushed the resident's wheelchair to the dining room for lunch. During an interview on 1/22/25 at 11:15 A.M. Licensed Practical Nurse (LPN) K said he/she was a charge nurse. The facility needed additional CNA staff especially for the East side (200 hall) and memory care unit. Two CNA staff were not enough for the East Hall, the residents required a lot of assistance with care, and many required mechanical lift transfers. During an interview on 1/22/25 at 11:46 A.M. CNA B said he/she toileted the resident and changed the resident's clothing before lunch. The resident was soiled and wet. The East Hall (200 hall) had many two person transfers and the residents required staff assistance to meet care needs. The East Hall needed additional CNA staff. Observation on 1/23/25 showed the following: -At 8:30 A.M. the resident sat in a wheelchair in his/her room, dressed in black pants and gray shirt. The square foam dressing dated 1/19/25 remained covering the resident's inside and outside ankle areas; -At 9:50 A.M. the resident sat in a wheelchair in his/her room, dressed in the same black pants and gray shirt; -From 11:30 A.M. through 12:45 P.M. the resident sat in a wheelchair in the dining room eating lunch, dressed in the same black pants and gray shirt. A strong urine odor was noted coming from the resident. CNA G said the resident was last toileted at about 9:00 A.M.; -At 12:45 P.M. staff pushed the resident in his/her wheelchair from the dining room to his/her room and parked the resident's wheelchair facing the television and did not offer to assist the resident with toileting or check the resident for incontinence. The resident had a strong urine and feces odor. During an interview on 1/23/25 at 12:48 A.M. the resident said staff got him/her up about 9:00 A.M. Staff had not taken him/her to the toilet or changed his/her incontinence brief since 9:00 A.M. The resident needed to go to the bathroom and change his/her soiled incontinence brief. Observation 1/23/25 at 1:00 P.M. showed the following: -CNA H and Nurse Assistant (NA) E transferred the resident to the toilet and removed the resident's urine and feces saturated incontinence brief. Feces was noted on the inside of the resident's pants; -CNA H repeatedly wiped the resident's buttocks and perineal area removing feces stuck to the resident's skin from the resident's buttock and perineal areas. CNA H said the feces had been there awhile as it was dried and was hard to clean. During an interview on 1/23/25 at 1:15 P.M. NA E said he/she worked the resident's hall and last toileted and changed the resident at 9:00 A.M. The East Hall needed three CNA staff to provide adequate care for the residents. The East Hall had multiple residents who required two-person total assistance with mechanical lift transfers and total care including showers and incontinence care. Staff was not able to keep the residents clean and dry. During an interview on 1/23/25 at 1:20 P.M. CNA H said staff should check the resident every two hours at least and change the resident if the resident was incontinent. Staff should not let the resident sit in feces and urine. The East Hall (Resident #2's hall) needed additional staff. The East Hall was usually staffed with two CNAs on the day shift, and they were not able to provide the resident cares, showers and two person transfers to meet the resident needs. Residents were left soiled and wet for extended periods of time and were not toileted as frequently as they should be. Review of the East Hall resident roster on 1/23/25 at 1:30 P.M., with LPN C and CNA H, showed 12 of the 19 residents who lived on the East Hall required a two-person mechanical lift transfer. During an interview on 1/23/25 at 1:45 P.M. the MDS Coordinator said the following: -He/She was responsible for completing the resident's MDS assessments. He/She should have completed a significant change MDS assessment for Resident #2 following the 12/31/24 hospital discharge and updated the resident's Care Plan at that time. He/She should also have updated the resident's care plan following the 1/20/25 hospital discharge. The resident's assessments and Care Plan updates were behind. He/She was currently working on December MDS assessments and was about three weeks behind. He/She was usually pulled to the floor to work as a charge nurse two days per week and could not keep up with the MDSs and Care Plan updates. 3. Review of the resident roster provided 1/22/25 showed eight residents resided on the memory care unit. Observation of the Memory Care Unit (a locked unit located adjacent to the 200 hall and the 200 hall nurses' desk) on 1/22/25 at 11:05 A.M. showed eight residents and one staff member. Multiple residents sat in wheelchairs at the core area table with the television on, drink cups sat on the table. CNA D came out of a resident's room. During an interview on 1/22/25 at 11:10 A.M. CNA D said he/she was the only staff assigned to the memory care unit. The memory care unit was usually staffed with one CNA. The CNA provided the residents' meals, incontinence care and toileting needs, showers, safety monitoring and activities. While the CNA provided resident cares and showers there was no staff to monitor the other residents. If behaviors occurred while he/she was providing a resident's care there was no other staff to ensure safety. Observation of the Memory Care Unit on 1/22/25 at 2:30 P.M., showed Resident #8 yelled for help multiple times from the bathroom. No staff was in the resident's room or bathroom. The resident shuffled out of the bathroom with pants down to his/her ankles, a shirt on and no shoes or socks. The resident shuffled towards his/her bed yelling for help. CNA B rushed into the resident's room, pulled up the resident's pants and sat the resident in a chair. CNA B returned to the core dining area where three residents sat in wheelchairs. Resident #9 hollered and attempted to stand. Two other residents' wheelchair wheels were tangled and the residents attempted to reach for the table and each other. CNA B attempted to redirect the residents. During an interview on 1/22/25 at 2:40 P.M. CNA B said he/she did not know what was wrong with Resident #9, the resident was new to the memory care unit. One staff member on the memory care unit was not enough to meet the residents' needs and provide supervision. During an interview on 1/23/25 at 8:55 A.M. Certified Medication Technician (CMT) F said the memory care unit staff provided all the residents care needs and supervision. One staff member was not enough to provide cares, showers and supervision. 4. During an interview on 1/23/25 at 9:50 A.M. Registered Nurse (RN) A said the following: -The charge nurse was responsible to complete a head-to-toe clinical assessment and document the findings in the medical record on admission and readmission. Staff did not assess Resident #2 following the two hospitalization s and readmissions and did not complete and document clinical assessments and assess vital signs as clinically indicated. The electronic medical record system triggered the assessments required at the time of admission and readmission. Staff had not completed the nursing admission assessment and had not documented a head-to-toe assessment including skin condition following either re-admission as required. The charge nurses filled in the CNA staff and floated to the memory care unit to meet the resident care needs. Additional CNA staff on the East Hall and memory care unit would allow the charge nurses additional time for clinical assessments and follow ups; -The charge nurse should have assessed the resident's skin and removed the 1/19/25 foam dressings from the resident's ankles. Staff did not know if the resident had a wound under the dressings or not. There was no documented skin assessments in the resident's medical record since the resident's re-admission on 12/31/24. The charge nurse should complete a weekly skin assessment for every resident and document the findings. -The facility did not have enough staff to meet the resident's needs. Additional CNA staff was needed on the East Hall and the memory care unit. One CNA staff was not enough on the memory care unit to meet the resident's needs and provide supervision. Staff from the East Hall had to float over to the memory care unit and left the East Hall understaffed. The East Hall had heavy care and many residents required two person transfer assistance with mechanical lifts. During an interview on 1/23/25 at 10:30 A.M. the Human Resources Director said he/she made the nursing schedule. The facility did not have enough staff currently to meet the residents' needs. The facility was trying to hire additional staff. During an interview on 1/24/25 at 11:45 A.M. the Director of Nursing said the following: -Staff should keep residents clean and dry, check and change residents every two hours and should not leave residents wet and soiled for extended periods of time; -The charge nurse should complete the admission or readmission process and assess the resident on admission. The admission check list should be completed to ensure accuracy of the admission and all assessments were completed timely. The assessments and check list were not done 99 percent of the time and admission assessments were not completed. Staff were not completing a head-to-toe assessment on admission or readmission and not completing and documenting daily clinical assessments as should be done. The charge nurses were helping the CNA staff complete cares and floating to the memory care unit when needed preventing the charge nurses from completing the assessments and clinical care; -The Care Plan should be updated with any new changes to the resident's care following hospitalization or a change in condition. -It was difficult to get all things done as they should be. The facility needed additional staff. The memory care unit needed two CNA staff on each shift to provide the residents' needs and safety, currently one CNA staff was generally scheduled for the memory care unit and a staff member from the East Hall floated to the memory care unit at times. The CMT or chare nurse should not be pulled to the memory care unit unless it was emergent. The East Hall needed an additional CNA staff on the day shift to meet the residents' needs. The MDS coordinator was pulled to work the floor and was three weeks behind on MDS assessments and Care Plan updates. The MDS coordinator should not be pulled to the floor to work as a charge nurse. During an interview on 1/24/25 at 11:15 A.M. the Administrator said the following: -On admission or readmission, the electronic medical record triggered all the assessments staff should complete and all the assessments should be completed timely. The charge nurse should complete a head-to-toe assessment and document the findings in the medical record including skin condition. He did not know why charge nurses were not completing the assessments; -Staff should follow the physician orders and ensure medical devices were attached and functioning. Staff should have assessed Resident #2's cardiac status and should have monitored the resident's vital signs. -Care Plans should be up to date and reflect the residents' current status; -Staff should check incontinent residents every one hour and provide incontinence care as needed. Staff should make sure residents were clean and dry and not left soiled; -The facility assessment reflected the current staffing needs of the facility. The facility was not meeting the staffing needs; -The MDS coordinator was pulled to fill in as a charge nurse and MDSs and Care Plans were not up to date; -Currently the staff was pulled from one area to help another. Two CNA staff assigned to the memory care unit would help. MO244306 MO246518

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2), who staff identified as incontinent and required staff assistance with toileting and incontinence care, in a review of nine residents, was provided incontinence care timely and maintained good personal hygiene. The facility census was 54. Review of the facility policy, Urinary Continence and Incontinence, Assessment and Management, dated 8/2022 showed the following: -As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence; -Staff will check the resident for incontinence and change the resident at regular intervals using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24 showed the following: -Severely impaired cognition; -Frequently incontinent of urine; -Always incontinent of bowel; -Required substantial/maximum staff assistance (helper does more than half the effort) with toileting, dressing lower body and personal hygiene; -Dependent on staff for transfers to and from the toilet. Review of the resident's Care Plan dated 10/20/24 showed the following: -Diagnoses of dementia, urinary incontinence, abnormal gait and mobility, unsteadiness on feet, kidney disease, stroke and urinary tract infection; -Impaired physical mobility and risk for self-care deficit. Staff should determine the level of assistance needed, provide assistance with Activities of Daily Living (ADL) as needed; -ADL self-care performance deficit related to stroke. Staff should provide assistance with ADLs, transfers, dressing and personal hygiene and total assistance with toileting. Observation of the resident on 1/22/25 showed the following: -At 10:05 A.M. the resident sat in a wheelchair in his/her room, facing the television. A strong urine odor was noted in the room; -At 11:00 A.M. the resident remained in the wheelchair with no change in position. A strong urine odor was noted coming from the resident; -At 11:45 A.M. Certified Nurse Assistant (CNA) B pushed the resident's wheelchair to the dining room for lunch. During an interview on 1/22/25 at 11:46 A.M. CNA B said he/she toileted the resident and changed the resident's clothing before lunch. The resident was soiled and wet. Observation on 1/23/25 showed the following: -At 8:30 A.M. the resident sat in a wheelchair in his/her room facing the television, dressed in black pants and a gray shirt; -At 9:50 A.M. the resident sat in a wheelchair in his/her room facing the television, dressed in the same black pants and gray shirt, in the same position; -From 11:30 A.M. through 12:45 P.M. the resident sat in a wheelchair in the dining room eating lunch, dressed in the same black pants and gray shirt. A strong urine odor was noted coming from the resident. CNA G said the resident was last toileted at about 9:00 A.M.; -At 12:45 P.M. staff pushed the resident in his/her wheelchair from the dining room to his/her room and positioned the resident's wheelchair facing the television and did not offer to assist the resident with toileting or check the resident for incontinence. The resident had a strong urine and feces odor. During an interview on 1/23/25 at 12:48 P.M. the resident said staff got him/her up about 9:00 A.M. Staff had not taken him/her to the toilet or changed his/her incontinence brief since 9:00 A.M. The resident needed to go to the bathroom and needed his/her soiled incontinence brief changed. Observation of the resident 1/23/25 at 1:00 P.M. showed the following: -CNA H and Nurse Assistant (NA) E transferred the resident to the toilet and removed the resident's urine and feces saturated incontinence brief. Feces was noted on the inside of the resident's pants; -CNA H repeatedly wiped the resident's buttocks and perineal area removing firm feces stuck to the resident's skin from the resident's buttock and perineal areas. CNA H said the feces had been there awhile as it was dried and was hard to clean. During an interview on 1/23/25 at 1:15 P.M. Nurse Aide (NA) E said he/she worked the resident's hall and last toileted and changed the resident at 9:00 A.M. that day. During an interview on 1/23/25 at 1:20 P.M. CNA H said staff should check the resident at least every two hours change the resident if the resident was incontinent. Staff should not let the resident sit in feces and urine. During an interview on 1/24/25 at 11:45 A.M. the Director of Nursing said staff should keep residents clean and dry, check and change residents every two hours and should not leave residents wet and soiled for extended periods of time. During an interview on 1/24/25 at 11:15 A.M. the Administrator said staff should check incontinent residents every one hour and provide incontinence care as needed. Staff should make sure residents were clean and dry and not left soiled. MO242963 MO245840 MO246518

