Every finding on record at Beloved Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), who was identified as at risk for elopement, in a review of six sampled residents, did not leave the facility without staff knowledge. Staff failed to ensure an interior, alarmed, coded double door, as well as the front entrance door alarms were activated and secured on 3/27/25. The resident exited the facility through the interior, alarmed, coded double doors, leading from the dining room to the facility front entrance and exited through the front entrance door without the alarm sounding and without staff knowledge. He/She walked one mile to a convenience store across four lanes of traffic and fell by the roadway. A passing car assisted the resident and called the police who returned the resident to the facility. Facility staff failed to complete face checks every two hours and the resident was out of the facility for four hours before staff identified the resident was missing. The facility census was 78. On 4/4/25 the administrator was notified of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 3/27/25. On 3/27/25, the administrator identified Resident #1 eloped from the facility. Upon discovery, staff conducted an investigation and notified appropriate parties including the police. In-service education was provided for all facility staff including updated elopement policies, face check policies and door monitoring policies. Staff completed elopement risk assessments for all residents and the elopement risk and code white procedure books were updated with current risk assessments and code white procedures. The IJ was corrected on 3/28/25. Review of the facility's facility Elopement Policy, dated 2/15/23, showed the following: -The purpose was to ensure the safety of the residents by establishing a clear and effective protocol for responding to incidents of elopement, defined as a resident leaving the facility without authorization; -The facility was committed to maintaining a safe and secure environment for all residents. In the event that a resident was discovered missing, the following steps must be taken immediately by all staff members to initiate a thorough search and ensure the resident's swift and safe return; -Call a Code White, begin an in-building search immediately, notify the designated supervisor or facility manager, initiate an outside search if the resident is not found inside the facility, call the police, document the incident in detail; -All staff members receive training on the elopement policy as part of orientation and ongoing education to ensure familiarity with procedures and responsibilities. During an interview on 4/4/25 at 9:55 A.M., the Assistant Administrator said the facility did not have a written policy regarding expectations or frequency of staff completing resident face checks or on securing the entrance doors at night. Review of Resident #1's Elopement Risk Assessment, dated 3/2/24, showed staff documented the following: -The resident was cognitively impaired and independently mobile; -History of a desire to leave the facility and wandering activity; -At risk for elopement, proceed with interventions and elopement risk care plan; -Elopement risk factors included an active mental illness and anger related to placement in the facility; -Interventions put in place to prevent the resident from eloping included a secure unit and frequent visual monitoring. Review of the resident's Care Plan, initiated 6/18/24, showed the following: -Diagnoses of schizophrenia (a serious mental illness characterized by disorganized thinking, distorted perceptions, and impaired social and emotional behavior), restlessness and agitation, lung cancer, and muscle weakness; -At risk for injury and alteration in health. The resident had lung cancer and refused treatment; -Highly functional and able to complete activities of daily living with supervision and cues. Allow time to complete task and intervene as needed and monitor for decline in function; -At risk for falls. Ensure proper footwear, keep pathway cleared for safety. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, 12/2/24 showed the following: -Moderately impaired cognition; -The resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Independent in mobility; -Shortness of breath with exertion of walking, bathing, transferring and lying flat. Review of the resident's record showed staff had not documented any additional elopement risk assessments since 3/2/24. Review of the resident's annual MDS dated [DATE], showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in mobility. Review of the resident's Care Plan, revised 3/23/25, showed no staff direction or interventions regarding the resident's elopement risk and no staff direction to complete face checks every two hours. Review of the resident's Point of Care (electronic system used to document completed tasks. Staff click on the task box indicating the task was completed) face check documentation showed the following: -On 3/27/25 at 10:00 P.M. the face check task was green indicating staff completed a face check and visualized the resident; -On 3/28/25 at 12:00 A.M. and 2:00 A.M. showed the face check task was red indicating staff did not complete face checks at those times. Review of the resident's nurses' note, dated 3/28/25 at 5:05 A.M., showed Licensed Practical Nurse (LPN) C documented he/she was notified at 2:45 A.M. the resident was not on the unit. A thorough search was completed throughout the facility and staff were unable to locate the resident. The local police department, Director of Nursing (DON) and Administrator were notified. At 3:55 A.M. the resident was located and brought back to the facility by the local police department. Resident noted to have skin tear to the left hand. Resident said he/she tripped and fell . During an interview on 4/3/25 at 12:15 P.M., the Administrator said the facility video camera showed on 3/27/25 at 10:32 P.M., LPN B secured the front doors. The alarms were located at the top of the door and the camera footage did not show the door alarm indicators turned red indicating the two front doors were secured. At 11:30 P.M., Resident #1 pushed open the front exit door and exited the facility without any alarms sounding. The resident would not be able to push the door open without it alarming if the doors were secured and the alarms were activated. No other residents, staff, or visitors were seen entering or exiting the facility between 10:32 P.M. and 11:30 P.M. During an interview on 4/3/25 at 2:35 P.M., LPN B said on 3/27/25 he/she secured the facility front double doors sometime after 9:00 P.M. The charge nurse secured the front doors every night around 9:00 P.M. He/She made rounds and found the front exit doors were not secured and the alarm activated. He/She had a key and secured both doors with the key, the alarm lights turned red indicating the doors were secured and the alarm activated. The doors secured like normal, and the lights turned red. He/She saw Certified Nurse Aide (CNA) A at the nurses desk charting that night but was unsure of the time. LPN B did not see Resident #1 in the dining room area after the 10:30 P.M. smoke break. Staff were supposed to complete face checks every two hours on all residents. During an interview on 4/3/25 at 2:00 P.M., CNA A said on 3/27/25 the resident went out to smoke in the courtyard at 10:30 P.M. with other residents. The resident came inside after smoking and went to his/her room. CNA A sat at the nurses desk around 11:00 P.M. charting. He/She did not complete resident face checks at 12:00 A.M. or 2:00 A.M.; he/she completed cleaning duties and other assigned duties. At 2:45 A.M., he/she completed face checks and noted the resident was missing. Staff searched the entire facility and outside without finding the resident. CNA A did not see the resident walk through the dining room and had not seen the resident since the 10:30 P.M. smoke break. He/She should have completed rounds and face checks at 12:00 A.M. and 2:00 A.M. During an interview on 4/3/25 at 3:05 P.M., LPN C said LPN B secured the front doors around 10:30 P.M., a little later than usual. The charge nurse usually secured and activated the front door alarms between 8:00 P.M. and 9:00 P.M. every night. At 2:45 A.M., CNA A said he/she could not find Resident #1. Staff checked the entire facility and surrounding area outside, called the police and management staff. LPN C saw the resident when the police brought the resident back. The resident was shaken up and had a skin tear on his/her hand. During an interview on 4/3/25 at 1:45 P.M., the resident said he/she wanted to get outside and leave. He/She did not like it at the facility, especially the food. That night he/she went outside to smoke in the courtyard with other residents and a staff member. He/She came back inside after smoking and went to the dining room. He/She wore a coat outside to smoke and did not remove the coat. He/She did not see anyone in the dining room. He/She looked and the double door from the dining room light was green (indicating the door was not secured), and went through the double doors and then on to the front door. The front door code light was green (indicating the door was not secured). He/She went out the front door, walked down the hill to the road, and walked to the convenience store and tried to reach a highway towards home. He/She fell by the roadway and a passing car stopped, helped the him/her up and called the police department. The local police brought him/her back to the facility. It was hard to breathe and walk that far. Observation of the facility on 4/3/25 at 11:55 A.M., showed the following: -Interior, double doors leading from the dining room to the front entrance area. Staff entered a number code in the keypad allowing the doors to open without sounding the alarm when passing through the doors. The alarm code changed from red to green when the number code was entered and remained green for 45 seconds before relocking automatically and the alarm code turned red after the door automatically locked. If the door remained open or the door handle was pushed for 15 seconds, a door alarm sounded; -Exterior double doors at the front entrance. The doors were not alarmed during the day. Observation on 4/3/25 at 5:00 P.M., showed the facility entrance door lead to the parking lot and across a grassy area to a two lane well traveled city street without sidewalks. This led through an underpass that connected one residential area to a shopping area. The resident's path then turned east down a heavily traveled two lane road with sidewalks and across a bridge to a major highway and business area. The resident crossed four lanes of highway traffic with multiple stop lights to a large truck stop convenience store, one mile from the facility. On the night of 3/27/25 the outside environmental temperature ranged between 50 and 60 degrees. During an interview on 4/4/25 at 11:15 A.M., the DON said staff should complete an elopement assessment on every resident on admission and initiate a care plan with interventions to prevent elopements. Staff should be aware of residents at risk for elopement. A book was kept at the nurses desk listing the residents at risk for elopement and the code white procedure. Resident #1 was an elopement risk, but was not included in the elopement book at the nurses desk. Staff should have completed face checks every two hours as assigned on the electronic charting tasks. The dining room interior double doors were not secured, and the front entrance door was not secured. The resident went out the door without any alarms sounding and staff were unaware the resident was missing for four hours. During an interview on 4/3/25 at 12:15 P.M., the Administrator said the nurse was late closing and activating the front entrance door alarms on 3/27/25. Staff failed to do face checks on time that night. Staff needed to complete face checks every two hours and check the front door to make the sure the doors were secured. The resident went out the dining room double doors and front entrance doors without setting off an alarm. MO 00251823

Refer to 4RZT12. Based on observation, interview and record review, the facility failed to ensure staff offered suitable, nourishing evening snacks for three residents (Resident #10, #21, and #22), in a review of 23 sampled residents, who wished to have a snack offered. The facility census was 83.

Refer to 4RZT12. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 11/27/24. Based on observation, interview and record review, the facility failed to provide for a safe transfer for two residents (Resident #5 and Resident #12) in a review of 23 sampled residents. Facility staff failed to use a gait belt for the transfer of Resident #5 from his/her wheelchair to his/her bed, which resulted in a near-fall, and facility staff failed to use the appropriate size of a mechanical lift pad, based on resident weight, for the transfer of Resident #12 by a mechanical lift, causing the resident to complain of the sling hurting him/her during the transfer process. The facility census was 83.