Based on interview and record review, the facility failed to provide adequate protective oversight for one resident (Resident #1), in a review of seven sampled residents. Staff failed to lower the height of the bed after providing care as directed by the care plan. The resident rolled off the bed onto the floor and sustained injury. Staff sent the resident to the hospital and where the resident was found to have an orbital fracture (fracture of one or more bones surrounding the eye) and a brain bleed. The facility census was 42. On 7/19/23, the administrator was notified of a Past Noncompliance related to a fall with injury which occurred on 7/4/23. On 7/4/23 the facility in-serviced staff on fall prevention, positioning, ensuring low bed position, and residents' beds being properly bolstered to prevent rolling out of the bed. Policies and procedures were reviewed and updated. The facility implemented a post fall huddle form for assessment of root cause analysis and fall prevention. All staff were in-serviced for the new requirement for an immediate post-fall huddle to discuss all details about how a fall occurred. The Past Noncompliance was corrected on 7/4/23. Review of the facility Policy: Fall Assessment Policy and Procedures, dated 10/10/2015, showed the following: -Fall assessment is completed upon admission to identify residents who are at a high risk for falls in order to implement interventions and reduce the incidence of falls; -Fall assessments are also completed quarterly to identify residents who are at a high risk for falls and precipitating events and patterns leading to falls in order to implement interventions and reduce the incidence of future falls; -Residents will be reassessed after each incident to determine precipitating factors and methods of intervention; -Falls will be discussed weekly at the interdisciplinary team meetings; -Residents who present as a fall risk on admission or on quarterly review will be reported to the care plan coordinator by the nurse who completed the fall risk assessment; -The interdisciplinary team will then develop a plan of care to prevent falls; -Nursing will implement interventions to decrease or prevent future falls 1. Review of Resident #1's undated face sheet showed the resident had diagnoses that included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems) with behavioral disturbances (agitation, including verbal and physical aggression, wandering and hoarding), mood disorder (mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these), anxiety disorder, other symptoms and sign involving cognitive functions and awareness, history of falling, and altered mental status. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/10/23, showed the following: -The resident had severely impaired cognition; -The resident usually had the ability to understand others; -The resident was totally dependent on two staff for transfers, dressing, incontinent care, bathing and bed mobility. Review of the resident's care plan, dated 3/17/23, showed the following: -The resident required total assistance with all activities of daily living (ADLs); -The resident would be safe and free from accident/injury daily; -Anticipate the resident's needs. Review of the resident's care plan, revised 3/22/23, showed the following: -The resident had potential for falls, transfer with two assist and a mechanical lift; -The resident will not have falls or injuries from falls; -Keep the bed in low position except when giving care; -Mechanical bed with bolster overlay (built-in foam bolsters that define edges of a bed to prevent falling) with no transfer handles (bed rails to assist with resident positioning). Review of the resident's care plan, dated 6/20/23, showed the following: -The resident had severe cognitive impairment due to the progression of dementia. The resident was able to follow some commands; -Anticipate needs, approach in a calm, soothing manner; -Offer simple choices allowing sufficient time for decision making; -Speak clearly using simple words/phrases and concrete images. Encourage response to ascertain understanding and repeat as needed; -The resident had impaired verbal communication related to dementia. Review of the resident's physician order sheet showed an order, dated 6/20/23, for a mechanical bed with air mattress with bolster overlay with no transfer handles. Bed to be kept in the lowest position except during care. Review of a facility provided statement, written by Licensed Practical Nurse (LPN) F and dated 7/4/23, showed the following: -Staff certified nurse aide (CNA) G reported that Resident #1 was on the floor; -LPN F arrived to the resident's room where the resident lay on the floor in a prone (on his/her stomach) position with his/her head on the left side; -Apparently the resident rolled out of the left side of the bed. The resident had a wedge pillow underneath his/her head and left shoulder and a Hoyer lift (a mechanical lift used to transfer people from one spot to another) pad on top of him/her; -The resident was sluggish initially yet responded to verbal and tactile (touch) stimuli; -Blood was noted at the resident's head; -LPN F requested other nursing staff call emergency medical services; -The resident's bed was approximately 24 inches above the floor; -The side rails were completely lowered and a bolster mattress was in place, intact and functioning. Review of a facility provided statement, written by CNA G and dated 7/4/23, showed the following: -CNA G dressed Resident #1 at 5:00 A.M., lowered his/her bed and went to another resident room; -When CNA G left the other resident's room he/she looked in Resident #1's room and saw the resident on the floor; -CNA G ran to the nurse's station to call the charge nurse; -We (staff) confirmed the resident rolled out of bed. Review of the resident's progress notes, dated 7/4/23 at 9:02 A.M., showed the facility received an update from a nurse at the hospital who said the resident had a brain bleed and an orbital fracture (a fracture of one or more bones surrounding the eye). During an interview on 7/19/23 at 1:38 P.M., CNA G said the following: -Close to 5:00 A.M. he/she dressed Resident #1, covered the resident and lowered the bed; -He/She left the room and went to another resident's room and after leaving that resident's room, he/she looked in Resident #1's room and saw the resident on the floor face down; -Resident #1's bed did not go all the way down like other beds did. Observation on 7/19/23 at 1:55 P.M. showed both beds in the resident's room could be lowered so that the bottom of the mattress frame was approximately eight inches from the floor. During an interview on 7/24/23 at 1:24 P.M., LPN F said the following: -CNA G was in Resident #1's room by himself/herself and then went to at least three other resident rooms; -CNA G went back into Resident #1's room and came right back out and said nurse, you have a resident on the floor; -They both went in Resident #1's room and CNA G began lowering the resident's bed. CNA G told LPN F that the bed was in low position. LPN F told CNA G it was not because he/she saw CNA G lowering the bed. The resident did have a bolstered mattress and hand rails; -The bottom of the mattress frame was at least 24 inches from the floor at the time of the resident's fall, a height that would be consistent with providing cares; -When LPN F entered the resident's room, the resident was on the floor face down with the Hoyer lift pad on top of him/her. During an interview on 7/19/23 at 1:01 P.M., the assistant administrator said the following: -He would expect the staff to keep resident beds in a low position when not providing cares; -He believed Resident #1's bed was not in the lowest position and that resulted in discipline for CNA G. MO220987

Based on interview and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident #1), who utilized a Broda Chair (a type of wheelchair that tilts and reclines), was totally dependent on two or more staff for bed mobility and transfers, and had impaired range of motion on both sides of the upper and lower extremities. On approximately 2/24/23, the facility replaced the resident's air mattress but did not place bolsters on the bed. On the afternoon of 2/25/23, the resident fell out of bed and was transported by ambulance to the hospital. On the evening of 2/25/23, on-call transport Staff A arrived at the hospital to pick up the resident. Transport Staff A had difficulty getting the resident into and secured in the transport van. Transport Staff A pulled up to a stop sign in the hospital parking lot and the resident slid out of the Broda chair onto the floor of the van. The resident was evaluated in the emergency room and found to have multiple fractures. The deficient practice affected one resident of seven sampled residents. The facility census was 40. The administrator was notified on 3/8/23 at 4:35 P.M. of an Immediate Jeopardy (IJ) which began on 2/25/23. The IJ was removed on 3/10/23, as confirmed by surveyor onsite verification. Review of the undated facility policy, Fall Assessment policy and procedures, showed the following: Fall assessment is completed up on admission to identify residents, who are at high risk for falls in order to implement interventions and reduce the incidence of falls. It is also completed quarterly to identify residents who are at a high risk for falls and precipitating events and patterns leading to falls in order to implement interventions and reduce the incidence of future falls; -The Interdisciplinary team will then develop plan of care to prevent falls; -Nursing will implement interventions to decrease or prevent future falls; - Interventions will consider the following about each resident: 1. Time of day; 2. Area of incident; 3. Diagnosis, medications, and side effects; 4. Environmental hazards; 5. Increasing staff supervision; 6. Verbal reminders; 7. Diversional activities; 8. Evaluation of pain; 9. Scheduled toileting; 10. Low bed; 11. Bolster mattress; 12. Pad on floor; 13. Motion alarm; 14. Physical therapy (PT) and/or occupational therapy (OT) evaluation. Review of the facility transportation policy dated March 2023 showed the following: -The transportation/social service assistant will be responsible for most of the transportation for residents to and from physician/hospital/clinics both locally and out of the area; -Assist residents with repositioning, transfers, and/or ambulation; -Operate resident assistive devices (wheelchairs, walkers etc.) -Read, know, participate, and implement the plan of care for each resident; -Report any unsafe equipment to the maintenance supervisor. Review of the facility van user manual copyright date, 2001 showed no guidance or direction regarding the safety devices utilized in the van when transporting residents. 1. Review of Resident #1's care plan revised 8/15/22, showed the following: -Cognitive impairment for daily decision making; -Requires assistance with activities of daily living (ADL), totally dependent on one staff member at mealtimes, totally dependent on two staff members for bed mobility, transfer, toileting, grooming, bathing and dressing; -Up in Broda chair, transfer by mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility) with two assist; -Fall potential for injury, cue, reorient and supervise as needed, be aware of safety issues; -Keep bed in lowest position when not giving care; -Assist with transfer and positioning, assess cause and pattern of previous falls and act upon resolvable factors; -The care plan did not address an air mattress. Review of the resident's most recent fall risk assessment, dated 7/26/22 showed the resident did not have a fall in the past three months, was unable to perform the gait/balance function, had difficulties with ambulation and elimination, takes one to two medications currently or in the last seven days, indicating the resident was a 10 (a score of 10 or above indicated high risk). Review of the resident's fall risk assessment showed no documentation facility staff updated the resident's fall risk assessment quarterly per the facility policy. Review of the resident's physician orders dated 1/1/23 to 3/1/23 showed diagnoses included diabetes, weakness, anxiety disorder, chronic heart failure ( a chronic condition where the heart does not pump blood as well as it should), and dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning can include agitation including verbal and physical aggression), pseudobulbar affect (neurological disorder characterized by episodes of sudden uncontrollable and inappropriate laughing or crying); -Mechanical low bed with transfer handles; -No documentation the resident had an order for an air mattress. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/20/23 showed the following: -Severe cognitive impairment; -Total dependence on two staff members with bed mobility, transfers, eating, and personal hygiene; -Total dependence on one staff member with locomotion on and off the unit; -Functional limitation in range of motion in upper and lower extremities on both sides; -No falls since the previous assessment. Review of the resident's clinical monitoring form dated 2/24/23 showed the resident's weight was 169.4 pounds. Review of the resident's accident and incident report dated 2/25/23 at 3:15 P.M. (estimated) showed the resident was found on the floor, laying on his/her right side, with head against the night stand. Left hand and wrist swollen, left arm and above the elbow was swollen. The physician was contacted and gave an order to send the resident to the emergency room for evaluation. During interview on 3/15/23 at 9:25 A.M. Certified Nurse Assistant (CNA) D said the following: -He/She cared for the resident when the resident fell out of bed; -Residents that are dependent on staff like Resident #1 normally have bolsters (raised sides of a bed that keeps the resident from rolling or falling out of bed) on their beds so they don't fall out of bed. The resident had an air mattress; -During the shift, the resident kept reaching over and grabbing the bed frame on the left side of the bed, trying to pull himself/herself over in bed; -The resident had never tried to turn when in bed, it was not like the resident to try and turn. CNA D tucked a wedge in place to keep the resident in bed and placed the bed in low position; -Later he/she walked in and found the resident on the floor on the left side of the bed, beside the window. During interview on 3/8/23 at 10:50 A.M. Licensed Practical Nurse (LPN) C said the following: -He/She worked the shift the resident fell out of bed; -He/She had been in the resident's room earlier in the shift and observed the resident did not have bolsters on his/her bed. No resident should be on an air mattress without bolsters; -He/She was not sure if the resident had fallen out of bed before; -The resident had no muscle tone, the resident was very large in size and had a lot of loose skin, and the resident took up the entire bed; -He/She didn't work normally on the resident's hall so he/she didn't question the resident not having bolsters on his/her bed; -The resident was found on his/her side between the window and the left side of the resident's bed; -The resident was transferred to the hospital for evaluation. During interview on 3/8/23 at 1:15 P.M. the Director of Nursing (DON) said the following: -She thought the facility staff should have put bolsters on the bed for the resident when it was changed out to the new bed. She thought the resident had bolsters on his/her bed before. During interview on 3/8/23 at 1:00 P.M. the administrator said the following: -The day the resident fell out of bed his/her bed had just been replaced with a new air mattress as the old bed was not functioning properly, staff did not replace the bolsters on the bed which was why the resident fell out of bed; -Residents with air mattresses should have bolsters on the bed, however, review of the policy does not show this direction. Review of the resident's progress note dated 2/25/23 at 10:12 P.M. showed staff received a call from the hospital that the resident was ready to be released and needed to be transported back to the facility. During interview on 3/13/23 at 8:15 A.M. Registered Nurse (RN) B said the following: -On 2/25/23 he/she was informed in report the resident had gone out for an x-ray after falling out of bed the previous shift (6:00 A.M. to 6:00 P.M.); -Around 9:00 P.M. on 2/25/23 the hospital said all tests were clear and the resident was ready to be transported back to the facility; -He/She notified Transport Staff A, who was the on call for facility transports, the resident needed to be transported back to the facility. Review of the resident's progress note completed by Transport Staff A dated 2/26/23 at 9:56 A.M. (late entry for 2/25/23 approximately 9:15 P.M.) showed the following: -Transport staff was told the resident was ready to be picked up. No direction or guidance was given on transporting this resident; -He/She picked up the resident up from the emergency department and was having trouble getting the resident into the van; -A passerby helped take the tie down straps (used to secure a wheelchair to the floor of a vehicle) off the floor of the van and helped guide the resident into the van, the chair was all over with the wheels and there was very little room to get the chair in the van. He/She reclined the resident in the Broda chair and hooked the tie downs to the chair; -He/She then had to adjust the seatbelt all the way out on both sides in order for it to get around the resident. He/She had to run it through the chair for it to fit, it was resting on the metal part of the chair below the arm pads; -He/She pulled out of the drive and went down the road through two stops signs, he/she traveled less than 20 miles per hour (mph) while still on the hospital campus parking lot; -The resident yelled and he/she looked back, the resident had slid out of his/her Broda chair and was leaning to the right; -He/She drove back to the emergency room to get help, the resident was removed from the van by Transport Staff A and hospital staff. Review of the hospital emergency services note dated 2/26/23 at 6:46 A.M. showed the following: -Patient presents to Class III trauma transfer (a Level III trauma center has the ability to provide prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients and emergency operations) from the hospital (local) with bilateral femur fractures (a break in the thigh bone) ; -The resident was reportedly seen at the local hospital for fall and discharged yesterday, patient is wheelchair dependent and during transport back to the facility he/she reportedly fell out of the wheelchair and was found to have both of his/her lower extremities beneath the front seat of the car; -He/She was taken back to the local hospital and found to have bilateral femur fractures and tibia-fibula fracture (a fracture in the lower leg that happens when a fall or blow places more pressure on the bones than they can withstand), there he/she was found to have a pulseless right lower extremity which was reduced (set or put a broken bone in place) with return of pulse; -Patient was then transferred with need for orthopedic evaluation as well as possible need for vascular surgery consultation which was not available at the local hospital; -While in the emergency department the resident was redosed multiple times with Fentanyl (a narcotic used to treat severe pain) for additional pain control. During an interview on 3/8/23 at 12:10 P.M. Transport staff A said the following: -He/She was the transport staff on call on 2/25/23; -On the evening of 2/25/23 RN B notified him/her that Resident #1 needed to be picked up from the hospital and transported back to the facility; -He/She had transported other residents in Broda chairs in the facility van, but had not transported Resident #1 before; -Broda chairs were larger and more difficult to push up the ramp into the van; -When he/she arrived at the hospital to pick up the resident he/she observed the resident was positioned low in the Broda chair, he/she didn't question the hospital staff, but felt the resident was too low in the chair; -He/She pushed the resident in the Broda chair to the facility van; -He/She could not push the resident in the Broda chair up the ramp into the back of the van due to the resident being large in size; -A passerby assisted him/her with removing the tie down straps and helped him/her push the resident up the ramp into the van. The tie down straps were put back in place and attached to the resident's Broda chair; -He/She had difficulties with getting the resident's seat belt fastened, due to the resident's size; -He/She finally got the belt to fasten and he/she heard a click, but it was difficult to see the buckle as it was positioned under the arm rest of the chair. Typically the seat belt buckle was positioned on a resident's stomach when fastened; -Once the resident was in the van he/she was still concerned with how low the resident was positioned in the Broda chair, he/she tried to recline the chair a little further; -The resident was in the back of the van facing forward, positioned behind the back seats of the van; -He/She proceeded to drive and had made it to the second stop sign in the hospital parking lot when he/she heard the resident holler, Mamma help me!; -He/She turned around to see the resident was no longer in the Broda chair and pinned between the Broda chair and the back seats of the van; -He/She immediately drove back to the hospital emergency room ; -Transport driver said the hospital staff came out to assist and a hospital staff member said, He/She was not even in a seatbelt During interview on 3/8/23 at 4:10 P.M. the resident's family member said the following: -The resident had no muscle tone and could not hold himself/herself up in a chair, the resident required total care and had for a long time; -The resident received multiple fractures from the fall; -The plan was for the resident to be placed on Hospice care for comfort measures after the fall, the resident passed away at the hospital. During interview on 3/8/23 at 1:15 P.M. the DON said the following: -Facility staff should have notified her or the Administrator before attempting to transport the resident back to the facility; -The resident was transported to the hospital by ambulance so the resident should either be transported by ambulance back to the facility or possibly wait until the next day; -The resident was very dependent on staff. It was late at night and after hours, and she would not want one a staff member transporting the resident back to the facility; -If staff didn't feel safe or had concerns with the positioning of the resident, the transport should not have been attempted. During interview on 3/8/23 at 1:00 P.M. the administrator said the following: -The facility staff should have notified him or the DON before attempting to transport the resident back to the facility from the hospital; -They would determine if the resident should be transported with a two person transport team or by ambulance; -He would expect Transport Staff A to speak up if the resident was not positioned properly in the Broda chair when he/she arrived to the hospital to pick the resident up; -The current transportation policy did not address safety with transports or how to safely transport residents; -He looked through Transport staff A's employee file to try and locate what training was provided to him/her when he/she started working at the facility; -Transport staff A was hired in January of 2022, he/she was trained by observing staff and return demonstration of how to safely secure residents in the transport vehicle, he/she also went on three ride along trips with the previous transport staff; -He could not locate any information regarding what types of chairs were inappropriate to be transported in the van; -He could not find any information regarding the safety devices used in the van. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. 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). MO214610 MO213487

Based on interview and record review, facility staff failed to implement their policy and failed to initiate cardiopulmonary resuscitation (CPR) (process of providing rescue ventilation and chest compressions to maintain circulation of blood) and call 911 for two residents (Resident #105 and #106) identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the residents unresponsive and without a pulse. The facility census was 55. The administrator was notified on [DATE] at 2:30 P.M. of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the undated facility policy CPR showed the following: Standard: -Residents who have Full Code status will be given CPR in the absence of vital signs; Policy: -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 (or durable power of attorney (DPOA)/guardian, if in effect); Procedure: 1. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Social Service Designee (SSD) or person designated by SSD, discusses code status with resident and has resident (or DPOA/guardian, if in effect) sign DNR form, if DNR is chosen; 3. If Full Code is chosen, licensed nurse/medical records designates this with a green full code sticker on the resident's chart, if not places a red sticker on chart, also places a red DNR or green full code sticker/circle on door/door frame. Lists of Full Code residents are placed at each nurse's desk, activity hall, therapy room and in vehicle for transport purposes; 4. If a resident designated Full Code is found to be without a pulse, CPR should be initiated immediately in the absence of vital signs regardless of color or body temperature and regardless of the length of time that vital signs may have been absent. CPR will be initiated immediately by the first person who is CPR certified; 6. CPR will be continued until the ambulance personnel arrive and the staff shall assist emergency medical personnel in continuing CPR until physician or coroner arrives or until resident is transferred by ambulance; 7. Family and physician should be called as soon as possible after 911. 