Based on observation, interview, and record review, the facility failed to consistently assess pain, document why pain medications were not administered when pain was identified, failed to medicate prior to treatment, failed to develop a care plan to implement appropriate pain interventions during and prior to care that elicited pain, and failed to address a sling causing pain for three residents (Resident #19, #36, and #80) in a review of 20 sampled residents, when the residents displayed signs of pain and some were not able to verbalize pain. Resident #19 had fractures and swelling of his/her right extremity, and the resident's sling was placed incorrectly. The resident verbalized distress with his/her limited speech and staff failed to use ordered interventions to assist the resident who showed facial grimacing, guarding, and expressed his/her arm hurt. Resident #80 grimaced, moaned, and guarded limbs with extreme contractures during care and staff failed to identify pain and administer medications ordered for pain control. Resident #36 said the staff never asked him/her about his/her pain and did not administer medications or interventions ordered by the physician for pain, and he/she was in pain all of the time. The facility census was 87. Review of the facility policy Pain Care and Management, dated 11/30/22, showed the following: -The facility's Pain Care Committee consists of the Director of Nursing, Restorative Nurse, MDS Coordinator, and Quality Assurance Nurse/Designee; -QA will meet as needed to examine the effectiveness of the facility's pain care program -Comprehensive pain assessments must be completed with: -Every scheduled resident assessment; -A significant change in the resident's condition; -Any change in the resident's level or frequency of pain; -Any change in the resident's response to pain medications; -A specialized pain assessment must be used for residents with cognitive and/or communication deficits, that includes monitoring for indicators of pain, such as: -Grimacing, crying, or frowning; -Guarding or protecting a body part; -Groaning, grunting, moaning, sighing, or tense voice; -Pain assessments must include: -Location of pain; -Description of pain in the resident's own words and/or using a pain scale -Frequency of pain, usual level of pain; -What alleviates pain -What exacerbates pain; -Measurement of how pain effects areas of the resident's life, such as activities of daily living, sleep appetite, and mood; -Pain management should be based on the resident's changing needs and responses. -For residents with daily or chronic pain, maximum pain relief is achieved with around the clock medications and PRNs for breakthrough pain. -Pain medications are more effective when given before activities or treatments that exacerbate pain. -Non-pharmacological measures should be used along with pharmacological measures for maximum pain relief and include repositioning; -Care Planning - the care plan should be based on in-depth assessment of the resident's pain and treatment history, are individualized to his particular needs and preferences; -Pain care plans must be updated with any change in the resident's level or frequency of pain. -New interventions must be implemented when old interventions are ineffective. -Monitoring when the Unit Nurse administers a pain medication, she must document in the resident's Medication Administration Record (MAR), chart, and pain monitoring flow sheet, and on the 24 Hour Report: -Why the pain medication was administered - signs and symptoms observed or the resident's specific complaint of pain; -What non-pharmacological interventions were used; -Effectiveness of the medication and interventions -Cognitively impaired residents must be observed for pain at regular intervals. 1. Review of Resident #19's Care Plan, dated 09/22/23, showed the following: -Risk for pain and discomfort related to hemiparesis (paralysis one side of the body), and seizure activity; -Monitor/record/report to nurse if resident complains of pain; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Administer analgesia Tylenol as per orders; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Assess resident every shift for pain. Review of the resident's annual Minimum Data Set (MDS), a federally required assessment completed by staff, dated 07/09/24, showed the following: -Severe cognitive impairment; -Diagnosis of hemiplegia (paralysis one side of the body), total brain injury, seizure disorder, aphasia (inability to express themselves by speaking); -Rarely/Never understood or understands; -No behaviors or rejection of care; -Limited functional range of motion in one upper and one lower extremity; -Requires substantial/maximal assistance from staff for roll left and right, sit to lying, lying to sitting on side of bed; -Dependent on staff for oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer; -Always incontinent of bowel and bladder; -No scheduled or as needed pain medication; -Staff assessment of pain is blank (did not answer yes or no, questions not answered). Review of the resident's Nurses Progress Notes, dated 08/09/24, at 4:20 P.M., showed the following: -Resident approached nurses station saying, one, two, one, two which staff interpreted as the resident was in distress; -Resident nodded yes having right sided pain and left leg pain; -Tylenol administered; -Left message for physician. Review of the resident's Nurses Progress Notes showed no documentation staff assessed to determine if Tylenol administered on 08/09/24, at 4:20 P.M., was effective in relieving the resident's pain. Review of the resident's Nurses Progress Note, dated 08/10/24, at 4:56 P.M., showed the following: -Resident's DPOA (durable power of attorney) concerned with the edema in the resident's right arm; -Right arm swollen considerably more than the left arm; -Resident sent to the emergency room . Review of the resident's Nursing Progress Notes, dated 08/10/24, at 11:00 P.M., showed the following: -Resident returned from the emergency room with diagnosis of humeral fracture; (fracture of a bone in the arm); -Sling in place to right upper extremity; -New medication for Norco (narcotic pain medication) 5/325 mg every six hours as needed for pain. Review of the resident's Nursing Progress Notes, dated 08/16/24, at 2:01 P.M., showed a provider ordered Voltaren gel (a topical anti inflammatory medication) 1% to right shoulder every eight hours for pain, and new order for mechanical lift transfers. Review of the resident's Nursing Progress Notes, dated 08/19/24, at 2:57 P.M., showed the resident has had fluid shift from the shoulder to the forearm even with repositioning and elevation. Physician, guardian and orthopaedic physician notified of new edema. Review of the resident's Care Plan, updated 08/26/24, showed the following: -(Added 08/26/24 for fracture that occurred 08/10/24); -Resident returned from the emergency room with a diagnosis of a right humeral fracture with a sling in place to the right upper extremity; -Norco 5/325 mg every six hours as needed for pain; -Pillow placed under right upper extremity for stabilization. Review of the resident's Nursing Progress Notes, dated 09/02/24, at 2:10 P.M., showed the physician office faxed regarding the resident having increased swelling in the right hand. Resident's arm elevated and resident given pain medication as displaying he/she was in pain. Review of the resident's Nursing Progress Notes, dated 09/05/24, at 2:10 P.M., showed the following: -Resident pointed to his/her right side for the nurse; -Complaints of pain under his/her right breast down his/her right side; -White patches on his/her side and arm, physician notified. Review of the resident's physician's orders, dated 09/06/24, showed the resident may wear sling to right arm/shoulder when up in the wheelchair to minimize swelling for two weeks then discontinue. Review of the resident's Nursing Progress Notes, dated 09/28/24, at 1:52 P.M., showed the physician ordered to discontinue hydrocodone five days after 09/23/24, then begin Tramadol 50 mg every six hours for pain. Review of the resident's Nursing Progress Notes, dated 09/30/24, at 10:31 A.M., showed the following: -Right arm and hand was swollen and tender to touch; -Resident cries out in pain if right arm is lifted. Review of the resident's Nursing Progress Notes, dated 09/30/24, at 5:01 P.M., showed the following: -Resident received an order for right arm and hand being swollen: -Ice pack for 24 hours and to get an X-ray of the right arm; -Orders sent. Review of the resident's radiology report, dated 09/30/24, showed a fracture of the distal radius (bone in the fore arm where it connects to the wrist) with mild posterior angulation (Colles fracture-a break in the radius bone of the wrist that occurs when the broken end of the bone bends backward). The radiologist wrote that it was difficult to determine the age of the fracture given the severe osteopenia. (reduced bone mass). Review of the resident's quarterly MDS, dated [DATE], showed the resident had no scheduled or as needed pain medication and staff did not assess the resident's pain. (Pain section was blank). Review of the resident's Orthopaedic Note, dated 10/10/24, showed the following: -Resident being seen for evaluation of right wrist symptoms that have been going on for two weeks; -Symptoms include swelling; -Swelling at the wrist on examination; -Healing fracture of the right shoulder proximal humerous (a break in the upper arm bone near the shoulder joint); -Right wrist volatile minimally angulated fracture; -Both fractures are in the flaccid (hanging loose or limp) right upper extremity; -Plan: Os-Cal D500 twice daily (calcium supplement), splint on the right wrist for the radius fracture for four weeks, lymphadema sleeve (a compression sleeve to reduce swelling), have physical therapy specify might be ideal to manage the swelling, acetaminophen (Tylenol) for pain as needed; -Revisit in six weeks. Review of the resident's physician orders did not include the splint on the resident's wrist, orders for physical therapy, a lymphedema sleeve, or acetaminophen. Review of the resident's Medication Administration Record, dated 11/05/24, showed the resident had a pain level of two (on a scale of 1-10 with 10 being the worst pain possible), and staff administered Tramadol 50 mg for pain. Review of the resident's Medication Administration Record, dated 11/06/24, on day shift showed staff documented NA on the resident's pain score. Review of the resident's Medication Administration Record, dated 11/07/24, on night shift showed staff documented 1 on the resident's pain score. Review of the resident's Medication Administration Record, 11/08/24, on night shift showed staff documented 1 on the resident's pain score. Review of the resident's Medication Administration Record, 11/08/24, showed the resident had a pain level of six and staff administered Tramadol 50 mg for pain. Review of the resident's Medication Administration Record, 11/09/24, on day shift showed staff documented 3 on the resident's pain score. Review of the resident's Medication Administration Record, 11/09/24, showed the resident had a pain level of three and staff administered Tramadol 50 mg for pain. Review of the resident's Nurses Progress Notes showed no documentation staff assessed to determine if Tylenol administered on 08/09/24 at 4:20 P.M., was effective in relieving the resident's pain. Review of the resident's Medication Administration Record, 11/12/24, at 4:35 P.M. showed the resident had a pain level of four and staff administered Tramadol 50 mg for pain. Review of the resident's Nursing Progress Notes, dated 11/12/24, at 3:34 P.M., showed the following: -Faxed physician in regard to Tramadol 50 mg order; -Resident used Tramadol six times last month and three times this month so far, medication requires a new prescription, physician response requested to continue or discontinue medication. Review of the resident's Nursing Progress Notes, dated 11/12/24, at 4:26 P. M., showed the physician responded to fax for Tramadol and wanted to continue the medication, a new prescription was sent to the pharmacy. Review of the resident's Nursing Progress Notes, dated 11/12/24, at 7:11 P.M., showed the resident received Tramadol 50 mg at 4:35 P.M., and it was effective 0. Review of the resident's Medication Administration Record, 11/19/24, on day shift showed staff documented 0 on the resident's pain score. Observation of the resident on 11/19/24, at 12:26 P.M., showed the following: -The resident sat in a wheelchair at the dining room table; -The Resident had a sling on his/her right arm. The sling was not placed properly and the resident's arm was not resting in the sling. The resident's arm was straight and the sling cut into the resident's forearm. The resident's hand had 4+ edema; (a severe case of pitting edema, a condition where the skin retains fluid and appears indented after pressure is applied); -The resident repeated the numbers 1, 2, 1, 2, 5, 4; -The resident nodded yes when asked if he/she was in pain; -The resident grabbed his/her right arm and when the resident moved his/her arm he/she winced and moaned in pain; -The surveyor reported the resident's signs of pain to staff. During an interview on 11/19/24, at 12:45 P.M., the Director of Nursing (DON) said the resident has fractures in the shoulder and wrist. The resident was not supposed to have a sling on and it was not placed properly. She let the nurse know the resident was in pain and his/her edema was worse. The resident was supposed to get therapy to apply a lymphedema sleeve. Review of the resident's Orders Administration Note (Nursing Progress Note generated from the Medication Administration Record), dated 11/19/24, at 2:30 P.M., showed staff administered Tramadol 50 mg for pain (over one and half hours after pain was reported by the surveyor). Review of the Resident's Nurses Progress Notes, dated 11/19/24, at 7:10 P.M., showed staff documented unknown on the follow up pain assessment from the previous Tramadol administration on 11/19/24, at 2:30 P.M. Review of the resident's Orders Administration Note, dated 11/20/24, at 12:16 P.M., showed staff administered Tramadol 50 mg for pain. Review of the Resident's Nurses Progress Notes, dated 11/20/24, at 1:24 P.M., showed staff documented unknown on the follow up pain assessment from the previous Tramadol administration on 11/19/24, at 2:30 P.M. During an interview on 11/20/24, at 1:45 P.M., The DON said the following: -Staff are expected to treat the resident's pain and edema; -She was not sure why the resident had the sling on yesterday; -The resident has Tramadol and hydrocodone for pain control; -The resident's wrist fracture was a spiral shaped fracture and would not be repaired surgically; -The resident could answer yes and no questions, when the residents said numbers, the resident was expressing there was an issue; -The facility was supposed to be getting the resident a lymphedema sleeve and working with therapy. Observation on 11/25/24, at 10:45 A.M., showed the following: -The resident lay in his/her bed; -His/her right arm was positioned partially under his/her body; -The resident grabbed and pulled at his/her right arm, while wincing, moaning and saying 1, 2, 1, 2; -The resident's right arm and hand were swollen 4++, more swollen than the last observation on 11/19/24; -There was a distinct deep crease between the forearm and hand from the increased edema; -The surveyor reported to Licensed Practical Nurse (LPN) B. During an interview on 11/25/24, at 10:55 A.M., LPN B said the following: -Staff are expected to position the resident's arm on a pillow; -Staff are expected to ask the resident about pain every shift, the resident has had pain frequently since the fractures; -The resident can answer yes and no questions appropriately; -The resident has an order for Tramadol for pain and should receive the medication every six hours if he/she was in pain; -The Certified Medication Technicians (CMTs) ask resident's about pain and report pain to the nurse; -No one has reported the resident's pain today. During an interview on 11/25/24, at 11:25 P.M., CMT D said the following: -The resident had Tramadol for pain; -The Certified Nurse Assistants or the nurse tells him/her if a resident was in pain; -If a resident was in pain they try non medication methods to address pain and medication interventions to attempt to lessen a resident's pain; -Pain medication should be administered as soon as the staff are made aware of the pain; -Pain scores are documented as zero unless a resident complains of pain. They do not always ask the resident if they are in pain. During an interview on 11/25/24, at 12:22 P.M., the resident's durable power of attorney said the following: -The resident recently had fractures; -He/She expected staff to attempt to control the resident's pain. The resident had as needed PRN medication to administer. Staff should try to keep the resident's arm elevated on pillows; -The resident could not speak effectively to communicate so he/she expected staff to ask the resident yes or no questions to assess his/her pain every shift. Review of the resident's Medication Administration Record, on 11/25/24, at 3:00 P.M., showed no documentation staff administered pain medication to the resident following the observation on 11/24/24 at 10:45 A.M. Review of the resident's record showed there were no therapy orders since the fractures were found, and no orders for a lymphedema sleeve on the resident's physician orders sheet. 2. Review of Resident #36's care plan, revised 04/15/24, showed the following: -Resident is at risk for increased pain and discomfort related to related to diagnosis of chronic pain; - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; - Evaluate the effectiveness of pain interventions; -Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the resident's annual MDS, a federally mandated assessment completed by staff, dated 7/26/24, showed the following: -Cognitively intact; -Diagnosis included depression; -Minimal symptoms of depression; -No delusions, no hallucinations; -No behaviors, no rejection of care; -Dependent on staff for bed mobility, transfers with a mechanical lift, toilet use and bathing, manual wheelchair and dependent on staff for wheelchair mobility; -Schedule pain medication regimen, has received as needed pain medication, and non medication interventions for pain; -Pain present, frequently and rates his/her pain a 3 on a 1-10 scale; -Shortness of breath with exertion, and when lying flat. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Schedule pain medication regimen, has received as needed pain medication, and non medication interventions for pain; -Pain present, frequently and rates his/her pain a 3 on a 1-10 scale. Review of the resident's Physician's Order Sheet, dated November 2024, showed the following: -Gabapentin (medication for nerve pain) 600 mg four times a day; -Tylenol (pain medication) 650 mg every six hours as needed for discomfort; -Cyclobenzipine (medication for muscle spasms) 10 mg every eight hours as needed for muscle spasms; -Tramadol 50 mg every eight hours for pain as needed; -Baclofen 10 mg twice daily for pain; Review of the resident's MAR, dated 11/01/24-11/18/24, showed staff documented the resident's pain a 0 on every day and night shift. The resident has not received any PRN medications for pain. (Tylenol, Cyclobenzipine, or Tramadol). During an interview on 11/18/24, at 12:16 P.M., the resident said his/her pain is an eight or a nine all the time and he/she felt his/her pain was not controlled. The resident did not remember the last time he/she did not have pain. He/She has a lot of stomach and abdominal pain, and phantom pain from his/her leg amputations. The resident said staff do not ask him/her about his/her pain, but the pain was always there. The pain made it hard to sleep, or focus on what he/she was doing. 3. Review of Resident #'80's admission Minimum Data Set (MDS), a federally required assessment completed by staff, dated 03/09/24, showed the following: -Severe cognitive impairment; -Diagnosis include a stroke, blood clot, pneumonia, aphagia, malnutrition, depression, post traumatic stress disorder (PTSD); -Signs of minimal depression; -Unclear speech rarely/never understood; -Sometimes understands; -Functional range of motion limitations in both upper and both lower extremities; -Dependent all activities of daily living (ADLs); -Uses a wheelchair; -Always incontinent; -99 pounds; -No restorative nursing; -Scheduled pain regimen, unable to do pain interview, staff assessment not completed. Review of the resident's Care Plan, dated 06/04/24, did not include pain. Review of the resident's quarterly MDS, dated [DATE], showed the resident has scheduled pain medication. Review of the resident's quarterly MDS, dated [DATE] ,showed the resident has scheduled pain medication. Review of the resident's Care Plan, last updated 11/01/24, did not include pain. Review of the resident's Physician's Orders, dated November 2024, showed the following: -Tramadol 20 mg two times daily for pain; -Ropiniolol 0.25 mg two times a day for restless leg syndrome; -Acetaminophen 500 mg, give two tablets every six hours as needed for pain. Review of the resident's MAR, dated 11/01/24-11/09/24, showed the staff documented the resident's pain a 0 three shifts per day. Review of the resident's MAR, dated 11/10/23-11/18/24, showed the MAR changed to be a check off and no pain score values were documented. Review of the resident's MAR, dated 11/01/24-11/18/24, showed the staff did not administer the resident's Acetaminophen. Observation on 11/21/24, at 08:45 A.M., showed the following: -Certified Nurse Assistant (CNA) R and Nurse Assistant (NA) E provided care to the resident; -The resident had severe contractures of the right arm and leg; -The resident's body was not aligned, his/her back was curved, with the right leg and right arm drawn up; -When CNA R and NA E rolled the resident side to side the resident's body did not relax and it stayed in a drawn up/flexed position; -The resident grimaced, moaned in pain, and guarded his/her right leg grabbing his/her right leg with his/her left hand every time the staff moved him/her, and moving his/her arms to stop them from turning him in a guarding motion. During an interview on 11/21/24, at 8:55 A.M., CNA R said the resident was in pain because of his/her contractures. Once he/she was in a certain position he/she did not complain, but it hurt the resident every time they moved him/her. He/She was not sure what pain medication the resident was getting. During an interview on 11/25/24, at 11:25 P.M., CMT D said the following: -The resident had Tramadol for pain; -The CNA or the nurse tells him/her if a resident was in pain; -If residents are in pain, they use non medication methods and pain medication to attempt to lessen the resident's pain; -Pain medication should be administered as soon as the staff are made aware of the pain; -Pain scores are documented as zero unless a resident complains of pain. Staff do not always ask residents if they are in pain. During an interview on 11/25/24, at 10:55 A.M., LPN B said the following: -Staff are expected to reposition and try to make resident's experiencing pain comfortable; -Staff are expected to ask the resident about pain every shift; -The CMTs ask resident's about pain and report pain to the nurse; -Staff should attempt non medication and medication interventions for resident's experiencing pain; -If pain is not controlled staff after interventions are exhausted, staff are expected to notify the resident's physician. During an interview on 11/25/24, at 6:55 P.M., the DON said the following: -If a resident was in pain then staff are expected to administer as needed pain medications as soon as they are aware of the pain; -Staff are expected to assess a resident's pain every shift, not just assume if nothing is reported there was no pain. Staff are expected to ask or assess the resident for signs and symptoms of pain; -Uncontrolled pain was expected to be reported to the physician; -The facility reviews residents with increased pain during morning meetings, there was no pain care committee; -The charge nurse was responsible to ensure resident's pain was managed appropriately. MO245289

Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent injuries/accidents for four residents (Residents #6, #7, and #20). Resident #6 had a history of self harm and swallowing batteries. The facility failed to ensure the resident did not have accessibility to batteries. The resident swallowing four triple A batteries and required treatment at the hospital. The facility also failed to ensure staff transported Resident #7, #15 and #20 in their wheelchairs with foot rests, failed to ensure two residents (Residents #243 and #250) did not smoke near hazardous items, and failed to ensure chemicals were kept secured and not accessible to residents. The facility census was 87. During an interview on 11/25/24 at 2:46 P.M. the Administrator said the facility did not have a policy for protective oversight/preventing accidents/hazards, safety when propelling wheelchairs, safety when transporting residents in the facility van or storage of toxics. Record review of the facility's undated smoking policy showed the following: -The facility shall establish and maintain safe resident smoking practices; -Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas; -Metal containers, with self-closing cover devices, shall be available in smoking areas; -Ashtrays shall only be emptied into designated receptacles. 1. Review of Resident #6's progress notes, dated 7/28/24, showed the resident was at the nurse's station with four batteries and told staff he/she was depressed and wanted to swallow them but decided not to and to notify staff. Director of Nursing (DON) notified. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 9/4/24 showed the following: -Short and long term memory intact; -Moderately independent with with daily decisions, some difficulty in new situations only; -No behaviors impacting self or others; -Used a wheelchair or scooter; -Independent with locomotion on unit; -Supervision to touch assist with eating; -Received antipyschotic, antianxiety, antidepressants the last seven days of the look back period. Review of the resident's progress notes showed the following: -On 9/22/24 at 8:10 P.M., staff reported the resident swallowed four batteries. Resident on 1:1, 911 notified and resident sent per ambulance to the hospital; -On 9/23/24, call to hospital for update on resident who was admitted . Four non-eroded batteries were removed from the resident's stomach. Resident on 1:1, psychiatric evaluation in the morning. Review of the resident's care plan, last revised 9/25/24, showed the following: -Mood problem related to diagnosis of bipolar and depression; -History of self harm and swallowing batteries as a way of self harm; -Remove from situations as needed; -Behavioral health consults as needed. Review of a resident contract, dated 10/22/24, created by the facility and signed by the resident, showed the resident agreed to no longer cause harm to himself/herself by swallowing anything or trying to hurt himself/herself in any way. Review of the resident's Physician Order Sheet (POS), dated 11/2024, showed the following: -Diagnoses included post traumatic stress disorder (difficulty recovering after a traumatic event) (PTSD), bipolar disorder (high and low mood swings) and anxiety (worry and fear); -Allergies included lithium. Review of a standard progress note from the resident's Licensed Social Case Worker (LSCW), dated 11/12/24, showed the resident denied having any thoughts of suicide, but he/she did have thoughts of harming himself/herself after he/she had a flashback last Friday. Therapist informed staff the resident was having thoughts of hurting himself/herself. Review of the resident's progress notes showed the following: -On 11/19/24 at 9:00 P.M. (a late entry), the resident was at the nurse's station reporting to have ingested a foreign object. Order to send the resident to the hospital; -On 11/20/24 at 11:58 A.M., call from case manager who reported they were able to recover one battery. During an interview on 11/21/24 at 2:13 P.M., Certified Nurse Assistant (CNA) R said the following: -He/She was aware of the resident swallowing batteries in the past, but did not know the resident had swallowed them a second time; -He/She was not educated to search the resident's room for batteries; -He/She was not aware of any rules related to batteries such as counting or securing them. During an interview on 11/21/24 at 2:30 P.M., Licensed Practical Nurse (LPN) B said the following: -He/She did not know if the resident was allowed to have a remote control; -He/She was not aware of any routine room checks, daily, weekly or other to check for batteries; -He/She was not sure of any inservices related to the incident. During an interview on 11/21/24 at 3:00 P.M. Registered Nurse S said the following: -He/She knew the resident was 1:1 after the September incident ingesting batteries; -He/She had not been inserviced on anything related specifically to batteries; -Batteries were not to be laying out, they were locked and kept in the maintenance department. During an interview on 11/25/24 at 5:25 P.M the Director of Nurses (DON) said the following: -After the first incident in September the facility put the resident on 1:1, inserviced staff, updated the care plan, obtained the guardian's permission to search the resident's room, notified psych and consult completed, and started counseling services; -She had not conducted any investigation regarding the resident's latest incident. She had only talked with two licensed nurses; -They did not know where the resident got the batteries. During an interview on 11/26/24 at 11:35 A.M., the resident said the following; -He/She was depressed and wanted to kill himself/herself on the day he/she swallowed batteries (11/19/24); -He/She felt like he/she wanted to die because Thursday was the anniversary of him/her being sexually, mentally and physically abused; -He/She swallowed four triple A batteries while in his/her room before being sent to the hospital; -He/She obtained the batteries from his/her three remote controls (two for his/her television and one for his/her dvd player); -He/She had not told anyone he/she was going to swallow the batteries before he/she did it but did tell the nurse 30-45 minutes afterward; -The only time the facility had kept his/her remotes from him/her was when he/she was on 1:1 the last time he/she swallowed batteries. He/She has had his/her remotes (with batteries) in his/her room ever since. During an interview on 11/26/24 at 12:46 P.M. the Social Service Director said the following: -He/She became familiar with the resident in September when she took over this position; -She knew holidays and birthdays were triggers for the resident; -She was not instructed to look for remotes or batteries but did not see a remote in the resident's room; -When the resident was on 1:1 after the last incident the facility had his/her remote. 2. Review of Resident #3's quarterly MDS, dated [DATE] showed the following: -Moderately impaired cognition; -Used walker and wheelchair; -Independent with ambulation and transfers; -No falls since admission or prior assessment. Review of the resident's care plan, last revised 11/1/24 showed the following: -Diagnoses included seizures and muscle weakness; -At risk for and history of falls; -Used a wheelchair and rollator walker. Review of the resident's progress notes showed the following: -On 11/19/24 at 2:57 P.M. nurse received report from hospital as resident to return to the facility today; -On 11/19/24 at 6:34 P.M. showed the resident returned from the hospital via the facility transporter. During an interview on 11/21/24 at 11:50 A.M. the transporter said the following: -He/She had one resident (Resident #3), who liked to sit on his/her walker in the van during transport and he/she always transported the resident this way; -He/She would secure the walker to the floor of the van with (ratchet type) straps (which were bolted to the floor) to keep it from moving; -He/She had not secured a seatbelt around the resident as there was no way with a walker. 3. Review Resident #20's care plan, last revised 6/12/24 showed the following: -Impaired cognition and impaired thought processes related to Alzheimer's disease progression; -One to two staff assist with transfers; -History of falls, risk for falls; -Monitor placement of feet while assisting resident in wheelchair to reduce resident from planting her feet to stop the wheelchair suddenly causing the resident to propel forward to the floor. When staff is assisting resident in the wheelchair, staff should assist slowly and listen to the resident. If the resident says he/she needs to stop, staff need to stop to see what the resident is needing to reduce him/her from putting his/her feet down, causing him/her to fall forward. (2/22/23). Review of the resident's quarterly MDS dated [DATE], showed the following: -Moderately impaired cognition; -No behaviors or rejection of care; -Substantial to maximum assist for transfers; -Independent with locomotion in wheelchair on unit; -No falls since admission or prior assessment. Review of the resident's fall risk assessment, dated 10/23/24 showed the resident was a high risk (score of 30) for falls. Review of the resident's POS dated 11/2024 showed diagnoses included dementia (memory loss) and repeated falls. Observation on 11/18/24 at 1:45 P.M. showed LPN C pushed the resident in his/her wheelchair from the dining room to the resident's room without any foot rests on the wheelchair. The resident wore grippy socks and his/her feet drug the floor. The staff member did not encourage the resident to lift his/her feet. During an interview on 11/26/24 at 3:19 P.M. LPN C said staff should not push residents in their wheelchairs without foot rests. During an interview on 11/26/24 at 3:30 P.M. the Direct of of Nurses (DON) said the following: -Resident #6 should not have had remotes with batteries in his/her possession, she would have expected staff to monitor for this, staff met with the resident daily. She did not feel like the facility was able to provide protective oversight for the resident; -Staff should not push residents in wheelchair without foot rests as they could put their feet down and be thrown from the chair; -She would not expect staff to transport a resident, while the resident sat on the seat of their walker, in the facility van. Residents should sit in a seat with their seatbelt fastened. During an interview on 11/25/24 at 6:30 P.M. the Administrator said the following: -The first time Resident #6 swallowed batteries and returned from the hospital they put the resident 1:1 indefinitely and gave a 30 day discharge notice. As the weeks passed, the resident became better and they had him/her sign a behavior contract which said he/she would not self harm again. They slowly removed the 1:1, stopping the night 1:1 at first. The SSD was assigned to meet with the resident and he/she had a psych consult and started counseling; -The social service person met with the resident several times a week (but not daily) to check on him/her; -The facility could not provide inservice records related to the resident swallowing batteries in September as they did not have any records. 4. Observation on 11/18/24 at 3:28 P.M., in the courtyard outside the B and C halls, showed four unidentified residents and one staff member sat under the pavilion and smoked cigarettes. A barbecue grill with a connected propane tank that was located within one foot of two of the residents. Observation on 11/20/24 at 9:09 A.M., in the courtyard outside the B and C halls, showed the following: -Resident #243 sat alone under the pavilion and smoked a cigarette; -A barbecue grill with a connected propane tank was located within five feet of the resident; -A sign on the inside of the door to the courtyard read, Attention!!! No resident can be outside in the courtyard without staff being present with them, no exceptions!!! Observation on 11/20/24 at 10:18 A.M., in the courtyard outside the B and C halls, showed the following: -Resident #250 smoked a cigarette approximately three feet from the door; -Signs posted on the exterior walls near the door read, No Smoking; -Two oxygen cylinders sat in a holder, located on the interior side of the door, approximately 15 feet from where Resident #250 smoked a cigarette. During an interview on 11/20/24 at 12:38 P.M., the Maintenance Director said smoking should not occur around hazardous items such as propane or oxygen tanks. 5. Observations on 11/18/24 at 3:33 P.M. and on 11/20/24 at 9:09 A.M., in the courtyard outside the B and C halls, showed residents entered and exited the courtyard through a facility door. Residents routinely sat under the pavilion and smoked cigarettes. An unlocked shed, approximately 10-foot by 10-foot in size, was located near the pavilion in the courtyard and contained several bottles of nail polish remover. The label of one bottle read, Warning: harmful if ingested, keep out of reach of children. During an interview on 11/20/24 at 12:38 P.M., the Maintenance Director said items such as nail polish remover should be stored in a secure manner and inaccessible to residents. The facility's former activity director, who resigned over the weekend, was responsible for ensuring these items were stored securely. 38016 MO245438 MO245274

Based on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (which would disqualify an individual from working in the facility) for nine of ten newly hired employees reviewed. The facility census was 87. Review of the facility's policy, Abuse and Neglect, dated 12/28/23, showed the facility would not employ individuals who have been convicted of abusing, neglecting or mistreating individuals. Potential employees are screened for a history of abuse, neglect or mistreating a resident. 1. Review of the Maintenance Director's employee file showed the following: -Date of hire 01/05/24; -No documentation the facility completed a Nurse Aide Registry check. 2. Review of Certified Nurse Assistant (CNA) K's employee file showed the following: -Date of hire 10/23/24; -No documentation the facility completed a Nurse Aide Registry check. 3. Review of Certified Medication Technician (CMT) L's employee file showed the following: -Date of hire 11/6/24; -No documentation the facility completed a Nurse Aide Registry check. 4. Review of Registered Nurse (RN) M's employee file showed the following: -Date of hire 11/18/24; -No documentation the facility completed a Nurse Aide Registry check. 5. Review of Housekeeper N's employee file showed the following: Date of hire 10/23/24; -No documentation the facility completed a Nurse Aide Registry check. 6. Review of [NAME] O's employee file showed the following: -Date of hire 8/13/24; -No documentation the facility completed a Nurse Aide Registry check. 7. Review of the Business Office Manager's employee file showed the following: -Date of hire 11/27/23; -No documentation the facility completed a Nurse Aide Registry check. 8. Review of the Housekeeping Supervisor's employee file showed the following: -Date of hire 10/16/24; -No documentation the facility completed a Nurse Aide Registry check. 9. Review of Laundry aide P's employee file showed the following: -Date of hire 10/8/24; -No documentation the facility completed a Nurse Aide Registry check. During an interview on 11/20/24 at 3:40 P.M., Human Resources R said the following: -All new hires are checked through the Family Care Safety Registry (FCSR). If not registered she would register them and get a highway patrol criminal background check, employee disqualification list (EDL), and Sam.gov; -For CNA's she will check for active licensure through a public perform search (Trainer Meet Up) (TMU) (a public website to check the status of CNA and CMT certifications); -For licensed nurses she will check for active licenses through Nursys. -He/She was unaware that all employees should be checked against the Nurse Aide Registry. During an interview on 11/25/24 at 6:00 P.M., the Director of Nursing said she was not aware of the process of new hire checks or the Nurse Aide Registry checks. During an interview on 11/25/24 at 6:15 P.M., administrator 1 said the Nurse Aide Registry check should be completed on all newly hired nurse aides (NA) or CNAs.