1. Review of Resident #105's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Moderately impaired cognition; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the undated resident code list at the nurses' station showed the resident was a full code. Review of the resident's progress notes, dated [DATE] at 5:33 A.M., showed the following: -Upon helping to change resident found him/her warm to the touch temperature checked 100.4 F (normal adult temperature 97.5 to 98.9) temporal (a handheld thermometer that measures the temperature of a branch of the superficial temporal artery by pointing an infrared scanner directly at the forehead or lightly passing the scanner across the skin of the forehead); -Tylenol (pain reliever/fever reducer) crushed and given through feeding tube. Review of the resident's progress notes, dated [DATE] at 6:30 A.M., showed the following: -Upon entering the room, resident was found with no vital signs of life; -Family was called and did not wish for facility staff to start CPR. During interview on [DATE] at 5:12 P.M., Licensed Practical Nurse (LPN) Z said the following: -He/She was the charge nurse the night before the resident passed away; -He/She administered the resident's medications and tube feeding around 5:00 A.M. and noticed the resident felt hot when he/she assisted the resident to turn in bed; -He/She administered Tylenol for the elevated temperature; -The resident acted normal that shift, other than feeling hot to touch, and the resident did not fight him/her when he/she gave the resident's medication and tube feeding; -He/She reported to the oncoming nurse during report that the resident would need his/her temperature rechecked. During interview on [DATE] at 10:34 A.M. Certified Medication Technician (CMT) U said the following: -He/she was CPR certified; -He/she entered the resident's room shortly after 6:00 A.M. on [DATE] to check the resident's temperature because the resident had a fever during the night; -The resident was breathing when he/she was in the room; -The resident responded to his/her touch when he/she checked his/her temperature; -The resident's temperature was 97.7 degrees Fahrenheit. During interview on [DATE] at 10:00 A.M., Certified Nurse Aide (CNA) K said the following: -There was a list of resident code status at the nurses' stations; -The resident was a full code, he/she had a green dot on his/her door; -A green dot means go, do CPR; -A red dot means stop, don't do CPR; -When LPN C went to the resident's room to check on him/her, he/she was already gone; -He/She did post mortem care (care of the body after death) on the resident; -The resident's body was still warm and his/her extremities were still flexible, he/she hadn't been gone long. During interview on [DATE] at 2:10 P.M., LPN C said the following: -The night nurse had given the resident Tylenol around 5:00 A.M., because the resident had a fever; -He/She went down the hall at 6:30 A.M. and checked on the resident; -The resident had no pulse or respirations; -The resident's skin was cool and he/she had already turned a greenish color, he/she was already mottled; -He/She sent one of the aides to go get the other nurse (LPN T); -LPN T called the family and the family said they didn't want staff to do CPR; -He/She didn't see the resident go down (stop breathing); -His/Her impression was that if he/she saw the resident stop breathing, he/she should do CPR; -He/She was CPR certified; -He/She did not do CPR or call 911. During interview on [DATE] at 12:47 P.M., LPN T said the following: -The resident was alert, but not always verbal; -The resident was a full code; -He/She was called into the room by LPN C; -LPN C was assessing the resident; -The resident's color was purple, his/her skin was still warm, he/she was not cold to touch; -The resident was deceased , he/she had no vital signs; -He/She and LPN C did not perform CPR; -He/She was following LPN C's lead; -He/She called the resident's family member who said no, don't do anything; -He/She did not do CPR on the resident, because he/she did not know how long the resident had not been breathing and he/she was not his/her resident. During interview on [DATE] at 12:10 P.M., the SSD said the following: -She did advance directive paperwork with the resident on admission; -The resident requested to be a full code. 2. Review of Resident #106's care plan, dated [DATE], showed the following: -Advanced directives: Full Code status; -Will be kept safe and comfortable and will receive artificial resuscitation if needed. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes, dated [DATE] at 4:22 P.M., showed the following: -At 3:00 P.M. the resident was seen by this nurse and the other nurse on the floor as resident was complaining of anxiety, oxygen saturation at that time was 94% (normal range) and temperature was 97.7 Fahrenheit temporal. Had resident deep breathe and he/she calmed down. No more complaints voiced at that time; -At 4:12 P.M. went into resident's room and noted the resident did not appear to be breathing, no heartbeat detected, and when touched the resident was cold to touch; -When noted cool skin of resident, physician notified of resident passing, and said to notify family that it's too late for CPR and okay to release body to funeral home. During interview on [DATE] at 12:20 P.M., Registered Nurse (RN) V said the following: -He/She was the charge nurse on [DATE]; -He/She was CPR certified; -The resident was fine, then complained of being anxious which was his/her normal behavior; -He/She found the resident cold, stiff and blue; -The resident wasn't rigor stiff (stiffening of joints and muscles of a body a few hours after death), but he/she was kind of stiff and his/her coloring looked bad; -He/She called for the other nurse, they both listened for a heartbeat, and assessed the resident; -Collectively, he/she and the other nurse decided to call the physician; -Due to the resident's coloring, being cold, and being a little stiff, he/she wanted the physician's opinion before doing CPR; -He/She tried to get hold of the resident's family as well to get their opinion as to whether or not to do CPR; -The resident was a full code, but he/she felt like since the resident had no blood, was cold and stiff, the last thing he/she wanted to do was CPR if the resident was already gone. 3. During interview on [DATE] at 12:25 P.M., the administrator said the following: -She posted a list at each nurses' station of residents' code status; -She updates the resident code status list monthly; -If a full code resident was found without pulse or respirations, she would expect staff to immediately start CPR; -It would not be appropriate for staff to call the family prior to starting CPR; -Family wishes would not supersede physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -She would expect staff to start CPR and call 911 before doing anything else including calling the physician; -Licensed nurses can't pronounce a resident as deceased in the facility. NOTE: At the time of 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 level of the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 578

Based on interview and record review, the facility failed to communicate accurate and consistent information related to Resident #42's condition to the resident's physician, including the resident's variations in level of alertness and expressions of thirst. The facility failed to include hospice and the resident's family in an effective plan of care, to address the resident's needs after the facility received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had periods of fluctuating levels of alertness both before and after [DATE] when the NPO order began. Following the NPO order the resident verbalized thirst. The facility failed to ensure the resident was assessed and received appropriate interventions to address thirst, hydration and nutrition. Additionally the facility failed to ensure the resident received a speech therapy evaluation after it was recommended by the speech therapist to evaluate the resident's ability to safely swallow fluids/food. The resident remained NPO for eight days until he/she expired. This deficient practice affected one resident of 19 sampled residents, The facility census was 55. The administrator was notified on [DATE] at 5:10 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's undated policy, Hydration and Nutrition, showed the following: -The nutrition and hydration status of each resident is maintained as close to optimal level as possible; -Fluid is available to residents at all times; -An ongoing assessment of ability to consume and assimilate food by residents is conducted by nursing personnel. -Assessment includes: a. Ability of resident to feed self; b. Ability of resident to chew, drink, and swallow; c. Weight loss or gain; d. Signs of dehydration (dry mouth, poor skin turgor); -Nursing staff is responsible for charting at each meal on resident's appetite sheets the percentage of meal/fluids consumed; -The physician and/or Advanced Practice Registered Nurse are notified of changes in nutrition and hydration status as they occur; -Observation for the desired effect or adverse response is performed at all times and documented in the clinical notes. Review of the facility's policy End of Life Care, undated, showed the following: -End of life care: a. The active total care of patients whose disease is not responsive to curative treatment; b. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount; c. The goal of palliative care is achievement of the best quality of life for patients and their families. -Palliative care: a. Affirms life and regards dying as a normal process; b. Neither hastens nor postpones death; c. Provides relief from pain and other distressing symptoms; e. Offers an interdisciplinary team to help residents live as actively as possible until death; These principles are quite applicable to the LTC (long term care) facility and should guide efforts at providing humane, palliative care: -Provide access to any therapy that may be expected to improve the resident's quality of life including alternative or nontraditional treatments; -Provide access to palliative care and hospice care. Procedure for nurses and nurse assistance on hospice services: -Monitor the resident frequently for comfort levels, anxiety levels, side effects from medications, and implement interventions to relieve discomfort; -Document daily assessment on all end of life care residents; -Notify primary care physician, hospice, and family with changes in residents' condition. 1. Review of Resident #42's face sheet, showed the resident current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No inattention, disorganized thinking, behaviors present; -Limited assistance of one staff member for eating; -Swallowing issue, holds food in mouth or cheeks, coughing when eating/drinking; -New mechanically altered diet. Review of the resident's POS, dated [DATE], showed mechanical soft diet, nectar thick liquids, no concentrated sweets, may have regular dessert upon request. Review of the resident's Speech Therapy Note, dated [DATE], showed the following: -Gains in swallow safety and strength have impacted the patient's ability to perform by mouth intake with a reduction in assist to minimal; -At this time the resident required feeding assistance, but not consistently; -When he/she was experiencing medical issues TIA ([CONDITION(S)] -temporary period of symptoms similar to those of a stroke) activity, he/she needed assistance, because he/she cannot handle utensils; -He/She also needs minimal cues to swallow safely; -During some meals, swallow function was within functional limits (WFL) and swallow timing was WFL; -Facilitated use of safe swallow strategies including alternating solids with liquids, 5 bites/1 drink; -Resident gave himself/herself drinks; -Family members feeding him/her led speech language pathologist to educate family about aspiration (a person accidentally inhaling an object or fluid into their windpipe and lungs that can lead to coughing, difficulty breathing, discomfort, and sometimes choking) and what it is, signs and symptoms of aspiration; -Modifications during this progress reporting period included diet was previously regular diet and plan was to get back to regular. However with inconsistent medical condition within and from day to day, decision was made to leave resident at current diet where he/she can safely eat and have adequate intake for nutrition and hydration; -Nursing staff and family members educated in aspirations precautions, feeding techniques, signs and symptoms of aspiration, mechanical soft diet and nectar thickened liquids ordered diet precautions and was able to recount information with 80% accuracy. -Still had deficits in moderate swallow deficit, but inconsistent which limit the ability to perform by mouth intake without assist and without signs and symptoms of aspiration/coughing/choking; -Caregivers report fewer incidents of coughing/choking; -Some days he/she required feeding assistance, because he/she can't handle utensils; -Can follow one step directions; -Impulsive: drinks entire glasses of liquids without stopping which increases aspiration risk, No thin liquids; -Precautions fair due to unstable medical conditions with TIA activity. Review of the resident's care plan, updated [DATE], showed the following: -Resident had a terminal illness and resident and/or family had elected palliative care through hospice services; -Resident will have pain and symptoms managed to a tolerable level; -Resident's dignity will be maintained by honoring resident and/or family's wishes regarding care; -Assess and evaluate nutritional intake; -Provide food preferences and nutritional supplements as needed. Review of the resident's significant change in condition (SCSA) MDS, dated [DATE], showed the following: -Inattention and disorganized thinking behaviors present/fluctuates; -Extensive assistance of one staff member for eating; -No swallowing issues; -Hospice added with prognosis of six months or less to live. Review of the resident's POS, dated [DATE], showed pureed diet, nectar thick liquids, no concentrated sweets, may have regular dessert upon request. Review of the resident's care plan, updated [DATE], showed the following: -At risk for dehydration; -Assess resident's eating habits, food preferences, monitor intake; -Encourage fluids daily when medically appropriate; -Educate family about food restrictions and offer alternatives or food preference; -Encourage nutritional supplements and adequate hydration; -Offer diet as ordered. Review of the resident's nurse's notes, dated [DATE], showed the following: -Called to dining room as resident was unable to effectively swallow pureed diet or nectar thick liquids, also unable to effectively clear his/her throat or cough; -Oxygen saturation level 80% on room air; -Oxygen applied at 4 liters, oxygen saturation level came up to 97%; -Mouth was cleaned out and staff tried to see how he/she did with honey thickened water; -He/She was able to swallow, but not effectively and ended up weakly coughing several times; -Unable to check gag reflex; -He/She does have gurgles in the back of his/her throat that he/she is unable to clear; -Hospice contacted and will be coming back to see him/her; -Resident's physician was contacted and given report; -Physician to change diet order to NPO at this time and discontinued all oral medications; -Will give this report to hospice nurse when he/she gets here to contact family. During an interview on [DATE] at 7:00 A.M., Feeding Assistant BB said the following: -He/She was assisting the resident to eat at the noon meal on [DATE]; -The resident's mouth was not full of food; -The resident swallowed and it was like the food was stuck there; -He/She kept trying to swallow and it wouldn't move; -He/She sent staff to go and get the SLP (Speech Language Pathologist - on site in the facility at the time of this issue) and the charge nurse; -The resident was still able to move air, but it was not as much air; -The resident tried to cough, but it was weak and he/she couldn't get it cleared. During an interview on [DATE] at 3:36 P.M., Licensed Practical Nurse (LPN) D said the following: -On [DATE] the resident consumed 100% of breakfast without any issues; -He/She usually ate 100% at all meals; -Feeding Assistant BB was feeding the resident (lunch meal [DATE]); -Feeding Assistant BB said the resident was going through the motions, but the food was not going down; -Feeding Assistant BB sent for help so staff got the Speech Therapist (SLP) and LPN D, because the resident was choking; -The resident was trying to swallow, but it was like the food was stuck; -His/Her throat was moving up and down trying to swallow, but he/she couldn't get it down; -The resident never stopped moving air; -Staff worked with the resident until he/she was able to clear the food; -Staff tried to follow with honey thickened liquids, the resident could swallow, but had residual in his/her mouth; -The resident was able to cough a little, but was not effective; -Oxygen saturation dropped to the 80's, and he/she wasn't as responsive; -He/She called resident's physician to let him know what was going on and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -No orders were given for comfort water or feedings. During an interview on [DATE] at 8:45 A.M., the SLP said the following: -On [DATE] at the noon meal, staff came and got him/her for a major choking incident with the resident; -When he/she arrived the resident had food in his/her mouth stuck in the upper pharynx (membrane-lined cavity behind the nose and mouth, connecting them to the esophagus); -The resident had no pharyngeal lift (a process during swallowing that lifts the larynx (voice box) and helps food go the throat the correct way (not go in the lungs)) at that time; -LPN D tried to suction the resident without success; -It was three or four minutes the resident struggled to swallow, then all of the sudden he/she just cleared it; -There were times when his/her breathing was not the most effective during the incident, but staff did not have to do the [MEDICATION(S)] Maneuver and his/her lips and fingers were never dusky or blue; -The resident looked panicked; -He/She was responding to the emergency, but couldn't give recommendations because he/she did not have orders for an evaluation or treatment; -LPN D told him/her hospice would have to approve orders for speech therapy; -He/She requested orders from hospice, because the resident would have times he/she would have mini-stroke like symptoms where he/she could not effectively swallow or follow cues, and the next meal the resident would be fine; -He/She did not know if this was one of those times or if he/she was not going to be able to respond later; -He/She asked hospice for orders to do an evaluation and Hospice Nurse/Registered Nurse (RN) HH declined the order and said hospice would not pay for therapy; -LPN D was aware he/she requested orders and hospice declined; -He/She did not know if the request for orders were passed on to facility administration; -He/She wanted to see if the resident could safely consume food or water; -If the resident had periods of being alert he/she might have been safe to eat; -He/She would have liked to set parameters for the staff on when it was safe for the resident to eat and/or drink (for example set levels of alertness for the resident and with each level if he/she could drink or eat); -If the resident could not consume food he/she would have at least recommended cleansing his/her mouth well, sitting him/her up at 90 degrees to have thickened water for comfort; -He/She would have been able to train staff and the family how to do give the resident thickened water safely, and how to feed the resident safely if he/she was able to eat. During an interview on [DATE] at 10:22 A.M., LPN D said the following: -The resident did not have a swallow study, so he/she did not report that the resident had a swallow study; -He/She did not ask the physician for a speech therapy evaluation and did not speak to administration about hospice denying the speech therapy evaluation, because hospice denied the order; -Resident was not unresponsive, but was less responsive after the near choking episode [DATE] at the noon meal; -During the incident the resident was never unresponsive, but not able to 100% follow with cues; -He/she did not work with the resident much after that shift as he/she was assigned to the other nurses station; -The SLP spoke to Hospice RN HH when he/she called about the incident; -The SLP requested an evaluation order, but Hospice RN HH said no. Review of the resident's POS, dated [DATE], showed the following: -Diet order changed to NPO; -Discontinue all by mouth medications; -[MEDICATION(S)] concentrate (narcotic pain medication concentrated in liquid form) 100 milligrams (mg)/5 milliliters (ml) (20 mg/ml), administer 0.25 ml (5 mg) by oral route ever 6 hours as needed for pain; -[MEDICATION(S)] [MEDICATION(S)] (antianxiety medication concentrated in liquid form) 2 mg/ml oral concentrate, give 0.5 ml (1 mg) by oral route three times per day for generalized anxiety disorder; -[MEDICATION(S)] 1% drops (medication used to dry secretions), give 4 drops by sublingual (under tongue) route every 4 hours as needed for excessive secretions. Review of drugs.com showed the following potential side effects of [MEDICATION(S)] and [MEDICATION(S)] included severe drowsiness and weakness. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Hospice Nurse, here and contacted family; -Hospice nurse obtained comfort medication orders. Review of the resident's medical record showed no evidence of a nurses note or assessment of the resident on [DATE]. During an interview on [DATE] at 9:30 A.M., LPN A said the following: -He/She worked with the resident on [DATE]; -The resident was not unresponsive, but was more lethargic than his/her normal self. They had also started [MEDICATION(S)] and [MEDICATION(S)] for comfort; -Staff tried toothettes (mouth swab with sponge on the end), but the resident would bite down on them and we would have to get the sponge out. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Blood pressure ,d+[DATE], pulse 89, respirations 16, temperature 98.6; (Normal parameters: blood pressure ,d+[DATE]-,d+[DATE], pulse ,d+[DATE], respirations ,d+[DATE], and temperature 97.,d+[DATE].1 Fahrenheit) -Resident continued on hospice care; -[MEDICATION(S)] given routinely; -Family at bed side; -No signs or symptoms of distress or discomfort noted so far this shift; -Will continue to monitor. Review of the resident's nurses notes, dated [DATE], showed the following: -Hospice nurse here to see resident; -The note did not include any assessment related to the resident's NPO status, nutrition, or hydration. Review of the resident's nurses notes, dated [DATE], showed the resident's vital signs for the 6:00 P.M.-6:00 A.M. shift were blood pressure ,d+[DATE], pulse 85, respirations 18, temperature 97.2, oxygen saturation 94%. The note did not include any assessment/ information about the resident's NPO status, nutrition, or hydration. Review of the resident's nurses notes, dated [DATE], showed the following: -Resident continued on NPO diet due to decreased swallowing and aspiration; -[MEDICATION(S)] and [MEDICATION(S)] administered to ensure resident stays comfortable; -Provide oral care as needed; -No signs or symptoms of distress; -Will continue to monitor and follow current plan of care. Review of the resident's nurses notes, dated [DATE], showed the following: -Continues on hospice, [MEDICATION(S)] and [MEDICATION(S)] given as ordered; -Contacted Hospice nurse resident was gritting his/her teeth and drawing his/her arms up; -Hospice nurse on his/her way; -Orders to increase [MEDICATION(S)] to 0.5 every hour as needed; -Family aware at bedside all day and evening; -Turned and changed. The note did not include any information about the resident's NPO status, nutrition or hydration. Review of the resident's medical record did not show evidence of a nurses note or assessment on [DATE]. Review of the resident's Care plan, updated [DATE], showed the addition of NPO order that was received on [DATE]. The care plan did not include any interventions to provide comfort from dehydration or strategies to hydrate/nourish the resident. During an interview on [DATE] at 1:00 P.M., resident's family member 1 said the following: -The facility stopped giving the resident food and water on [DATE]; -When the resident complained of being thirsty, it was awful; -The resident would bite down on the mouth swabs and bit off the sponge and that wasn't safe; -The resident's family member 2, a Registered Nurse (RN), started giving the resident a wet washcloth to suck on to help the resident, (it was not the facility). During an interview on [DATE] at 1:00 P.M. and [DATE] at 10:30 A.M., resident's family member 2 said the following: -He/She had been coming in once a day for months before the noon meal on [DATE] to feed the resident at least one meal a day; -The resident would have a bad meal once in a while where his/her alertness would change and he/she would just pocket his/her food; -The next day the resident would eat 100% with no signs or symptoms of pocketing or aspiration; -Speech therapy worked with the resident in October and that helped, and that was when it was decided if he/she was having the issue with alertness/responsiveness and pocketing food we would just stop for that meal; -The resident loved to eat and drink, he/she was an eater; -On [DATE] family member 1 got the call that the resident had a rough time at the meal and the physician made the resident NPO; -There were no options presented, no care plan meeting, or any options to help with discomfort from dehydration and nutrition issues at that time, it was a decision the family was not included in making; -The resident was an anxious kind of person, so if he/she wasn't going to be able to eat and drink, family knew it would be difficult because he/she was a hungry thirsty person-always; -The staff tried to do oral care with the swabs (toothettes), but he/she would bite down on them and it was not safe, and trying to dig it out of his/her mouth was not comfortable, but they did not offer anything else; -He/She tried the wash cloth and that was better, it could not break off in his/her mouth; -The resident was his/her normal responsiveness (same as before [DATE]) when he/she wasn't sleeping; -He/She would not have a full conversation, but could respond when spoken to, smile, say words just not in conversation form (related to his/her dementia) but same as before [DATE]; -He/She would say he/she was thirsty; -He/She would get fidgety and move around, look at different people when they were talking and you could tell he/she understood what they were saying, might nod in response appropriately; -The resident was not unresponsive until the last two days he/she was with them (prior to the day he/she expired); -With the washcloth, the resident would suck the moisture out of the cloth, when he/she was more alert family would wet it more, and he/she would suck the water out of it and swallow without an issue; -After [DATE], staff would come in occasionally, but not very often to check on him/her, mainly came in when family called for medication or if family requested help to turn or reposition him/her; -Family was not told that the SLP wanted to do an evaluation and make recommendations; -He/She thought speech therapy would have been a good recommendation; -Family would have liked to be part of that decision making process, and part of strategizing what we could do to make him/her the most comfortable he/she could be; -The resident was capable of sitting upright in his/her chair; -If the resident could have had water even when he/she was more alert, he/she believed the resident would have been more comfortable; -The resident was responding to family and talking to family off and on until [DATE], he/she would sleep heavy with the [MEDICATION(S)] and [MEDICATION(S)], but was not unresponsive, he/she would wake up and talk; -The resident quit responding to family on the evening of [DATE]; -There was not a Director of Nursing, RN, or a nurse in an administrative role to talk to at the facility. Review of the resident's nurses notes, dated [DATE] at 9:03 P.M., showed the following: -Vital signs this morning temperature 99, pulse 74, respirations 14, blood pressure ,d+[DATE]; -[NAME] stokes respirations (breathing can be very deep and rapid, followed by periods of slow shallow breaths, or interrupted by episodes of no breaths; -Family at bedside and told staff when they noticed he/she needed pain meds or any anything done; -Hospice nurse took oxygen off this a.m. Review of the resident's nurses note, dated [DATE], showed the resident expired on [DATE] at 9:55 P.M. During an interview on [DATE] at 9:45 A.M., Certified Nurse Assistant (CNA) K said the following: -The resident was not unresponsive, but did not talk as much as usual; -Resident smiled or gritted his/her teeth during care; -Staff tried the mouth swabs, but the resident would bite down on them; -The resident sucked aggressively on the washcloth, it helped a lot; -He/She could tell the resident was thirsty, because of how he/she sucked on the washcloth; -He/She did not report it, because they knew he/she was NPO. During an interview on [DATE] at 10:30 A.M., Hospice RN JJ said the following: -He/She was the resident's Hospice case manager, but he/she was out last week so Hospice RN HH was covering the resident; -Hospice does not usually pay for long periods of therapy, but would, with approval, if there was a specific reason, or to determine safety or a diet change for a short time; -Usually they do not get NPO orders for hospice. If a resident was unresponsive then we would not try to feed them, but if they were alert or able to request food or water they would cautiously attempt if there were swallowing issues, especially would attempt water; -Hospice expected staff to attempt to hydrate and offer nutrition unless the resident was unresponsive; -His/Her review of the hospice notes and on the 10th ([DATE]) showed the hospice nurse charted the resident nodded his/her head in response and on the 11th that the resident spoke. During an interview on [DATE] at 10:15 A.M., Hospice RN HH said the following: -He/She was covering the resident on [DATE]; -He/She was not there during the choking incident, but staff called him/her about it; -The SLP requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She let the facility LPN get the orders after the incident for NPO, and to stop all by mouth medications; -He/She did go see the resident later that day and tried to get him/her to respond, but when he/she spoke to him/her he/she just laid there; -He/She went to see the resident every day that week