Based on observation, interview and record review, the facility failed to ensure the walk-in cooler fan shrouds were free of a buildup of debris; failed to ensure a chest freezer was maintained to keep food items frozen solid; failed to ensure food items were labeled, dated, and closed/sealed; failed to ensure dishware was not stacked and stored wet; and failed to ensure the ice machine was free of a buildup of black debris. The facility census was 87. 1. Observation on 11/18/24 at 10:24 A.M. showed two blue fan shrouds inside the walk-in cooler in the kitchen had a moderate buildup of fuzzy debris. 2. Observation on 11/18/24 at 10:38 A.M. of the thermometer inside the chest freezer, located inside the hot water heater/storage room in the kitchen, showed the temperature inside the freezer was 8 degrees Fahrenheit (F). The freezer contained an unopened box of pie shells, an unopened box of breaded fish, containers of whipped topping and a cardboard box of cookie dough (individual cookies) The packages of whipped topping were soft and were not frozen solid, and the cookie dough was soft to touch and not frozen solid. 3. Observation on 11/18/24 at 10:44 A.M. in the food preparation area showed the following: -A 12-ounce plastic container of Italian seasoning sat on a shelf above the food preparation counter. The lid was not closed and was open to air; -A 28-ounce box of wheat cereal sat on a shelf above the food preparation counter. The pour spout was not closed and was open to air. Observation on 11/18/24 at 11:40 A.M., showed a clear plastic bottle sat on a shelf next to the microwave. The lid was missing and the bottle had plastic wrap covering the top. [NAME] debris was visible on the plastic wrap. The bottle was not labeled or dated. Observation on 11/19/24 at 8:20 A.M. showed an unsealed plastic bag of cheese puffs sat on a metal shelf next to the microwave. Observation and interview on 11/19/24 at 8:40 A.M. on A Hall inside room A-11, showed an open unsealed bag of pizza rolls in the freezer. The freezer was not equipped with a thermometer. Observation on 11/19/24 at 9:00 A.M. of the refrigerator in the clean utility room showed the following: -A thermometer inside displayed a temperature of +48 degrees F; -Four bowls of pureed PB&J were not dated; -One burrito or soft taco from a fast food restaurant was very hard and was not dated; -A large plastic zipper bag containing several peanut butter and jelly sandwiches was not dated; -The thermometer inside the freezer was broken and not functional; -There was no temperature log sheet available for monitoring the unit's refrigerator or freezer temperatures. 4. Observation on 11/18/24 at 10:47 A.M. showed a stack of ten large baking sheets sat on a storage shelf. Water droplets were visible in between the baking sheets when separated. Observation on 11/18/24 at 10:50 A.M. showed a stack of seven medium-sized steam table pans sat on a storage rack next to the handwashing sink. Water droplets were visible in between the pans when separated. Observation on 11/19/24 at 8:25 A.M. showed a stack of six steam table pans sat on the green storage rack next to the handwashing sink. Water droplets were visible in between the pans when separated. 5. Observation on 11/18/24 at 11:47 A.M. showed an ice machine located in the staff break room adjacent to the kitchen. The water filter, dated 6/21, located behind the ice machine, had a heavy buildup of white and tan crusty debris on the exterior and water line connection. A buildup of black-colored debris was located inside the ice machine on the white plastic piece over the accumulated ice below. 6. During an interview on 11/19/24 at 9:15 A.M., the Dietary Manager said the following: -The facility did not have a policy manual for the kitchen or dietary department; -She was unsure who was responsible for cleaning the fan shrouds in the walk-in cooler; -Food items should be labeled with an opened date and an end date; -Leftovers were good for seven days; -The food item name should be written on the dissolvable stickers; -Food items should be closed or sealed; -No one checked the temperatures of the refrigerator or freezer in the clean utility room; -She was unsure who was responsible for checking for labels and dates on food items in the clean utility room; -Dietary staff should date the snacks, and dietary cleaned out old snacks daily (i.e. sandwiches, etc.); -Refrigerator temperatures should be maintained between 30-40 degrees F; -Freezer temperatures should be maintained at least -10 degrees F or at least below zero; -She was unaware the chest freezer in the hot water heater storage room was reading +8 degrees F or that items inside were not frozen; -She was unaware the temperature inside refrigerator in the clean utility was running high. Dietary staff was not monitoring temperatures of this unit and this had been accidentally overlooked. She was unaware the thermometer in the freezer was broken; -Dishware should be inverted after washing to allow items to air dry before storage or stacking. Hard to dry items such as steam table pans and baking sheets should be stood up vertically to dry fully; -Dietary staff was not responsible for maintaining or cleaning the ice machine. Maintenance staff was responsible for these tasks. She was unsure who was responsible for changing the water filter. During an interview on 11/19/24 at 10:29 A.M., the Maintenance Supervisor said he was unsure who was responsible for changing the water filter on the ice machine. Dietary staff was responsible for cleaning the ice machine.

Based on observation, interview, and record review, the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 87. 1. Observation and review during the survey process from 11/18/24 through 11/21/24 and 11/25/24 showed the following: -No yearly staff education regarding care of residents with dementia; -No yearly staff education on abuse and neglect; -No yearly required training hours for certified nursing assistants; -No education calendar was completed; -No staff member was monitoring staff education hours; -Review of the staff training did not show required training was completed for all staff or nurse aides/certified nurse assistants; -The facility failed to ensure payroll based journal (PBJ) data was entered and submitted timely; -The facility failed to ensure dietary services were provided to meet residents individual requests on an ongoing basis; -The facility failed to ensure medication orders were followed through with; the facility had not ensured medication were available for administration as ordered; -The facility failed to ensure quality of care issues regarding management of foot care and services to prevent decline in mobility and range of motion were consistently provided; -The facility was not providing service to prevent resident's with contractures from getting worse; -The facility failed to keep a resident safe by not putting into place any interventions to keep the resident from obtaining/swallowing batteries; -The facility failed to provide adequate pain management to ensure residents were comfortable and free of pain; -The facility failed to provide protective oversight and to consistently provide safety measures to prevent injuries; -The facility failed to consistently provide assistance with activities of daily living to meet the needs of individual residents; -Facility staff failed to consistently follow infection control measures; -The facility failed to ensure reasonable accommodation of needs, preferences and choices of residents were met; -The facility failed to ensure Advance Beneficiary Notices (ABN) were completed and provided when needed and as required; -The facility failed to provide quarterly statements for the residents' trust account; -The facility failed to maintain accurate records for the residents' trust account; -The facility failed to ensure residents' funds were not misappropriated; -The facility failed to refund resident money on the accounts receivable report; -The facility failed to ensure residents fully understood what a binding arbitration agreement was; -The facility failed to keep the floors and walls in good repair and failed to maintain a homelike environment in the facility; -The facility failed to provided sufficient staffing to ensure residents needs were met; -The facility failed to provided oversight to ensure a notice of transfer to the hospital or bed hold policy was being provided to a resident and/or the resident representative; -The facility did not ensure staff completed required assessments timely and accurately; -The facility failed to ensure pharmacy reviews were received and followed up on; -The facility failed to ensure admission contracts were completed with one resident admission; -The facility failed to follow their legionella policy; -The facility failed to ensure there was a water management team; -The facility failed to monitor their water temperatures for legionella management; -The facility failed to screen residents for legionella as indicated; -The facility failed to ensure a process was in place to ensure pneumonia vaccines were offered and administered; -The facility failed to ensure a survey book was available for the resident's to review with recent statements of deficiencies that was up to date; -The facility failed to ensure the resident rights were posted on A hall; -The facility failed to ensure residents had dental, podiatry and vision appointments as ordered or requested; -The facility was not able to provide all requested policies. During an interview on 11/20/24 at 2:00 P.M., Administrator 1 said the facility did not have most of the policies requested by the survey staff. The facility had not completed the policies for the facility. The facility has had many changes in management, so the systems were not all in place to ensure everything was getting done.

Based on observation, interview, and record review, the facility failed to ensure Tuberculin Skin Tests (TST) were completed and documented in accordance with the requirements for Tuberculosis (TB) (infectious bacterial disease that affects the lungs) testing for long-term care employees for six employees, in a review of ten employees, when the facility did not ensure the first-step TST was read on or prior to the employee's start date (first date of compensation). The facility failed to develop and implement a Legionella (bacteria found in water which can cause Legionnaires' disease, a serious type of pneumonia caused by Legionella bacteria that infect the lungs after being inhaled from water or soil.) Prevention Program. The facility failed to ensure staff performed proper hand hygiene when providing incontinence care to one resident (Resident #67), in a review of 20 sampled residents, and failed to ensure all parts of the urinary catheter drainage system was maintained off the floor for one resident (Resident #74), who had a history of urinary tract infections. The facility census was 87. 1. Review of the facility policy, Tuberculosis Testing (New Hires), revised 11/25/24, showed the following: -Orientation training will consist of three days of training with Human Resources (HR) or (preorientation) training on-site; -Staff will not be allowed to have any contact with residents during the preorientation period. They will have to fully complete preorientation training first; -All staff will receive the first dose of TB solution (first-step TST) on the first day of preorientation training and will have that dose read on the third day of training. 2. Review of the Maintenance Director's employee file showed the following: -First-step TST was administered on 01/09/24; -First time card punch (first date of paid compensation) was on 01/10/24; -First-step TST was read on 01/11/24; 3. Review of Certified Medication Technician (CMT) L's employee file showed the following: -First-step TST was administered on 11/04/24; -First time card punch was on 11/04/24; -First-step TST was read on 11/07/24. 4. Review of Housekeeper N's employee file showed the following: -First-step TST was administered on 10/23/24; -First time card punch was on 10/23/24; -First-step TST was read on 10/25/24. 5. Review of [NAME] O's employee file showed the following: -First time card punch was on 08/07/24; -He/She had a negative chest x-ray completed on 08/16/24. 6. Review of Laundry Aide P's employee file showed the following: -First-step TST was administered on 10/09/24; -First time card punch was 10/09/24; -First-step TST was read on 10/11/24. 7. Review of Certified Nurse Assistant (CNA) H's employee file showed the following: -First-step TST was administered on 10/9/24; -First time card punch was 10/9/24; -First-step TST was read on 10/11/24. 8. During an interview on 11/20/24 at 3:40 P.M. and 12/05/24 at 3:47 P.M., Human Resources Staff R said the following: -Staff complete the first-step TST on the first day of orientation and read the results prior to the new employee's actual working day; -Staff get paid for preorientation; -She was unaware staff could not receive paid compensation until the first-step TST had been read. During an interview on 11/25/24 at 12:45 P.M., Administrator 1 said the following: -New employees start employment with Human Resource orientation for three days; -The first-step TST was administered on the first day of orientation; -The first-step TST was read on the third day of orientation. 9. Review of the undated facility policy, Water Management Program, showed it only addressed what to do in the event of an outbreak and no instruction regarding regular monitoring and maintenance. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 10. Review of the facility Water Management binder on 11/21/24, showed the following: -Legionnaire flushing log sheet was to be completed weekly; no evidence in the binder that this had ever been completed; -Temperature checks (no indication of hot or cold) were to be completed weekly on the 100 hall, 200 hall, 300 hall, 400 hall, dietary, laundry, beauty shop, 100 hall shower, 200 hall shower, whirlpool, lobby bathroom, 100 hall bathroom and 200 hall bathroom; no documentation of cold water temperature checks in these areas for October 2024 or November 2024. (Review showed no documentation staff checked the hot water temperature in the laundry, beauty shop, 100 hall shower, 200 hall shower, whirlpool, lobby bath, 100 hall bathroom or 200 hall bathroom for October 2024 or November 2024); -Mixer valve inspection was to be completed weekly. (Review showed no evidence this had ever been completed); -Legionella water management meeting form showed staff was to document the meeting time, location, topics discussed, include the water management team members present in attendance and documented notes. (Review showed no evidence in the binder that meetings had been held or that this form had ever been completed). The facility did not provide any documentation to show the water management team conducted a risk assessment annually and did not provide any documentation of a water flow diagram of the facility. Observation on 11/20/24 at 9:11 A.M. in the bathroom for rooms A3 and A5 on the A hall (100 hall), showed flecks of a dark material came out of a cold water faucet when it was turned on. During an interview on 11/21/24 at 10:50 A.M., the Maintenance Director said he checked the hot water temperatures for the past two months. He checked the water temperature in the kitchen, the dishwasher and random rooms on each hall daily. He did not document in which resident rooms he/she took the water temperatures. He never checked the cold water temperature in the building. There was no water management team at the facility, and there had been no water management team meetings since he had been employed at the facility. He knew there were bathtubs in the facility that were not in use, but he had never flushed any of the bathtubs. He should have had a water management book, but he did not. A member of the management team just brought a binder into the facility and gave it to the Administrator. He did not know if the facility had a water mixing valve and if there was one, he had never inspected it. He had never checked the water temperature in the laundry room. He has never checked the chlorine level of the water coming into the facility. He did not know were the water entered the building or how it flowed throughout the building. He had never checked the water faucets for sediment. During an interview on 11/21/24 at 5:06 P.M., the Infection Preventionist (IP) said she did not know if she was on the water management team. She had never been to a water management team meeting. To test a resident for Legionella, she would assess to see if a resident had a cough or respiratory symptoms, then Legionella would be checked by getting a chest x-ray. To test for Legionella had to do with the water and there would have to be a water test yearly. During an interview on 11/26/24 at 3:58 P.M., the Director of Nursing (DON) said there was no water management program being completed at the facility. During an interview on 11/21/24 at 4:30 P.M., Administrator 1 said someone from the corporate office put the water management binder in his office. Someone from their corporate office was supposed to provide training for the water management program. Currently, there was no water management program being completed at the facility. There had been no water management team meetings and he was responsible to make sure the facility was following a water management program. 11. Review of the facility policy, Hand Hygiene, dated 11/1/22, showed the following: -All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. -Employees will use waterless hand rub or soap and water to clean their hands: -Before having direct contact with residents; -Before donning gloves and after removing gloves; -After contact with a resident's intact skin; -After contact with a resident's non-intact skin, wound dressings, secretions, excretions, mucous membranes, if hands are not visibly soiled; -When moving from a contaminated body site to a clean body site during patient care; -When hands are visibly soiled. 12. Review of Resident #67's care plan, last updated 8/5/24, showed the following: -Check the resident for incontinence. Wash, rinse and dry the perineum; -One staff to assist with personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 10/3/24, showed the following: -Required substantial to maximum assist with bed mobility, personal hygiene and toileting; -Always incontinent of bladder and bowel. Observation on 11/20/24 at 6:27 A.M. showed the following: -The resident lay in his/her bed; -CNA T entered the room and without washing his/her hands, put on gloves, picked up the mat from on the floor and moved the bed away from the wall; -CNA T unfastened the urine soiled incontinence brief, rolled the resident to his/her right side, and cleaned the resident's buttocks and anal area with disposable wipes. He/She laid the soiled wipes directly on the resident's air mattress before moving them to a plastic bag. He/She tucked two urine soiled bath blankets under the resident. -Without removing the gloves he/she wore to provide incontinence care, CNA T placed a clean incontinence brief under the resident, removed the resident's soiled gown from the resident's arm and head, touched the resident's hip and legs to roll the resident to his/her left side, and secured the incontinence brief on the resident. During an interview on 12/6/24 at 1:49 P.M., CNA T said the following: -He/She should wash his/her hands upon entering the room, when he/she changed his/her gloves and upon exiting a resident's room; -He/She should change his/her gloves when they were soiled and after providing perineal care; -He/She should place used perineal wipes directly into a plastic bag and not on the resident's mattress. He/She should have disinfected the mattress after he/she placed the wipes on the resident's mattress. During an interview on 11/26/24 at 3:58 P.M., the DON said the following: -She expected staff to wash their hands upon entering the room, when their hands were soiled, when changing gloves and upon exiting the room; -Staff should change their gloves when they become soiled; -Staff should not touch clean surfaces with soiled gloves/hands; -Staff should not place soiled incontinence wipes on a resident's mattress, but should put the wipes in a bag. 13. Review of Resident #74's quarterly MDS, dated [DATE], showed the resident had a urinary catheter. Review of the resident's Physician's Orders, dated November 2024, showed the following: -Diagnoses included urinary tract infection. -The resident had a urinary catheter. Change monthly and PRN (as needed). Review of the resident's care plan, last revised 11/17/24, showed the following: -The resident had a urinary catheter; -The care plan did not address keeping the urinary drainage bag off the floor. Observation on 11/18/24 at 11:30 A.M., showed the resident lay on his/her back in the bed. The urinary drainage bag hung from the bed frame and touched the floor. Observation on 11/20/24 at 7:20 A.M., showed the resident lay on his/her back in the bed. The urinary drainage bag hung from the bed frame and touched the floor. During an interview on 12/4/24 at 3:30 P.M., CNA I said no part of a urinary drainage system should touch the floor. The bed should be raised high enough so the drainage bag did not touch the floor. During an interview on 11/26/24 at 3:58 P.M., the DON said no part of a urinary drainage system should touch the floor. 47008

Based on observation, interview and record review, the facility failed to ensure staff prepared and served the correct portion size of food items to residents with a physician's order for a pureed diet, failed to ensure staff prepared and served the correct portion size of food items to residents with a physician's order for a mechanical soft diet and failed to ensure staff prepared and served the correct food items to residents with a physician's order for a regular diet. The facility census was 87. 1. Review of the Diet Type Report, dated 11/18/24, showed two residents had a physician's order for a pureed diet. Review of the Diet Spreadsheet for lunch on 11/18/24 (Week 3, Day 16) showed residents on a pureed diet were to receive the following items: -Pureed smothered pork chop with gravy (#8 dip or 1/2 cup serving); -Pureed buttered cabbage (4-ounce or 1/2 cup serving); -Pureed buttered dinner roll (#20 dip or 3 and 1/5-tablespoon serving). Observation on 11/18/24 between 12:30 P.M. to 1:47 P.M. during the lunch meal service, showed staff served residents with a physician's order for a pureed diet, 3-ounces of pureed pork instead of 4-ounces and also served 3-ounces of pureed cabbage instead of 4-ounces as directed by the diet spreadsheet. Staff also did not prepare or serve pureed dinner rolls as directed by the diet spreadsheet. 2. Review of the Diet Type Report, dated 11/18/24, showed 15 residents had a physician's order for a mechanical soft diet. Review of the Diet Spreadsheet for lunch on 11/18/24 (Week 3, Day 16) showed residents on a mechanical soft diet were to receive the following items: -Ground smothered pork chop with gravy (#8 dip or 1/2 cup serving); -Potato salad (4-ounce or 1/2 cup serving); -Soft chopped buttered cabbage (4-ounce or 1/2 cup serving); -Soft dinner roll, one each. Observation on 11/18/24 between 12:30 P.M. to 1:47 P.M. during the lunch meal service, showed staff served residents with a physician's order for a mechanical soft diet, a 2-ounce serving of ground pork chop instead of 4-ounces, served large leaves of cabbage instead of chopped cabbage, and served mashed potatoes instead of potato salad. Staff did not prepare or serve soft dinner rolls as directed by the diet spreadsheet. 3. Review of the Diet Type Report, dated 11/18/24, showed 70 residents had a physician's order for a regular diet. Review of the Diet Spreadsheet for lunch on 11/18/24 (Week 3, Day 16) showed residents on a regular diet were to receive the following items: -Smothered pork chop (3-ounce serving); -Red skin potato salad (4-ounce or 1/2 cup serving); -Buttered cabbage (4-ounce or 1/2 cup serving); -Apple cobbler (#6 dip or 2/3 cup serving); -Dinner roll, one each. Observation on 11/18/24 between 12:30 P.M. to 1:47 P.M. during the lunch meal service, showed staff did not prepare or serve dinner rolls as directed by the diet spreadsheet. Observation on 11/18/24 at 1:49 P.M. of a surveyor requested sample test tray showed staff served no dinner roll. 4. During an interview on 11/18/24 at 10: 26 A.M. and on 11/19/24 at 9:30 A.M., the Dietary Manager said the following: -She had been the dietary manager since September 2024; -Staff should refer to the production sheet and spreadsheet when selecting serving utensils; -All food items listed for each diet should be prepared and served by staff according to the spreadsheet; -She met with the cook prior to each meal to ensure staff prepared all items listed on the menu.

Based on interview and record review, the facility failed to ensure four nurse aides (NA) (NA U, NA Q, NA V and NA W) completed a nurse aide training program within four months of their employment as an NA in the facility. The facility also failed to ensure 16 hours of instructional training covering communication, infection control, safety/emergency procedures, residents' rights and promoting independence before any resident interaction for one NA (NA F) in a sample of five NA employee files reviewed. The facility census was 87. Review of the facility's policy, Nurse Assistants/Certified Nurse Assistants, undated, showed the following: -This policy defines the qualifications, roles and restrictions for Nursing Assistant (NA) Students and Certified Nursing Assistants (CNA) at the facility; -It ensures compliance with Missouri Department of Health and Senior Services (DHSS), Centers for Medicare & Medicaid Services (CMS) and the Missouri Nursing Practice Act; -This policy applies to all Nursing Assistant Students, Certified Nursing Assistants, and supervisory staff: -Enrollment in a State-Approved Training Program: Be actively enrolled in a CNA training program approved by DHSS (Department of Health and Senior Services); -Complete at least 16 hours of instructional training coveting communication, infection control, safety/emergency procedures, residents' rights, and promoting independence before any resident interaction; -To qualify as a CNA, the individual must successfully complete: -75 hours of state-approved instructional training; -100 hours of supervised on-the-job training; -Pass the CNA certification exam administered by a DHSS-approved third-party test administrator. The policy did not define how long the NA had to complete the course, or what happened if staff did not complete the course. 1. Review of NA U's employee files showed the following: -His/Her employment as an NA started on 12/12/23 (approximately eleven months prior); -No documentation he/she had completed CNA training or had received a CNA certification. Review of the facility's staffing sheets showed the NA worked as a Nurse assistant on 11/24/24. 2. Review of NA Q's employee files showed the following: -His/Her employment as an NA started on 01/08/24 (approximately nine months and two weeks prior); -No documentation he/she had completed CNA training or had received a CNA certification. Review of the facility's staffing sheets showed the NA worked as a Nurse assistant on 11/24/24. 3. Review of NA V's employee files showed the following: -His/Her employment an an NA started on 04/04/24 (approximately seven months and three weeks); -No documentation he/she had completed CNA training or had received a CNA certification. Review of the staffing sheets for November 2024 showed the employee working on the locked unit or on the D hall with mentally ill residents. The employee file did not clearly define the title and qualified roles of the employee. 4. Review of NA W's employee files showed the following: -His/Her employment as an NA started on 06/24/24 (approximately five months prior); -No documentation he/she had completed CNA training or had received a CNA certification. Review of the staffing sheets for November 2024 showed the employee working on the locked unit or on the D hall with mentally ill residents. The employee file did not clearly define the title and qualified roles of the employee. 5. Review of NA F's employee, showed a hired date of 10/08/24. The employee file did not contain documentation of 16 hours of instructional training covering communication, infection control, safety/emergency procedures, residents' rights, or promoting independence before any resident interaction. Review of the facility staffing sheets showed NA F last worked as a Nurse Assistant, having contact with residents, on 11/21/24. NA F's punch details showed the employee worked seven other shifts in November 2024 as a nurse assistant. 6. During an interview on 4/16/24, at 10:21 A.M., the Director of Nursing said the following: -The facility had four nurse assistants; -The NAs completed CNA training classes online and the clinical hours in the building; -Registered Nurse (RN) A and human resources (HR) coordinated their training to ensure it was completed timely; -The last HR person was not tracking very well and the new HR person just started, so he/she probably did not know where the NAs were with their training. During an interview on 11/20/24 at 2:00 P.M., RN A said the following: -She provides NA training for the facility and worked part time doing education; -She confirmed all of the NAs' start dates; -NAs were expected to be certified within four months of their start date; -She worked part time and only worked to do the education; the HR person in the role before did not keep good records of the education; the new HR person has only been here a short time and did not know who the nurse aides were; -NA's are expected to complete 16 hours of instructional training coveting communication, infection control, safety/emergency procedures, residents' rights, and promoting independence before any resident interaction; -NA U was not employed by the facility from 08/29/24 to 10/07/24, so the facility thought that started his/her time over; -She was not sure if NA Q started as a nurse assistant or if he/she started as a hall monitor, so it wouldn't be as long as it looked but was not sure since NA Q was only listed as a NA; -NA V is now only doing hall monitor but is still listed in HR as a NA; -NA W was now only doing hall monitor but is still listed in HR as a NA; -She did not know how long NA V and NAW worked as a NA or if the facility was out of compliance with their time as a NA, the previous HR employee did not track well; -NA F did not do his/her 16 hours at the facility; he/she started at another facility and the facility did not obtain documentation of his/her 16 hours of training from the other facility. During an interview on 11/20/24 at 2:45 P.M., the HR coordinator said she had only been employed a week and did not know what a nurse assistant was. During an interview on 11/20/24 at 3:15 P.M., Administrator 1 said HR and RN A oversaw the NA certification process. There has been a change in HR staff, and the last HR did not track training well.

Based on observation, interview and record review, the facility failed to ensure resident rights were posted on the 100 hall. Residents on the 100 Hall resided on a locked, secured unit. The facility also failed to ensure resident rights were reviewed with residents at least annually. The facility census was 87. Review of the facility's undated policy, Admission Contract and Authorization for Treatment, showed the following: -The following is a statement of resident's rights under federal and state regulations; -The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibility during the stay in the facility; -Each resident admitted to the facility, or his/her guardian or legally qualified representative, shall be fully informed of his/her rights and responsibilities as a resident and of all facility rules governing resident conduct and responsibilities. These rights shall be reviewed annually with each resident, guardian, or legally qualified representative, either in a group session or individually; -Information regarding resident rights and facility rules shall be posted in a conspicuous location in the facility. 1. During the resident council meeting on 11/20/24 at 2:21 P.M., seven out of eight residents in attendance said staff do not verbally go over resident rights or review resident rights with them. None of the residents present at the resident council meeting resided on the A Hall. Review of the resident council meeting notes, dated 09/19/24 and 11/15/24 (the only notes provided by the facility), showed no documentation of any resident rights topic discussion. Observation of A Hall (100 hall,a locked, secured unit) on 11/20/24 at 9:15 A.M., 11/21/24 at 8:40 A.M. and 11/25/24 at 10:35 A.M., showed no resident rights posted in the unit. During a telephone interview on 11/26/24 at 2:08 P.M., the Social Services Director (SSD) said the previous Activity Director had conducted the resident council meetings. She had attended the resident council meetings in the past and had never witnessed staff discuss resident rights with the residents. During a telephone interview on 11/26/24 at 3:58 P.M. and 12/05/24 at 9:08 A.M., the Director of Nursing (DON) said the previous Activity Director was in charge of resident council meetings and she never reviewed resident rights with the residents. She would expect resident rights to be discussed during resident council meetings. Resident rights were supposed to be reviewed annualy with all residents and/or guardians. When the information was reviewed, a form was supposed to be signed and then scanned into the resident's chart. Currently resident rights were not being reviewed verbally by any staff member in the facility. During a telephone interview on 11/26/24 at 5:08 P.M., Administrator 1 said he expected the resident rights to be posted on the 100 hall, and he expected staff to discuss the resident rights during resident council meetings.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 87. Review of the facility maintained Resident Trust Bank Statements for the period 11/2023 through 10/2024, excluding 03/2024, showed an average monthly balance of $5,470.41. Review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 11/19/24, showed the facility held a balance of resident funds in the amount of $29,602.51. Review on 12/19/24 of the Department of Health and Senior Services approved bond list showed the facility had a $50,000 approved bond, making the bond insufficient by $2,500.00. During an interview on 11/25/24, at 5:40 P.M., Business Office Manager (BOM) #2 said she did not know the A/R amounts would increase the amount of the bond needed. She was new to this role and did not know about how all of it worked.