and the resident would talk softly and nod his/her head with questions on some visits; -The resident never complained to him/her, but family said the resident was requesting to drink; -He/She told the family not to deny the resident a drink and to let him/her know if he/she responded; -He/She did not know if he/she told the facility not to deny the resident a drink or to let him/her know if he/she responded; -Staff requested oral swabs, but then staff said the resident bit them; -Family only reported he/she requested a drink one time; -The facility got the order for NPO and discontinued all of the medications; -Hospice would not get a NPO order if a resident's level of consciousness was fluctuating; -The facility should be assessing the resident on a routine basis; -No one from the facility said the resident was thirsty. During an interview on [DATE] at 1:00 P.M., Executive Director Hospice RN II said the following: -Facility and hospice should collaborate regarding resident care; -Hospice did not have a meeting with the facility regarding the resident's NPO status; -Hospice did review the resident in the hospice weekly meeting in regards to the resident was unresponsive and could not eat; -Typically hospice patients are not NPO for eight days; -The facility nurse got the orders for NPO and to discontinue medications; -Hospice RN HH did not call to get approval for a speech therapy evaluation; -Hospice staff should discuss therapy request with the hospice team when made by a therapist or the facility; -Hospice will allow a one time speech evaluation and ask for recommendations with diet changes; -Facility staff and hospice staff are expected to re-evaluate the resident's alertness continually. During an interview on [DATE], at 10:32 A.M., the resident's physician said the following: -On [DATE] he received a call from the facility nurse; -The nurse said the resident did not pass a swallow study; -The resident was unresponsive and could not swallow; -He gave the NPO order and an order to discontinue medications, because he thought the resident was unresponsive; -No one notified him the resident was alert, or complained of being thirsty; -If he had been notified he would have requested a meeting with the facility, family, and hospice to decide how to proceed to make the resident comfortable. During an interview on [DATE] at 4:45 P.M., the administrator said the following: -She was not consulted about the Speech Therapist's request for an evaluation; -The speech therapist did not consult her about an evaluation for the resident; -The facility would have paid for the evaluation if hospice wouldn't; -If the therapist wants an evaluation, there was a good reason for it; -She was told the resident was unresponsive and did not hear the resident had complained of being thirsty or was even responsive; -Staff are expected to re-evaluate a residents every shift after a change in condition; -She expected facility staff and hospice to collaborate on care decisions and re-evaluate and continually assess residents, to provide what ever is needed for their comfort. NOTE: At the time of 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 level of the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 908 MO 210

Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident, Resident #27, in a review of 19 sampled residents. The facility staff failed to implement fall prevention interventions as indicated on the resident's care plan, failed to provide safe transfers as directed by the resident's plan of care. Resident #27 had multiple falls with injuries including a subdural hematoma (pool of blood between the brain and its outermost covering). The facility census was 55. Review of the undated facility policy, Fall Assessment policy and procedures, showed the following: Fall assessment is completed up on admission to identify residents, who are at high risk for falls order to implement interventions and reduce the incidence of falls. It is also completed quarterly to identify residents who are at a high risk for falls and precipitating events and patterns leading to falls in order to implement interventions and reduce the incidence of future falls; - The Fall Risk Assessment will be complete upon admission by a licensed nurse; - The Fall Risk Assessment will also be completed quarterly on each resident; - The resident will be reassessed after each incident to determine precipitating factors and methods of intervention; - Following each fall, each resident is assessed to determine patterns related to occurrence of falls; - Falls will be discussed weekly at the Interdisciplinary Team meetings; - Residents who present as a Fall Risk on admission or on quarterly review will be reported to the care plan coordinator by the nurse who completed the Fall Risk Assessment; -The Interdisciplinary team will then develop plan of care to prevent falls; -Nursing will implement interventions to decrease or prevent future falls; - Interventions will consider the following about each resident: 1. Time of day; 2. Area of incident; 3. Diagnosis medications and side effects; 4. Environmental hazards; 5. Increasing staff supervision; 6. Verbal reminders; 7. Diversional activities; 8. Evaluation of pain; 9. Scheduled toileting; 10. Low bed; 11. Bolster mattress; 12. Pad on floor; 13. Motion alarm; 14. Physical therapy (PT) and/or occupational therapy (OT) evaluation. 1. Record review of Resident #27's undated face sheet showed the resident was admitted to the facility on [DATE] with diagnosis of fluid overload, cerebral infarction (stroke), and chronic peripheral [CONDITION(S)]. Record review of the resident's admission progress notes, dated 02/08/2021 at 10:17 A.M., showed the following: - The resident's family member said he/she had a stroke a few years ago; - The resident had needed more care; - The resident was an increased fall risk; - Had stress incontinence and wears pull up brief; - Usually went to the bathroom right after meals; - Walked with a walker around his/her house on his/her own; - Had three falls in the past six months, two of those were in the past three months; - No skin issues aware of, does bruise very easy; - Plans are for long term stay. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/21/21, showed the following: - Cognitively intact; - Occasionally incontinent; - Independently toileting; - Walker used for mobility; - Independent in transfers, locomotion in room and unit; - Balance during transitions and walking steady at all times; - Fall history one month prior to admission. Record review of the resident's care plan, dated 2/23/21, showed the following: - Potential for injury related to falls due to history of multiple falls; - Cue, reorient and supervise resident as needed. Be aware of safety issues; - Keep bed to lowest position when not giving care; - Assess visual/hearing deficit to determine safety needs; - Verbal cues as needed for safety; - Assess cause, pattern or previous falls and act upon resolvable factors; - Promote proper use of handrails, hand grips in bathroom; - Assess cause, pattern of previous falls and act upon resolvable factors; - Environmental checks keep floor uncluttered and kept dry (notify housekeeping for cleanup of spills with ten minutes); - Check assistive devices daily for damage (Example: Commode legs not loose); - Check that all locks are working on wheels of bed, wheelchairs, walkers, commodes etc; - Adequate lighting; - The resident had impaired communication due to minimal hearing loss when environment noise; - Will remain able to communicate, have needs met within environment, and answer call light promptly. Record review of the resident's admission fall risk assessment, dated 3/15/21, showed the resident had a history of two falls in the past three months, required use of assistive device (walker), unsteady gait/balance and predisposing disease. Staff scored the resident at five indicating the resident was a low risk for falls (a score of 10 or above indicated high risk). Record review of the resident's care plan notes, dated on 3/25/21, showed discharge from physical therapy and occupational therapy. Review of the resident's therapy notes, dated on 3/25/21, showed the resident plateaued, being moderately independent (supervision needed) with mobility, transfers and ambulation. Review of the resident's restorative therapy notes, dated 3/29/21, showed began ambulating the resident 15 minutes a day on 3/29/21 and ended 4/3/21. During interview on 2/23/22 at 11:30 A.M., the Secretary/Restorative Aide said the following: -The resident received restorative therapy when discharged from physical therapy; -The goal, to ambulate the resident personally three times a week for 15 minutes a day; -The Special Care Unit (SCU) staff ambulate the resident daily. During interview on 3/10/22 at 10:22 A.M., Therapy Coordinator said the following: - The resident evaluated for PT (physical therapy), OT (Occupational therapy), and ST (Speech Therapy) on 2/9/21; - The resident plateaued, being moderately independent with mobility, transfers and ambulation; - Restorative therapy began ambulating the resident 15 minutes a day; - Restorative therapy ended 4/3/21. Record review of the resident's progress notes, dated 4/24/21 at 10:32 A.M., showed the following: - Unwitnessed fall; - The resident was found on floor next to the bed; - The resident was trying to reach his/her shoes; - The resident had an eight centimeter (cm) skin tear on left forearm to elbow; - The resident had a black bruise to right index finger; - The resident's gait unsteady, one assist with gait belt; - New order to cover skin tear left forearm with [MEDICATION(S)] and loosely wrap with Kling every day. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 4/24/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 4/24/21. Record review of the resident's progress notes, dated 07/09/21 at 07:08 P.M., showed the following: - Unwitnessed fall; - The resident's roommate reported that resident was on floor in his/her room; - Small cut to right fourth finger; - The resident said he/she was helping his/her roommate get something out of a drawer and went to turn around and fell to the floor on his/her knees. Review of the resident's care plan showed no documentation facility staff updated, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 7/9/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 7/9/21. Record review of the resident's progress notes, dated 07/22/21 at 03:29 P.M., showed the following: - Unwitnessed fall; - The resident noted to have multiple bruises at different stages of healing all throughout body during shower this evening; - The resident said he/she had fallen, but did not tell anyone; - The resident noted to have a 3.5 centimeter (cm) x 5 cm round black bruise on his/her anterior left leg above the knee; - A 4.5 cm x 5 cm purple and black bruise on the anterior left leg below the knee; - Below that another 2 cm x 3 cm purple bruise; - Multiple other bruises on both legs; - On left arm resident has 8 cm X 7 cm bruise that wraps around anterior and posterior sides about wrist; - On right anterior arm resident has a 20 cm X 3.5 cm black bruise. Review of the resident's care plan showed no documentation facility staff updated, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 7/22/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions to address falls. Record review of the resident's quarterly MDS, dated [DATE], showed the following: - Severely impaired cognition; - Independent toilet use and ambulation (completes activity by him/herself with no assistance); - Independent with transfers; - Balance during transitions and walking steady at all times; - The resident had one fall since admission causing injury such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain of pain; (review of the resident's medical record showed the resident had three unwitnessed falls since admission on 4/24/21, 7/9/21, and 7/22/21). Record review the resident's progress notes, dated 08/31/21 at 05:03 P.M., showed the following: - Unwitnessed fall; - The resident was found in bathroom doorway by therapy at 3:15 P.M.; - The resident said, just fell ; - Noted bump to center of the back of head with slight bleeding; - The resident assisted to wheelchair by two staff members and told not to walk at this time; - The therapy department notified of the resident being weaker and confusion increased in the afternoon into the night; - Requested to see if therapy could work with the resident and therapy going to look into picking up (PT evaluated the resident on 8/31/21). During interview on 3/10/22 at 10:22 A.M., the Therapy Coordinator said the following: - PT evaluated the resident on 8/31/21; - The resident plateaued, being moderately independent (supervision needed) with mobility, transfers and ambulation; - PT therapy from 8/31/21 until discharged on [DATE]. Record review of the resident's assessments showed no documentation facility staff updated the resident's fall risk assessment per policy. Record review of the resident's progress notes, dated 9/5/21 at 02:56 A.M., showed the following: - Unwitnessed fall 9/4/21; - The resident discovered by nurse walking down hall; - Resident in a sitting position on the floor between the bed and the bathroom door; - The resident indicated he/she hit his/her head when he/she fell ; - The resident had blood from back of head, right elbow, and just above the right wrist; - Resident alert, but did not know if he/she was going to the bathroom or had already been to the bathroom; - Transferred at 11:40 P.M. to local hospital. Record review of the resident's hospital records, dated 9/4/21, showed the following: - Performed a CT (Computed tomography scan-reveals anatomic details of internal organs that cannot be seen in conventional X-rays) of the resident's head and cervical (neck) spine; - Showed a subdural hematoma (pool of blood between the brain and its outermost covering), present at the vertex (highest point) on the left frontal region 12 mm x 52 mm; - The resident fell at the facility tonight and struck the back of his/her head. This also occurred several days ago; - The back of the head was painful and there was a small amount of weeping blood; - The facility staff reported the resident fell three days ago; - Transferred to trauma center for further evaluation by neurology and neurosurgery on 9/5/21. Record review of the resident's progress notes, dated 09/08/21 at 05:39 P.M., showed the following: - Report received from trauma center, CT revealed left frontal subdural hematoma with no midline shift (blood buildup or swelling around the damaged brain tissues is powerful enough to push the entire brain off center). No treatment, just letting it resolve on its own; - The resident started on [MEDICATION(S)] (medication to prevent seizures); - Provider to determine if [MEDICATION(S)] can be discontinued; - Alert and oriented to self and sometimes place, which was baseline; - The resident remains one assist. Record review of the resident's progress notes, dated 9/9/21 at 2:06 A.M., showed the resident was readmit after 9/8/21 fall. The resident had rested with eyes closed so far this shift, monitored closely. Record review of the resident's five-day scheduled assessment MDS on 9/15/21 showed the following: - The resident needs one assist in activities of daily living (ADL) including ambulation, transfers, toileting, and hygiene, - The resident needs assistance with balance with transitions and walking; - Supervision of one assist while walking; - Balance not steady, needs one assist for balance; - No fall since prior assessment. (Review of the resident's medical record showed the resident had two unwitnessed falls on 8/31/21 and 9/4/21). Record review of the resident's progress note, dated 11/26/21 at 02:49 A.M., showed the following: - Unwitnessed fall; - The resident found on floor in a sitting position at 2:15 A.M.; - Confused if going to or coming back from the bathroom; - The resident denied hitting his/her head; - The resident had multiple bruising from previous falls. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented interventions to prevent falls following the resident's fall on 11/26/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident fell on [DATE]. Record review of the resident's progress note, dated 11/27/21 at 11:58 A.M., showed fall with skin tear to left forearm. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented interventions after multiple falls including the fall on 11/27/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident fell on [DATE]. Record review of the resident's progress notes, dated 11/29/21 at 09:22 P.M., showed the following: - Unwitnessed fall; - At approximately 9:00 P.M., Certified Nurse Aides (CNAs) reported the resident was on the floor beside his/her bed; - The resident reported he/she did not hit his/her head; - No complaints of pain or discomfort at this time; - The resident's scab on left elbow bumped and bled a small amount; - The resident out bed and to the nurse's station four to five times today. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 11/29/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 11/29/21. Record review of the resident's care plan notes, dated 11/30/21, showed the following: - Directed to keep call light attached to his/her clothing; - Keep orienting the resident due to confusion. Record review of the resident's progress note, dated 12/1/21 at 5:07 P.M., showed the following: - Staff found the resident on the floor at 8:41 P.M.; - Unwitnessed fall; - The resident had a scrape on the left side of his/her back; - The resident's right eye was swollen. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 12/1/21. Review of the Communication Book on SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident fell on [DATE]. Record review of the resident's progress note, dated 12/2/21 at 3:40 A.M., showed the following: -Staff found the resident on the floor; - Unwitnessed fall; - Blood on the floor; - The resident had a hematoma (bleeding under skin, bruise) and laceration to the head; - Transferred to the emergency room , laceration repaired with skin glue. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented interventions after the resident's fall on 12/2/21. Record review of the resident's progress note, dated 12/20/21 at 1:20 P.M., showed the following: -The resident lay on the floor; - The resident fell to the floor onto his/her right side; - A 2.8 cm skin tear to his/her right arm near the elbow; - Hematoma right elbow; - The resident complained of right shoulder pain; - Physician order to X-Ray the right shoulder, negative for fracture. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 12/20/21. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions to address falls following the resident's fall on 12/20/21. Record review of the resident's progress note, dated 12/22/21 at 2:40 P.M., showed the following: - Staff found the resident on the floor on his/her side; - Unwitnessed fall; - The resident had a 4.5 cm skin tear on his/her left arm, area approximated well and steri strips applied. Record review of the resident's progress note, dated 12/22/21 at 5:30 P.M., showed the following: - Unwitnessed fall; - Right forearm skin tear, exposing bone; - The resident was confused and did not understand what happened to his/her arm; - Transferred to the emergency room . Record review of the resident's progress note, dated 12/22/21 at 11:06 P.M., showed the following: - The resident fell twice today; - The resident was having loose stools; - The resident returned from the emergency room at 1:25 A.M.; - Pressure dressing to right forearm; - Two fingers of left hand bond together with a dressing. Review of the resident's care plan showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented new interventions after the resident's falls on 12/22/21. Record review of the Communication Book on the Special Care Unit (SCU), dated 12/28/21, showed the following: - Update sheet on the resident for 12/19/21 and 12/22/21 falls (no documentation in EMR for 12/19/21 fall); - Staff please make sure assist of one; - Use of walker; - No other update sheets in book for the resident from October 2021 to present. Record review of the resident's care plan notes on 1/3/22 showed the following: - Resident up with one assist and walker; - No documentation facility staff determined precipitating factors, evaluate or implemented further interventions after the falls on 12/19/21 and 12/22/21. Record review of the resident's significant change MDS on 2/4/22 showed the following: - Severely impaired cognition; - The resident sometimes able to understand others; - The resident responds adequately to simple, direct communication only; - Balance not steady; - The resident has two falls since admission causing injury. (The progress notes show the resident with seven of eight falls unwitnessed since 9/15/21). Record review of the resident's progress notes, dated 2/7/22, showed the resident was transferred out to the local hospital by ambulance and report called to the emergency room . Record review of the resident's hospital record dated 2/7/22 at 9:50 A.M., showed the following: - The resident had severe dementia; - The resident fell out of bed this morning; - CT of cervical (neck) spine showed no fracture; - X-rays of right shoulder and arm showed no fracture; - Laceration of skin. Review of the resident's care plan showed no documentation facility staff determined precipitating factors, evaluated or implemented interventions after the resident's witnessed fall on 2/7/22. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented interventions after the resident's fall on 2/7/22. Observation on 02/14/22 at 2:25 P.M. to 2:35 P.M., in the dining room showed the following: - The resident sat in wheelchair with six other dependent residents; - The resident scooted from the table, one hand gripped the table and he/she attempted to get out of the wheelchair at 2:28 P.M.; - No staff were present in the dining room; - Other residents in the dining room told the resident not to get out of wheelchair and to sit down before he/she fell ; - The resident continued to scoot away from table, one hand gripped the table and the resident attempted to get out of wheelchair; - CNA N came out of a resident room, returned to the dining room and redirected the resident to sit down at 2:35 P.M. Record review of the resident's progress notes on 2/15/22 at 6:50 A.M., showed the following: -Certified Medication Technician (CMT) F heard the housekeeper twice holler out the resident's name. Housekeeper reported the resident had fallen and he/she could not get to the resident in time; -The housekeeper witnessed the resident fall on his/her right side from a standing position and the resident hit his/her head on the floor. By the time this nurse got there he/she had rolled himself/herself onto her back; - Resident moving arms and legs but holding right elbow; - Noted lump to back of head; - Unsteady gait; - Sent to local hospital per ambulance for evaluation of head injury. Record review of the resident's local hospital record, dated 2/15/22 showed the following: - The resident fell again in facility; - The resident complained of neck tenderness; - Performed CT cervical spine and CT of the head; - The resident's diagnosis, posterior occipital hematoma (bruise under skin); - The resident returned to facility. Review of the resident's care plan showed no documentation facility staff determined precipitating factors, evaluated or implemented interventions after the resident's witnessed fall on 2/15/22. Review of the Communication Book on the SCU showed no documentation facility staff updated the care plan, determined precipitating factors, evaluated or implemented interventions to prevent falls after the resident's fall on 2/15/22. Observation on 2/22/22 at 10:10 A.M., of the resident in the SCU showed the resident sat in a wheelchair and wore fleece lined socks without grippers on the bottom of his/her socks. During interview on 3/10/22 at 10:22 A.M., the Therapy Coordinator said the following: -PT evaluated the resident for skilled services on 12/30/21; -PT began gait training, increasing toe clearance and step length on 12/31/21 through 1/25/22; -The resident had confusion, poor insight, poor balance and needed one assist for activities; -The resident discharged on [DATE] due to transfer to the local hospital for fluid retention; -The resident moved to the SCU after hospitalization due to confusion and falls; -On 1/31/22 the resident ambulated five feet with moderate assistance (one assist) and on discharge of 2/11/22 the resident ambulated 75 feet with minimal assistance. During an interview on 2/16/22 at 4:50 P.M. and 2/23/22 at 4:30 P.M. CMT F said the following: - He/she did not know where to find fall interventions or updates on residents; - He/she did not know where to find a communication book and did not know there was a communication book; - He/she cannot access care plans on the electronic medical record (EMR); - Staff try to keep a close eye on the resident, offer toileting and ambulation; - Impossible for one staff member to keep up with checks and performing cares; - Report given on every resident to the next shift, may not get a full length report when starting the shift. During an interview on 2/22/22 at 10:40 A.M., Social Service staff member AA said the following: - He/she relieved staff for lunch and monitored residents in the dining room; - He/she did not know what care or interventions are required for the residents on the SCU. During an interview on 02/16/22 at 5:00 P.M. and 2/23/22 at 4:23 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she was the charge nurse for the SCU; - Staff tried to keep a constant watch on the residents; - The resident is quick, didn't remember that he/she needs assistance when getting up and there isn't enough staff to prevent him/her from falling; - The resident started on west wing and had lots of falls; - The resident had therapy in the past and staff walks to dine; -The charge nurse was responsible for vital signs and assessing residents after a fall; -He/she did not document the evaluation of each fall intervention in the progress note and does not evaluate the care plan; -He/she does not look at care plan after falls, he/she said the MDS/care plan coordinator will post intervention updates after fall meetings on Mondays and put in the communication book on SCU; - The MDS/Care Plan Coordinator prints the resident's care plan with intervention updates and places it in communication book for each unit (The communication book on the SCU showed last update for resident was on 12/28/21), only charge nurses could view the care plans on the EMR; - The MDS/Care plan coordinator responsible for care plan updates. During an interview on 2/22/22 at 10:00 A.M., charge nurse LPN D said the following: - On Mondays, the MDS/care plan coordinator will update the communication book on what staff need to do to prevent falls or what has changed on the care plan; - The resident's room direct in the line of sight of nurses station; - SCU staff offer toileting, in dining room with majority of staff/residents; -Electronic reporting by staff was sent to administrator and DON of any changes or updates in resident condition. During interview on 2/15/22 at 12:05 P.M., the MDS/care plan coordinator said the following: -Her responsibility to update the care plans after change in condition such as falls; -The administrator or nurse sends an alert through their electronic charting system, then he/she was responsible to update the care plan; -He/she did not attend the fall meetings, because she did not have enough time; -If the administrator or nurse fails to send information or updates, then the care plans are not updated. During an interview on 2/25/22 at 8:30 A.M., the administrator and DON said the following: - The licensed staff could not access to edit the care plan to update or change; - She thought staff could all look at care plans on the EMR; - All licensed staff couldn't see the resident's care plan on the EMR yesterday, but now they can; - Fall interventions should be re-evaluated in an ongoing process by staff; - If new interventions are put in place, the MDS/Care plan Coordinator prints out intervention updates and puts them in binder for the CNA's and staff; - Care plans are re-evaluated after falls by the MDS/Care plan Coordinator; - She expects the MDS/Care Plan Coordinator attend the fall meeting every Monday for evaluating falls and updating interventions; -She would expect staff to follow the care plan, assist in residents' needs, provide a safe environment, call for assistance when needed and monitor closely to prevent falls for the resident. MO 908 MO 164 MO 843 Surveyor: [NAME], [NAME] Surveyor: [NAME], [NAME]