Based on observation, interview and record review, the facility failed to provide adequate means of dining furniture/equipment for three residents (Resident #10, #36, and #80) of 20 sampled residents, in order to allow the residents to reach their food and drinks. The residents use a reclining chair on wheels and cannot sit up to the table. The residents sat parallel to the table and had to twist to reach items or place their plates on their laps to try to feed themselves. The facility census was 87. Through an email correspondence on 12/09/24 at 9:57 A.M., the Director of Nursing (DON) replied the facility had no policy for choices/self determination. 38016 1. Review of Resident #36's care plan, revised 01/22/24, showed the resident needed supervision and touch assistance with eating. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/26/24, showed the following: -Cognitively intact; -No behaviors and did not reject care; -Dependent on staff for bed mobility, transfers with a mechanical lift, and dependent on staff for wheelchair mobility. Review of the resident's quarterly MDS, dated [DATE], showed the resident needed partial assistance with eating and was dependent on staff for upper body dressing. Observation on 11/18/24, at 12:21 P.M., showed the following: -The resident sat reclined in a geri-chair (reclining chair on wheels) at the dining room table; -The geri chair was positioned parallel to the dining room table; -The resident reached across his/her body and reached to access her meal; -The resident could not reach his/her water or dessert; -Observation showed the support in the center of the table would not allow the resident's geri-chair to roll up to and allow the resident to face the table. Observation on 11/25/24, at 6:05 P.M.-6:25 P.M., showed the following: -The resident sat reclined in a geri-chair positioned parallel to the dining room table; -Observation showed the support in the center of the table would not allow the resident's geri-chair to roll up to and allow the resident to face the table; -The resident was not close to the table and could only reach his/her plate which he/she pulled off the table and placed on his/her stomach; -The resident's divided plate rested on the resident's stomach. The resident attempted to hold the divided plate with one hand and feed himself/herself with the other hand. The resident's hands shook. The resident's silverware was wrapped on the table out of the resident's reach; -The resident attempted to scoop food with his/her hands, but his/her hands were shaking. -The resident could not reach his/her silverware which remained rolled in a napkin on the table; -The resident had small particles of food all over his/her face, stomach, and down the sides of his/her chair; -The resident attempted to feed himself/herself but was only able to get very little food to his/her mouth. An unidentified staff walked by the resident 6:07 P.M. and did not offer assistance; -At 6:22 P.M., the resident said, my food is all over me; -The resident took the cake from the plate and NA E put the plate on the table. -The resident could no longer reach his/her plate. During an interview on 11/25/24, at 6:23 P.M., the resident said most of the time he/she could not reach his/her food at mealtimes. 2. Review of Resident #80's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unclear speech; rarely/never understood; -Sometimes understands others; -Functional range of motion limitations in both upper and both lower extremities; -Dependent on staff for all activities of daily living (ADLs); -Used a wheelchair. Observation on 11/18/24, at 12:30 P.M., showed the following: -The resident sat reclined in his/her geri-chair in the dining room; -The resident's geri-chair was positioned parallel to the table; -Observation showed the support in the center of the table would not allow the resident's geri-chair to roll up to and allow the resident to face the table. -The resident's right arm showed contractures, the resident's left arm was parallel with the table and he/she could only reach items on the edge of the table; -The resident could not reach his/her drinks. Observation on 11/18/24, at 01:23 P.M., showed staff removed the resident from the dining room table. The resident did not consume the food on the side of the plate he/she could not reach which contained his/her potato and cabbage. The resident's coffee and juice were also out of the resident's reach and remained full when staff took the resident from the table. Observation on 11/21/24, at 8:38 A.M., showed the following: -The resident sat reclined in a geri-chair in the dining room; -Observation showed the support in the center of the table would not allow the resident's geri-chair to roll up to and allow the resident to face the table. -The resident's right arm showed contractures, the resident's left arm was parallel with the table and he/she could only reach items on the edge of the table; -The resident could not reach his/her drinks. Observation on 11/25/24, at 5:43 P.M., showed the following: -The resident sat reclined in a geri-chair in the dining room; -Observation showed the support in the center of the table would not allow the resident's geri-chair to roll up to and allow the resident to face the table. -The resident's right arm showed contractures, the resident's left arm was parallel with the table and he/she could only reach items on the edge of the table; -The resident could not reach his/her water, juice, or his/her nutritional shake. 3. Review of Resident #10's quarterly MDS, dated [DATE] showed the following: -Moderately impaired cognition; -Set up or clean up only for eating; -Dependent for transfers; -No ambulation; -Used a wheelchair; -No limitation in range of motion. Review of the resident's POS, dated 11/2024 showed the following: -Type II diabetes mellitus (uncontrolled blood glucose) and tremors (involuntary, quivering movements); -Consistent carbohydrate diet, regular texture. Review of the resident's care plan, last revised 11/8/24 showed the following: -Extensive assist with activities of daily living; -At nutritional risk related to use of mechanically altered diet; -Allow time to complete task and intervene as needed; -Provide assistance as needed; -Serve diet as ordered, encourage appropriate intake of foods and fluids. Observation on 11/18/24 at 1:00 P.M. showed the resident sat in a partially reclined broda chair (a specialized tilt in space chair) positioned parallel to the corner of a dining table. Observation on 11/20/24 at 1:35 P.M. showed the following: -The resident sat in a partially reclined broda chair which was positioned at the corner of a dining table in the main dining room; -The resident stretched to reach the dessert plate and then asked the surveyor to move his/her entree so that he/she could reach it; -The surveyor alerted staff to assist the resident to reach his/her plate of food; -The resident's broda chair was not positioned upright and was positioned to allow the resident to reach his/her food comfortably. He/She awkwardly reached for and scooped his/her food. During an interview on 11/25/24 at 10:33 A.M. the resident said it was hard for him/her to reach his/her food and feed him/herself when he/she was not sitting close to the table and positioned upright. During an interview on 11/25/24, at 6:30 P.M., Nurse Assistant (NA) E said he/she thought the staff put the geri-chairs sideways (parallel) to the table because the support in the center of the table would not allow the chairs go under the table allowing the residents to sit up to the table. During an interview on 11/26/24 at 3:58 P.M. the Director of Nurses said the following: -Residents should be positioned upright in their chairs when eating; -The broda chairs and wheelchairs should be in a full upright position; -If a chair could not be positioned under a table adequately, staff should supply an over-the-bed table; -Staff should assist the residents with eating as needed.

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for six residents (Resident #9, #27, #30, #69, #77 and #301). The facility census was 87. Record review of the facility maintained Accounts Receivable Aging Report, dated 11/19/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #9 $100.00 #27 $3,708.00 #30 $1,928.00 #69 $22,638.51 #77 $1,072.00 #301 $156.00 Total $29,602.51 During an interview on 11/25/24, at 5:40 P.M., Business Office Manager (BOM) #2 said she was not sure what the amounts on the A/R report were, she would have to check and get back to State Agency (SA) staff. The BOM did not provide any additional information on the details of the amounts shown as money the facility owed to the residents.

Based on interview and record review, the facility failed to give appropriate Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMS-10055) and the CMS Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing with all required information to three residents (Residents #245, #391, and #246), reviewed in a sample of three residents, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 87. Through an email correspondence on 12/09/24 at 9:57 A.M., the Director of Nursing (DON) replied the facility had no policy for ABN and NOMNC notices. The facility followed the regulatory guidelines related to these areas. 1. Review of Resident # 245's face sheet shows the resident has a durable power of attorney (DPOA) for health and financial decisions, and the resident admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/12/24, showed the resident was rarely or never understood and rarely or never understands. The resident was unable to complete the cognitive interview and the resident has severe cognitive impairment. Review of the resident's census showed he/she started on Medicare Part A services 04/05/24, and his/her last covered day determined by the facility showed 5/3/24 Review of the resident's ABN, showed Medicare part A may not cover services because the resident was not participating. Options 1, 2, 3 on the form were blank (Option 1: I want the services and to bill Medicare and I am responsible for payment if Medicare does not pay; Option 2: I want the services but do not bill Medicare, and I am responsible for payment; Option 3: I do not want the services, so there will be no services to pay). The notice was signed by the resident, not the resident's DPOA, and did not have the date the notice was signed (or the date the resident received the notice). Review of the resident's NOMNC, showed services would end on 5/3/24. The NOMNC did not contain the resident's name, the Quality Improvement Organization (QIO) number (the phone number to appeal the decision if the resident chose to) was not filled in, it said {insert QIO name and toll-free number of QIO}. The notice did not contain the date staff gave the NOMNC to the resident, or the date when the resident signed the NOMNC. 2. Review of Resident #391's face sheet, showed the resident had a DPOA for financial and health care decisions, and the resident admitted to the facility on [DATE]. Review of the resident's census showed he/she started on Medicare Part A services 09/23/24, and his/her last covered day determined by the facility showed 10/31/24. Review of the resident's ABN, showed Medicare Part A may not cover services because the resident was not participating and wants to be taken off therapy. Options 1, 2, 3 on the form were blank (Option 1: I want the services and to bill Medicare and I am responsible for payment if Medicare does not pay; Option 2: I want the services but do not bill Medicare, and I am responsible for payment; Option 3: I do not want the services, so there will be no services to pay). The notice was signed by the the resident's DPOA on the day services ended 10/31/24 (No prior notice of payer change). Review of the resident's NOMNC, showed services will end on 10/31/22 (incorrect year). The NOMNC did not contain the resident's name, the Quality Improvement Organization (QIO) number (the phone number to appeal the decision if the resident chose to) was not filled in, it said {insert QIO name and toll-free number of QIO}. The notice was signed by the DPOA on the date the services were discontinued (10/31/24) (Not in advance of payer change). 3. Review of Resident #246's face sheet showed the resident admitted to the facility on [DATE]. The resident was responsible for himself/herself. Review of the resident's census shows he/she started a Medicare Part A stay on 05/02/24, and his/her last covered Medicare Part A day was 07/02/24. The facility was unable to locate an ABN or NOMNC for the resident's Medicare Part A stay. 4. During an interview on 11/20/24, at 9:53 A.M., the Business Office Manager #2 said the following: -The ABN and NOMNC requested for Resident #246 were not found; -She was now responsible for giving the ABN and NOMNC notices when residents will be discharged from Medicare Part A; -She was not working at the facility when Resident #245's, and #246's notices were given; -With Resident #391, she had just started and used the forms the facility had, she did not realize the QIO number was not listed; -ABN and NOMNC notices should be given three days prior to discontinuing services if possible to allow notice for the resident/resident representative to know about payer changes; -She was just learning the process for the ABN and NOMNC notices; -If resident's were unable to understand or make decisions, their guardian or DPOA should be the ones to sign the notices.

Based on interview and record review, the facility failed to ensure resident money was free from misappropriation for ten residents (Resident #13, #25, #30, #31, #52, #67, #72, #85, #88 and #243) when Business Office Manager #1 removed and used resident funds in the amount of $6,117.21, for his/her personal use. The deficiency has the potential to affect any resident the facility managed funds for at the time of Business Office Manager #1's employment. The facility census was 87. Review of the facility policy Abuse and Neglect, dated 12/28/23, showed the following: -To outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. -To ensure immediate reporting all of abuse allegations to the Administrator of designee and the Director of Nursing or designee and outside persons or agencies. -To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -Misuse of funds/property: The misappropriation or conversion of a resident's funds or property for another person's benefit. This includes, but is not limited, to theft of money from bank accounts and theft of money from residents; -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to; -Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -The Facility will identify and correct by providing interventions in which misappropriation of resident property is more likely to occur; -The Facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the Administrator and the proper authorities. Review of the facility self report sent on 11/08/24, showed the following: -It was reported to the administrator that the resident trust for the facility had funds that were not accounted for after an audit was conducted; -On 08/21/24, a check for $4,007.00 from the resident trust account was cashed and on 08/23/24 another check for $2,110.21 was cashed and allegedly distributed to residents; -No receipts were made available proving residents received these funds; -Business Office Manager (BOM) #1 alleged that he/she gave out the funds but did not have residents sign receipts confirming that they were given the funds. -An investigation started and the following enacted: -BOM #1 was suspended pending investigation -Police Notified Report# 2024-22816 -Facility will reimburse funds and placed in residents' accounts. 1. Review of the facility reported investigation, showed a check by Business Office Manager (BOM) #1. Check #1269 was endorsed with Petty Cash Beloved. Check #1273 was endorsed by BOM #1. 2. The money was not accounted for in the resident trust account. When the facility interviewed BOM #1, he gave the facility a hand written accounting saying he gave the following residents the following amounts: -Resident #13, $27.00; -Resident #31, $20.00; -Resident #88, $30.00; -Resident #243, $50.00; -Resident #25, $50.00; -Resident #30, $600.00; -Resident #72, $50.00; -Resident #52, $3,000.00; -Resident #85, $50.00; -Resident #67, $30.00. 3. During an interview over the phone on 12/10/24, at 2:09 P.M., Resident #52 said BOM #1 never gave the resident $3,000.00. He/She had no money in the resident trust account. He/She has his/her own bank account and paid his/her own room and board and got his/her own cash if needed from his/her private bank account. He/She gives give the facility $3,000 for his/her room and board. 4. During a telephone interview on 12/10/24 at 2:12 P.M., Resident #13 said he/she did not remember receiving any cash in August 2024 from BOM #1. 5. During a telephone interview on 12/10/24 at 2:14 P.M., Resident #72 said he/she was not sure if he/she received $50 from BOM #1 in August 2024. 6. During a telephone interview on 12/10/24 at 2:15 P.M., Resident #85 said he/she did not receive $50 from BOM #1 in August 2024. He/She did not start getting his/her money until November 2024. 7. During a telephone interview on 12/10/24 at 2:18 P.M., Resident #31 said he/she was not sure if he/she received $27 from BOM #1 in August 2024. 8. During a telephone interview on 12/10/24 at 2:14 P.M., Resident #67 said he/she did not recall receiving $30 from BOM I in August 2024. 9. Review of BOM #2's written statement, dated 11/21/24, showed the following: -After closing the resident trust in November, this writer began auditing resident trust for the month of August due to amount of turnover during the month; -During auditing this writer found two checks that had no receipts to verify that funds were given to residents; -Reported finding to ADM #1; -ADM #1 and BOM #2 interviewed BOM #1. He/She said he/she was making corrections but was unable to explain the transaction; -BOM #1 told BOM #2 and ADM #1 that he gave the residents cash in an effort to balance the resident trust; -BOM #1 was unable to provide any documentation or receipts to corroborate his/her claim; -Resident #52 said BOM #1 never gave him/her any cash, and he/she did not have any funds in the resident trust account; -BOM #1 was terminated. 10. Review of the Administrator (ADM) #1's written statement, dated 11/21/24, showed the following: -It was reported by BOM #2 there was a discrepancy in the resident trust and that it appeared funds were given out but there were no receipts to back up or verify the transactions; -We they approached BOM #1 about these transactions, he/she could not give an explanation, but said the funds were given to the residents in an attempt to balance the resident trust; -ADM #1 and BOM #2 interviewed Resident #52 who said he/she did not receive $3000 from BOM #1; -BOM #1 was terminated. 11. During an interview on 11/25/24, at 5:40 P.M., BOM #2 said the following: -She has not been able to verify the resident's balances related to money missing found during her audit; -She does not know if the resident's balances are correct at this time; -When she started at the facility she discovered in August the balance in the resident trust dropped. Upon investigation she found two large checks with corrections in the memo. Upon her investigation and review there were no signed receipts where the residents received the funds; -The investigation for resident funds showed BOM #1 wrote checks for $4007 and a check for $2110.21 with corrections in the memo; -The $6117.21 amount was not accounted for, the facility was still in the process of auditing and was not sure if there was more money that is not accounted for or not, and do not know the exact resident balances; -BOM #1 was terminated, and the facility reported the findings to the state agency and law enforcement; -During BOM #2's investigation, BOM #1 hand wrote he had given some residents cash. BOM #1 said he gave one of those residents, Resident #52, $3000. When she interviewed Resident #52, he/she said he/she has never had money in the resident fund account, he/she has his/her own bank account; -Resident #52 told BOM #2, BOM #1 never gave the resident any money. During an interview on 11/21/24, at 10:45 A.M., ADM #1 said he terminated BOM #1 because he wrote checks from the resident trust account and BOM #1 could give no explanation where the funds were. MO245046 49528

Based on observation and interview, the facility failed to ensure the facility was clean and the ceilings and walls were in good repair. The facility failed to ensure the facility was free of persistent strong urine odors and failed to ensure bathroom vents were free from a heavy accumulation of dust and debris. The facility census was 87. Review of the facility policy, Safe/Clean/Comfortable/Homelike Environment, dated 11/1/22, showed the following: -The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely; -The facility must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belongings to the extent possible; -Housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. 1. Observation on 11/18/24 at 1:47 P.M., showed the ceiling in occupied resident room [ROOM NUMBER] had an area measuring approximately 2.5 feet by 2.5 feet, which had areas of peeling paint and was discolored light brown. Observation on 11/18/24 at 2:18 P.M., showed the ceiling in occupied resident room [ROOM NUMBER] had an area measuring approximately 1.5 feet by 2 feet, which had areas of paint that had blistered from the surface of the ceiling and was discolored light brown. Observation on 11/18/24 at 3:08 P.M., showed the ceiling in occupied resident room [ROOM NUMBER] had an area measuring approximately 2 feet by 1 foot, which had areas of blistered paint and was discolored light brown. Observation on 11/18/24 at 3:20 P.M., showed the ceiling in occupied resident room [ROOM NUMBER] had an area measuring approximately 4 feet by 2 feet, which had areas of the ceiling that were discolored light brown. Observation on 11/21/24, at 09:12 A.M., showed occupied room [ROOM NUMBER] with a rectangle shaped hole in the wall where staff accessed plumbing, and a large area on the wall painted with irregular edges a different color than the rest of the wall. During an interview on 11/21/24 at 8:34 A.M., the Maintenance Director said the following: -He had an app on his phone where employees could put in work order requests if there was an item that maintenance needed to address; -He did not have a list of needed repairs; he kept a list of the needed repairs in his head; -He currently only had one outstanding job to be completed (an outlet in a resident's room that needed to be repaired); -He did not have any work orders for the 100 hallway; -He did ongoing maintenance in the building when he had time. During an telephone interview on 11/26/24 at 3:58 P.M., the Director of Nursing (DON) said she did not know the ceilings on 100 hall were in disrepair. She expected any repairs needed for the ceilings on the 100 hall to be completed. During an interview on 11/26/24 at 5:13 P.M., Administrator 1 said he expected the Maintenance Director to keep a log of all of the repairs needed in the facility. He expected staff to have repaired the ceilings on the 100 hall. 2. Observation on 11/18/24, at 10:00 A.M., showed a very strong urine odor permeated throughout the dining room. Observation on 11/18/24, at 10:20 A.M., showed a strong urine odor on the B hall. The odor was strongest at the beginning of the hall and around room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 11/19/24, at 9:30 A.M., showed a strong urine odor in the dining room and on the B hall. Observation on 11/19/24, at 11:45 A.M., showed a strong urine odor in occupied room [ROOM NUMBER]. During an interview on 11/19/24, at 11:45 A.M., Resident #44 said the following: -The dining room and the B hall always smells like urine; -They do not take resident's to the bathroom often enough, -They will get his/her roommate up in the morning and it might be 4-6 hours before they toilet him/her and he/she would be saturated; -Their room often smelled like urine because his/her roommate cannot communicate when he/she needs to be changed and the staff do not check on him/her often enough. Observation on 11/25/24, at 10:23 A.M., showed a strong urine odor in the dining room. During an interview on 11/25/24, at 6:10 P.M., Resident #36 said it always smells like pee, he/she was not sure why. During an interview on 11/25/24, at 6:30 P.M., Certified Nurse Aide (CNA) R said the following: -He/She has noticed the urine smell in the dining room and on B and C halls; -He/She felt like resident wheelchairs were not cleaned well after residents were incontinent. Some resident urinate their clothing. The dirty utility room on the B hall can have a strong urine odor due to saturated linens; -He/She did not know of anyone addressing the urine odors at this time. 3. Observations on 11/18/24 from 9:45 A.M. to 3:40 P.M., during the life safety code tour of the facility, showed the following: -The bathroom vent in room A3 had a heavy accumulation of dust; -The bathroom vent in room A4 had a heavy accumulation of dust; -The bathroom vent in room A7 had a heavy accumulation of dust; -An 8-inch by 8-inch vent in the B hall shower room had a moderate accumulation of dust; -The bathroom vent in room B8 had a heavy accumulation of dust; -The bathroom vent in room B12 had a moderate accumulation of dust; -The bathroom vent in room C5 had a moderate accumulation of dust; -The bathroom vent in room C8 had a heavy accumulation of dust; -The bathroom vent in room C12 had a heavy accumulation of dust; -The bathroom vent in room D1 had a heavy accumulation of dust; -The bathroom vent in room D2 had a moderate accumulation of dust; -The bathroom vent in room D5 had a heavy accumulation of dust; -The bathroom vent in room D8 had a moderate accumulation of dust; -The vent in the restroom near the staff time clock and locker area had a heavy accumulation of dust; -An 18-inch by 18-inch vent in the staff breakroom had a moderate accumulation of dust. During an interview on 11/20/24 at 12:38 P.M., the Maintenance Director said he deep cleaned the vents monthly and dusted them off weekly but hadn't had a chance to clean or dust them lately. The staff who cleaned resident rooms were also supposed to help with cleaning the vents but that didn't always happen. 47008

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for four sampled residents (Residents #30, #80, #19 and #65), in a review of 20 sampled residents. The facility census was 87. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. -The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts; -It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. -Physical Restraints: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP); -Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block three-quarters to the whole length of the mattress from top to bottom, etc.). -Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition. 1. Review of Resident #30's annual Minimum Data Set (MDS), a federally required assessment instrument completed by staff, dated 06/01/24, showed the following: -Cognition section, interview not completed because the resident was rarely understood or understands; -Staff assessment of cognitive section documented the resident was independent with decision making and consistent/reasonable; -Section A communication section documented the resident was always understood and always understands; -Section D marked interview should not be completed because the resident was rarely understood or understands; -The resident's MDS showed inconsistencies and failed to include required interviews with the resident. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition section, interview not completed because the resident was rarely understood or understands; -Staff assessment of cognitive section documented the resident was independent with decision making and consistent/reasonable. -Section A communication section documented the resident was always understood and always understands; -Section D marked interview should not be completed because the resident was rarely understood or understands; -The resident's MDS showed inconsistencies and failed to include required interviews with the resident. During an interview on 11/18/24 at 1:14 P.M., the resident was able to have a conversation about his/her preferences and spoke to the surveyor staff easily about recent and appropriate topics. The resident easily completed an interview. 2. Review of Resident #80's medical record showed a Preadmission Screening and Resident Review (PASARR - an assessment completed on resident's with mental illness to ensure needs are met by the facility), dated 12/05/23. Review of the medical record showed the document was scanned into the resident electronic medical record with his/her admission paperwork and labeled appropriately. Review of the resident's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's entry MDS, showed the resident admitted to the facility on [DATE]. Review of the resident's discharge return anticipated MDS, dated [DATE], showed the resident transferred to the hospital. Review of the resident's entry MDS, showed the resident admitted to the facility on [DATE]. Review of the resident's admission MDS, dated [DATE], showed the following -Severe cognitive impairment; -Diagnoses included stroke, deep vein thrombosis (blood clot), pneumonia, aphagia (inability to speak), malnutrition, depression and post traumatic stress disorder (PTSD); -Inattention; -No PASARR. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses of stroke, deep vein thrombosis, pneumonia, aphagia, malnutrition, depression and PTSD; -Inattention; -No PASARR. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses of stroke, deep vein thrombosis, pneumonia, aphagia, malnutrition, depression and PTSD; -Inattention; -No PASARR. Review of the resident's medical record showed no documentation of the resident being sent out to the hospital or need for a re-admission between 02/02/24 and 03/09/24. (The resident did not require an admission assessment on 02/12/24 or 03/09/24 and a PASARR had been completed). 3. Review of Resident #19's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included hemiplegia (paralysis on one side of the body), total brain injury (TBI), seizure disorder, aphasia (inability to speak effectively); -Rarely/Never understood or understands; -No behaviors or rejection of care; -Limited functional range of motion in one upper and one lower extremity; -Uses wheelchair; -Requires substantial/maximal assistance from staff to roll left and right, sit to lying and lying to sitting on side of bed; -Dependent on staff for oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer and tub/shower transfer; -Bedrail coded as restraint. Observation on 11/19/24 at 12:25 P.M., showed the resident in his/her wheelchair, the resident was not able to move his/her right side and sat on a mechanical lift pad. The resident was not able to make significant body changes. Observation on 11/25/24 at 10:45 A.M., showed the following: -The resident was in bed; -The resident had 1/2 padded side rails on both upper sides of his/her bed in the upright position. During an interview on 11/25/24 at 10:55 A.M., Licensed Practical Nurse (LPN) B said the following: -The resident was unable to make significant position changes on his/her own; -Staff use a mechanical lift to transfer the resident; -The resident's bed rail was not considered a restraint because it did not prevent the resident from doing anything. The resident was marked as having a restraint, and the resident was not restrained. 4. Review of Resident #65's undated face sheet showed the following: -admitted on [DATE]; -His/Her diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the resident's admission orders dated 09/01/22 showed the resident had diagnoses of Covid 19, weakness, falls, depression, tremor and nicotine dependence. Review of the resident's May 2023 Physician Order Sheets (POS), showed the resident had diagnoses that included atherosclerotic heart disease coronary artery disease (CAD) (coronary arteries struggle to supply the heart with blood due to plaque buildup, narrowing the arteries). Review of the resident's quarterly MDS, dated [DATE], showed the resident had diagnoses that included CAD, hip fracture, depression and respiratory failure. The resident's MDS did not accurately reflect the resident's diagnoses as it did not include the diagnosis of Parkinson's Disease. Review of the resident's June 2024 physician order sheets (POS) showed no order for antipsychotic medication. Review of the resident's June 2024 medication administration record (MAR) showed no documentation staff administered antipsychotic medication to the resident. Review of the resident's physician's annual wellness progress note, dated 06/05/24 showed no documentation of the resident taking an antipsychotic medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included CAD, hip fracture, depression and respiratory failure; the resident's MDS did not accurately reflect the resident's diagnoses as it did not include Parkinson's Disease; -Antipsychotic medication review under section N medications was marked that antipsychotics were received on a routine basis; the resident's MDS did not accurately reflect the resident's medication use as the resident did not receive antipsychotics. Review of the resident's September 2024 POS showed no order for antipsychotic medication. Review of the resident's September 2024 MAR showed no documentation staff administered antipsychotic medication to the resident. Review of the resident's physician's progress note, dated 09/03/24 showed no documentation of the resident taking an antipsychotic medication. Review of the resident's annual MDS, dated [DATE] showed the following: -Diagnoses included CAD, hip fracture, depression, respiratory failure and gastroesophageal reflux disease (GERD) (digestive disease in which stomach acid or bile irritates the food pipe lining); no diagnoses of Parkinson's disease; the resident's annual MDS did not accurately reflect the resident's diagnoses; -Antipsychotic medication review under section N medications, was marked that antipsychotics were received on a routine basis; the resident's MDS did not accurately reflect the resident's medication use as the resident did not receive antipsychotics. During an interview on 12/09/24 at 8:15 A.M., the MDS coordinator, said the following: -She obtained diagnoses from the electronic medical record-medical diagnosis section, physicians history and physical, or hospital records; -She was unaware the diagnoses for Resident # 65 were not always correct; -Section N antipsychotic medication review information was obtained from the physicians orders for Resident #65; -She was unable to provide an explanation why the antipsychotic medication review was not correct on the MDS for Resident #65. During an interview on 11/26/24 at 3:58 P.M., the Director of Nursing (DON), said the following: -The MDS coordinator completes the assessments offsite; the assessment process does not include direct observation of the resident by the MDS Coordinator; -She expected the MDS's to be coded accurately according to the RAI manual. 47008 49528

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 account and by not reconciling each month. The facility also failed to provide quarterly statements to the residents. The facility managed funds for 27 residents. The facility census was 87. 1. Record review of the facility maintained attempted reconciliation forms, for the period 11/01/23 - 10/31/24, excluding 03/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. 2. During an interview on 11/25/24, at 5:40 P.M., Business Office Manager (BOM) #2 said she did not find any reconciliations of the resident trust account from the previous BOM so there wass only September 2024 and October 2024 reconciliations to review. 3. Record review on 11/21/24 of the facility maintained quarterly statements showed no quarterly statements were given to the resident/financial guardian. 4. During an interview on 11/25/24, at 5:40 P.M., the Business Office Manager (BOM) #2 said the following: -She could not find any evidence quarterly statements were given to the residents; -She had not been able to provide quarterly statements because she was unable to verify the residents' balances related to money missing found during her audit; -She did not know if the residents' balances were correct at this time.