Based on observation, interview, and record review, the facility failed to appropriately assess pain twice daily as directed in the facility policy, report pain during care to the charge nurse, provide medications in anticipation of cares that caused pain, for one resident (Resident #43), in a review of 19 sampled residents, who yelled out in pain during care. The facility census was 55. Review of the facility undated Pain Management Policy showed the following: -Each resident who experiences pain will have an assessment of that pain and will have a treatment plan established to treat his/her pain; -To effectively prevent or reduce the limits pain causes on the activities of daily living for our residents. And, assist in maintaining their dignity, self-respect and quality of life they are entitled to; -Resident preferences must be respected when deciding on methods to be used for pain management. Family members should be involved when appropriate; -Definitions of Pain: 1. Acute = sharp, severe, having rapid onset, severe symptoms, and a short course, not chronic; 2. Chronic = of long duration. Denoting a disease showing little change or slow progression; the opposite of acute; 3. Chronic malignant pain = growing worse; resisting treatment, said of cancerous growths; 4. Tending or threatening to produce death; harmful; -Pain assessment will be completed on each resident upon admission, with admission assessment and documented on the Pain Assessment section adapted from MDS 3.0 on the admission assessment in Matrix (electronic medical record); -Pain will be assessed on each resident twice daily and recorded on the eMAR (electronic medical record); -Residents will be assessed according to the 0-10 scale (rates pain, 0 is none and 10 is the worst) as long as they have the cognitive ability to use this scale; - All other residents will be assessed according to the [NAME] Pain Scale (pain assessment used in residents who are unable to articulate their needs, example a resident with dementia); - A conversion chart will be used to convert to the 0-10 scale and will be recorded on the eMAR; -Pain Assessment will also be completed quarterly on each resident and documented on the MDS (Minimum Data Set, a federally mandated assessment completed by staff) Pain Assessment; -Residents using/requesting PRN (as needed) pain medication will be assessed at the time medication is requested/given and this will be documented on the eMAR; - Response to pain medication will then be documented on the eMAR, also; - (Pain is assessed according to the 0-10 pain scale, with 10 being the worst pain and 0 being no pain or according to the [NAME] Pain Scale, if resident unable to do the 0-10 pain scale); -Non-pharmacological methods to relieve pain, may also be used and should be included in the resident's plan of care; -If current pain management is not effective, the physician will be notified to see if adjustments can be made to make the resident more comfortable. 1. Review of Resident #43's face sheet showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 7/3/19, showed the following: -Pain Management, alteration in comfort; -Goal: Resident will not experience negative side effects of pain regimen such as constipation, nausea or lethargy; -On-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors; -Implement the use of alleviating factors; -Avoid activities that aggravate or exacerbate pain; -Monitor side effects and adverse reactions resulting from interventions rendered; -Refer to rehabilitation services as needed; -Encourage participation in therapeutic recreation activity; -Encourage fluid intake with narcotic use; -Half side rails to assist with self positioning for comfort; -Encourage participation in activities of choice for distraction; -Monitor behavior and assess for pain/discomfort if change in behavior is noted; -Promote proper body alignment; -Muscle rub to right inner thigh twice daily as needed; -Warm moist pack to affected area for pain/muscle spasms as needed. Review of the resident's care plan, updated 10/23/19, showed the following: -Discontinue [MEDICATION(S)] (pain medication); -[MEDICATION(S)] (muscle relaxant) 10 mg every 12 hours as needed; -Warm moist pack to affected area for pain/muscle spasms as needed. Review of the resident's care plan, updated 1/16/20, showed [MEDICATION(S)] 5 milligrams (mg)-Tylenol (narcotic pain medication) 325 mg, one every four hours as needed for pain. Review of the resident's care plan, updated 3/30/21, showed the following: -Muscle rub to right inner thigh two times daily as needed; -Muscle rub to left anterior chest two times a day as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment, dated 12/24/21, showed the following: -Severe cognitive impairment; -Makes self-understood and understands others; -Required extensive physical assistance of two or more staff members for bed mobility; -Dependent on staff for transfers and toilet use; -Limited range of motion in both lower extremities; -Scheduled pain medication regimen; -As needed pain medications received; -Resident had frequent severe pain. Review of the resident's Nurses Notes, dated 12/27/21, showed staff documented this morning the resident was hollering and pain pill given, pain pill was effective. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen (non narcotic pain medication) 325 mg tablet every four hours as needed for pain or elevated temperature; -Acetaminophen 325 mg tablet two tablets (650 mg) by oral route once daily at 6:00 A.M.-11:00 A.M.; -[MEDICATION(S)] 5 mg-acetaminophen 325 mg tablet one tablet every four hours as needed for pain; -[MEDICATION(S)] 10 mg tablet one tablet every 12 hours as needed muscle spasms. Review of the resident's Medication Administration Record (MAR), dated 2/1/22-2/14/22, showed the following: -Pain score was scheduled to be documented once a day with scheduled acetaminophen 650 mg administration, and documented with as needed medication administration; -All scheduled doses of acetaminophen 650 mg administration 6:00 A.M.-11:00 A.M. daily documented as administered, -On 2/1/22 6:00 A.M.-11:00 A.M., pain score of 4 (On a scale of 1-10 with 10 being the worst pain possible), 5:00 P.M. [MEDICATION(S)]/acetaminophen administered for a pain score of 6; -On 2/2/22 6:00 A.M.-11:00 A.M. no documentation of a pain score, no as needed pain medication documented as administered; -On 2/3/22 6:00 A.M.-11:00 A.M. no documentation of a pain score, 3:00 P.M. [MEDICATION(S)] and [MEDICATION(S)]/acetaminophen administered for a pain score of 8; -On 2/4/22 6:00 A.M.-11:00 A.M., pain score of 2; at 8:00 A.M. [MEDICATION(S)]/acetaminophen was administered for a pain score of 6, and at acetaminophen 325 mg administered at 4:22 P.M. for a pain score of 2; -On 2/5/22 6:00 A.M.-11:00 A.M., pain score of 3, no as needed pain medication documented as administered; -On 2/6/22 6:00 A.M.-11:00 A.M., pain score of 3; at 1:00 P.M. [MEDICATION(S)]/acetaminophen was administered for a pain score of 6; -On 2/7/22 6:00 A.M.-11:00 A.M., pain score of 4, no as needed pain medication documented as administered; -On 2/8/22 6:00 A.M.-11:00 A.M. no documentation of a pain score, no as needed pain medication documented as administered; -On 2/9/22 6:00 A.M.-11:00 A.M., pain score of 4, no as needed pain medication documented as administered; -On 2/10/22 6:00 A.M.-11:00 A.M., pain score of 0, no as needed pain medication documented as administered; -On 2/11/22 6:00 A.M.-11:00 A.M. no documentation of a pain score, no as needed pain medication documented as administered; -On 2/12/22 6:00 A.M.-11:00 A.M., pain score of 3, no as needed pain medication documented as administered; -On 2/13/22 6:00 A.M.-11:00 A.M., pain score of 2, no as needed pain medication documented as administered; -On 2/14/22 6:00 A.M.-11:00 A.M., pain score of 2; at 8:45 A.M. [MEDICATION(S)]/acetaminophen was administered for a pain score of 6; -The record showed staff did not complete a pain assessment twice daily as directed per facility policy to ensure the presence of pain was addressed. Review of the resident's Nurses Notes, dated 2/1/22-2/14/22, showed no documentation regarding the resident's pain or any assessment of pain. Observation and interviews on 2/15/22 at 9:02 A.M.-9:37 A.M., showed the following: -Heard the resident call out Help!; -The resident sat in his/her wheelchair in his/her room; -The resident had slid towards the front of the wheelchair and his/her shoulders were against the back of the chair; -The resident said, My bottom hurts, I want to go to bed, it's bad, it's an eight; -The resident pushed his/her call light, and put his/her head back against the back of the wheelchair; -From 9:07 A.M.-9:12 A.M., the resident yelled out, Help me! three times; six unidentified staff walked by and did not respond to the resident yelling for help; -At 9:12 A.M., Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CNA) K entered the room. The resident said, I am in pain, I want to go to bed, then the resident leaned forward and said Oh it hurts; -LPN B inquired as to the location of pain, the resident said, my bottom; -LPN B and CNA K prepared to transfer the resident with the mechanical lift; -As staff lifted the resident in the sling, the resident yelled out in pain, and started crying; -CNA K proceeded to turn the resident in bed and pushed his/her left leg, the resident screamed out in pain, Don't touch that leg!; -The resident had discoloration and peeling skin with small purple areas on his/her right buttock; -The resident was contracted at the hips and knees bilaterally (resident's legs will not straighten); -LPN B said the area on the resident's bottom was a pressure area, the area was non-blanchable (area does not change color with finger tip pressure), and it felt like a rug burned area; -CNA K and LPN B turned the resident back and forth, each time when pressure was placed on the resident's left leg the resident cried out in pain; -LPN B told the resident he/she would get him/her a pain pill. During an interview on 2/15/22 at 9:37 A.M., CNA K said the following: -The resident cannot straighten out his/her legs or hips; -The resident's contractures have gotten worse in the last year; -The resident only yelled out in pain when you touch his/her legs or ankles, especially the right leg; -The resident had pain every time he/she was turned and when transferred in and out of bed; -He/She wants to go to bed between meals, because he/she says it hurts his/her bottom and lower back when he/she is in the chair; -He/She reports the resident's pain if the resident continues to have pain after the resident is settled down after cares or transfers. Review of the resident's MAR, dated 2/15/22, showed LPN B administered [MEDICATION(S)]/Tylenol at 9:42 A.M., for a pain score of 4, routine acetaminophen 650 mg administered at 6:00 A.M.-11:00 A.M., follow up documentation at 11:12 A.M. showed pain a zero, effective. Review of the resident's Nurses Notes, dated 2/15/22, showed no documentation about the resident's pain or assessment of pain. During an interview on 2/15/22 at 10:00 A.M., LPN B said the following: -He/She did not usually transfer the resident, and did not know the resident had pain with turning and repositioning with care; -Staff are expected to report pain any time they see a resident is in pain or a resident complains of pain; -Staff had not told him/her the resident had pain during transferring and repositioning; -Staff should pre-medicate for times when they anticipate an activity will cause pain; -Staff should assess for pain with every point of care, every shift for resident's known to have pain; -Pain and staff's response to pain should be documented in the resident's MAR and or Nurses Notes; -The physician should be notified if medications do not control pain. Observation on 2/16/22 at 6:36 A.M., showed the following: -The resident in his/her bed; -LPN A and Activity Director/CNA came into the resident's room to provide care; -Activity Director/CNA touched the resident's right leg, the resident yelled out in pain; -As the staff turned the resident side to side, the resident yelled out in pain when his/her right leg hit the right side of the bolster mattress; -The bolster edge was too high to turn the resident completely to his/her right side, and his/her legs were pressed against the high edge of the mattress as staff changed linens, dressed the resident and placed the sling for the mechanical lift under the resident; -Each time the mattress put pressure on the resident's leg he/she would yell out. Observation on 2/16/22 at 6:57 A.M., showed the following: -Resident in bed dressed with lift sling under him/her; -CNA K and Housekeeper S came into the resident's room with the mechanical lift; -CNA K hooked the resident's sling to the lift; -Housekeeper S raised the resident with the lift; -CNA K grabbed the resident in the sling and turned the resident to clear the edges of the bed; -The resident's feet caught the bolster edge of the mattress, the resident screamed out Ouch and tried to hit CNA K, swinging both arms at him/her; -Housekeeper S lowered the mechanical lift, as the resident's body lowered into the resident's wheelchair the resident grimaced. During an interview on 2/16/22 at 6:43 A.M., LPN A said the following: -The resident had the bolster mattress, because he/she used to put his/her legs over the side of the bed and fall; -Now the resident cannot move his/her legs independently, so the bolster mattress would not be necessary to keep in place if it is causing him/her pain. Review of the resident's MAR, dated 2/16/22, showed staff documented the resident's pain a 2, no documentation of as needed narcotic pain medication administered or of pain medication given prior to care. Review of the resident's Nurses Notes, dated 2/16/22, showed it did not contain documentation about the resident's pain or an assessment of pain. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing (DON) said the following: -Staff are expected to assess pain at the very least every shift but every time staff work with residents; -Staff are expected to assess for pain at every point of care; -Staff ask the residents for a pain scale score or use the pain aide scale at least once a shift; -If a resident had pain with cares as needed medication or interventions should be offered; -Staff are expected to document what they did about pain in the resident's MAR and/or Nurses Notes; -Uncontrolled pain is to be reported to the physician. During an interview on 3/22/22 at 11:00 A.M., the resident's physician said the following: -The resident had PRN pain medication, because it was known the resident had chronic pain; -Staff should check on the resident often and give him/her pain medication if he/she has pain; -If the resident had pain when he/she gets up or with care, he expected staff to give the resident pain medication before getting him/her out of bed or before providing care; -He was not sure how often or times when the staff assess for pain, but the resident could have pain medication every six hours, and it would make sense to assess if the resident needed it every six hours; -Many residents at the home have chronic pain, the goal should be to help them be comfortable and address pain as best it can be.