Based on interview, and record review, the facility failed to safely transfer one resident (Resident #14), who had a diagnosis of right dominant hemiparesis (weakness or paralysis of one side of the body), in a review of 17 sampled residents. Facility staff failed to utilize a gait belt appropriately and grabbed the resident under the arms which resulted in a displaced right proximal humeral fracture (a break in the upper arm bone where the bone fragments have shifted out of position). The facility census was 98. On 9/10/24 at 12:02 P.M., the administrator was notified of the past noncompliance which occurred on 8/9/24. Upon discovery of the injury, the facility completed an investigation, notified appropriate parties, and interviewed staff. The facility staff were educated on the facility policy on transfers and mechanical lifts. Staff were also required to complete return demonstration of transfers. The deficiency was corrected on 8/22/24. Review of the facility policy, Transfers and Lifts, dated 11/30/22, showed the following: -The facility will ensure that all staff members are instructed in safe transfer and lifting techniques and how to report suspected injuries; -The resident's care plan should be very explicit on exactly how the resident is to be transferred and lifted. If you think changes need to be made to the way the resident is lifted, discuss this with the charge nurse; -Know the resident's weight bearing status and balance problems; -Always transfer to the resident's strongest side; -Know the resident's ability to understand and assist; -Gait belts are a canvas belt without handles. Fasten it securely around the resident's waist, grip the belt when moving the resident. 1. Review of Resident #14's Care Plan, revised 10/26/23, showed the following: -Activities of daily living (ADL) self-care performance deficit related to right dominant hemiparesis, brain injury, aphasia (a language disorder that affects the ability to communicate), and seizure disorder; -The resident was able to bear weight, pivot transfer with one to two staff members, required extensive assistance from staff with the use of a gait belt. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 7/9/24, showed the following: -Adequate hearing; -Rarely or never understood by others; -Rarely or never understood others; -Unclear speech, slurred, or mumbled words; -Short and long-term memory problems; -Limited range of motion on one side to both upper and lower body; -Dependent on staff to come to a standing position and to transfer to and from bed to a chair or wheelchair; -Wheelchair used for mobility; -No symptoms of pain; -No falls since prior assessment. Review of the resident's nursing note, dated 8/9/24 at 4:20 P.M., showed staff was approached by the resident at the nurse's station. The resident was having right sided pain and left leg pain. Tylenol (analgesic used to treat aches and pains) was administered at 3:45 P.M., voicemail left for the physician awaiting to hear back. Review of the resident's nursing note, dated 8/9/24 at 4:40 P.M., notified the family member of the resident's right inner arm ecchymosis (bruising) and left leg pain. The family member said that was baseline for the resident. The family member did not want to send the resident out or have any x-rays (a photographic or digital image) at this time. Review of the resident's mobile radiology report of the chest, dated 8/9/24 at 6:50 P.M., showed the following: -Reason for exam: Right sided chest pain: -Findings showed no acute (severe or sudden onset) cardiopulmonary (related to heart and the lungs) findings. Right proximal humerus fracture favored to be chronic (something that continues over an extended period of time). Review of the resident's nursing note, dated 8/10/24 at 4:56 P.M., showed the resident's family member was at the facility and was concerned with edema (swelling) in the resident's right arm. The resident's right arm was swollen considerably more that the left arm. Called the physician's office per family member's request. The family wanted the resident to be sent out to the hospital. The physician agreed to send the resident out with concern of a blood clot. Review of the resident's hospital radiology report, dated 8/10/24 at 6:42 P.M., showed displaced right proximal humerus fracture. Review of the hospital discharge note, dated 8/10/24, showed the following: -Discharge diagnosis showed humeral fracture; -Take Norco (hydrocodone/acetaminophen, pain medication used to treat moderate to severe pain) as prescribed and wear arm sling as directed. Review of the resident's nursing note dated, 8/10/24 at 11:00 P.M., showed the resident returned to the facility at 10:15 P.M., family member with the resident. The discharge diagnosis was humeral fracture, sling in place to right upper extremity. Received a new prescription for Norco 5/325 milligrams (mg) as needed every six hours for pain. The Director of Nursing (DON) was notified of the diagnosis. The family said the resident received morphine (long-term opioid used to treat severe pain) in the emergency room for pain. Review of the resident's care plan, revised on 8/26/24, showed on 8/10/24 the resident returned from the emergency room with diagnosis of a humeral fracture (break of the upper arm bone), sling in place to right upper extremity and a new prescription for Norco 5/325 mg as needed every six hours for pain. Review of the resident's medication administration record ( MAR) on 8/11/24 showed staff administered hydrocodone/acetaminophen 5/325 mg at 11:00 P.M. for a pain level of five out of ten (ten being the highest level of pain). Review of the resident's MAR on 8/12/24 showed staff administered hydrocodone/acetaminophen 5/325 mg at 1:27 P.M. for a pain level of two. Review of the resident's MAR on 8/14/24 showed staff administered hydrocodone/acetaminophen 5/325 mg at 2:23 P.M. for a pain level of three. Review of the resident's August 2024 physician order sheets (POS) showed Hoyer lift (an assistive device used to transfer patients from one place to another) for transfers and hydrocodone/acetaminophen 5/325 mg one tablet at bedtime for pain (order date 8/16/24). Review of the resident's MAR showed staff administered hydrocodone/acetaminophen 5/325 mg on 8/18/24 at 5:50 P.M. for a pain level of one. Review of the resident's MAR showed staff administered hydrocodone/acetaminophen 5/325 mg on 8/19/24 at 12:28 P.M. for a pain level of seven. During an interview and observation on 9/5/24 at 9:55 A.M. the resident was questioned if he/she was in pain, the resident nodded his/her head and patted his/her right side. During an interview on 9/5/24 at 1:15 P.M. the resident's family member said the following: -He/She visited the resident routinely; -He/she had observed staff transfer the resident frequently. The staff at the facility did not use gait belts when they transferred the resident, they grabbed the resident under the arms; -On 8/9/24, Licensed Practical Nurse (LPN) E notified him/her the resident was complaining of rib cage pain and there was a bruise on the resident's arm. LPN E notified the physician and obtained an order for an x-ray to be done at the facility; -On 8/10/24, he/she went to visit the resident. The resident was in excruciating pain and his/her right shoulder was reddened and swollen down to his/her elbow; -He/She told staff to send the resident to the hospital; -The resident was diagnosed with an upper arm fracture. During an interview on 9/5/24 at 2:36 P.M. and 9/10/24 at 9:20 A.M. Certified Nurse Assistant (CNA) B said the following: -The last few months the resident couldn't stand like he/she used to, and it had been harder to transfer the resident. CNA B had reported concerns to the charge nurse, but could not recall who the nurse was; -On 8/9/24 and 8/10/24, CNA F assisted CNA B with the resident's transfer from bed to the wheelchair, as they were assigned the resident's hall. A gait belt was used, but it slid up under the resident's arms. CNA B grabbed the resident under the arms (arm pit) with one hand and grabbed a hold of the gait belt with the other hand, CNA F did the same on the opposite side; -CNA B always grabbed the resident under the arms when he/she transferred him/her, that was how all the aides transferred the resident; -On 8/9/24, the resident complained of pain in his/her right side approximately 30 minutes after the transfer. During an interview on 9/10/24 at 9:30 A.M. CNA F said the following: -The resident recently, in the past few months, had been more difficult to transfer with two staff members; -The resident really couldn't stand up, and could not bear weight. A gait belt was used, but staff also grabbed the resident under the arms; -On 8/9/24 or 8/10/24 the resident complained of pain in his/her chest and right arm after staff transferred him/her to the wheelchair. During an interview on 9/11/24 at 9:50 A.M. LPN E said the following: -On 8/9/24 the resident complained of right arm and right-sided pain. The resident had bruising noted to the right inner arm; -He/She notified the resident's family member and the family member preferred the resident have an x-ray at the facility instead of at the hospital; -The resident had a mobile chest x-ray, and it did not show a new fracture. The DON questioned staff on how they transferred the resident that morning as this was a new issue; -On 8/10/24, the resident's family came to visit and the family member reported swelling and redness in the resident's arm; -On 8/10//24, LPN E assessed the resident and he/she had significant swelling and redness to the arm. The resident winced when LPN E touched the resident's arm. The resident was in severe pain; -The resident was sent to the hospital. During an interview on 9/9/24 at 3:55 P.M. the Director of Nursing said the following: -On 8/9/24, the resident complained of pain in his/her right side and denied falling; -The resident was questioned if he/she hurt after the transfer and he/she indicated yes, and pointed to his/her right side (right side, arm and lower extremity); -Staff were immediately questioned regarding the transfer technique. She had staff demonstrate the transfer technique on herself. CNA F and CNA B placed the gait belt under her arms (not her waist) and grabbed her under the arms to demonstrate the transfer; -She notified the family that the fracture was due to an improper transfer; -She would expect staff to notify the charge nurse if the resident had a decline and a safe transfer could not be done; -Staff should never grab a resident under the arms and the gait belt should be placed around the resident's waist; -The resident continues to have pain on the right side and was scheduled to see an orthopedic physician due to this ongoing issue. During an interview on 9/10/24 at 12:05 P.M. the Administrator said he/she expected staff to follow the facility policy for transfers and lifts. He would expect staff to follow proper procedure for each transfer. He was notified by the DON on 8/12/24 that an improper transfer had occurred resulting in a fracture to the resident's arm. MO240387

Refer to Event ID C0JV13 Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). Staff administered injectable Glucagon (medication to treat very low blood glucose) three times when the resident was assessed as lethargic and difficult to arouse and did not notify the physician twice. The facility administered oral Glucagon without a physician's order and did not monitor the resident's blood glucose after giving Glucagon tablets. The facility failed to have a safe and effective system of insulin administration for diabetic residents. Facility staff withheld insulin without the direction of the physician, failed to follow physician orders, failed to ensure fast acting insulin was administered timely with meals, failed to notify the physician if a resident's blood glucose was outside of parameters, and failed to document blood glucose readings and administration of insulin. The census was 102. The administrator was notified of the Immediate Jeopardy (IJ) on 07/25/24 at 4:05 P.M. which began on 7/1/24. The IJ was removed on 8/2/24 as confirmed by surveyor onsite verification. Review of the facility's Medication Administration policy, last revised 03/28/24, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident; -A medication is administered outside the time frame ordered is considered late, the primary care physician should be contacted, and communication and interventions should be documented in the electronic medical record (EMR); -Blood glucose readings outside the parameters established by the physician and or Medical Director are to he reported immediately to the primary care physician for interventions. Documentation should be reflected in the progress note regarding communication made; -Whenever a medication is not given, the Unit Nurse/Certified Medication Technician (CMT) must document the in the EMR/medication administration record (MAR), and document in the EMR, in the resident's chart, and on the 24-Hour Report: a. Date and time; b. Why the medication was not given, such as dose refused or ordered to be held by the physician; -If medications are ordered to be withheld, the Unit Nurse must document on the electronic medication administration record (EMAR) and a nursing progress note the following: a. Reason withheld; b. Start and stop dates for withholding the medication; b. Nursing documentation/ initials. -The policy did not address physician notification if a resident refused an ordered medication or procedure. Review of the facility Blood Glucose Monitoring Policy, last revised 03/28/24, showed the following: -Charge nurses will keep a list of diabetics; -Blood glucose samples will be taken according to the methods and times described in the physician's orders; -The policy did not address hyperglycemic or hypoglycemic results, physician notifications, parameters or when to recheck a blood glucose. During an interview on 07/25/24 at 3:30 P.M., the Director of Nursing (DON) said the facility did not have a policy for how to treat hyperglycemia or hypoglycemia. 1. Review of Resident #1's care plan, dated 02/14/24, showed the following: -Diagnoses include type 1 diabetes mellitus (DM) (disease requiring insulin replacement to control blood sugar in the body), schizophrenia (mental condition that causes a false sense of reality and can cause individuals to have delusions or fragmented thoughts and can cause them to think, feel and behave differently), and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior); -The resident manipulated his/her blood glucose levels by withholding food to decrease levels and eating sweets to increase levels; -The resident will not have signs and symptoms of hyperglycemia or hypoglycemia through review date; -Educate the resident on the importance of controlling blood glucose levels; -Educate the resident on the risks of manipulating blood glucose levels; -Monitor the resident's blood glucose levels and administer insulin per physician orders. Review of the resident's admission Minimum Data Set (MDS), a federally required assessment completed by staff, dated 02/23/24, showed the following: -Cognitively intact; -Understands and is understood; -No behaviors or rejection of care; -Insulin injections daily. Review of the resident's Physician's Orders, dated 04/16/24, showed: -Humalog injection solution (Insulin Lispro) (rapid acting insulin) 100 units/milliliter (u/ml), inject 14 units subcutaneously (subq) (beneath or under the skin) with meals for diabetes mellitus type 1, for blood glucose greater than 400 call primary care physician; -GlucaGen HypoKit Injection Solution Reconstituted (Glucagon) inject 1 milligram (mg) subcutaneously every 15 minutes as needed for blood glucose less than 70 and unresponsive; -Blood glucose checks before meals and at bedtime. Notify the physician for blood glucose less than 60 or greater than 400; -No order for Glucagon tablets. Review of the prescribing information for GlucaGen, located on the Food and Drug Administration's website showed: -Used to treat severe hypoglycemic reactions; -Patients should be given supplemental carbohydrates as soon as they awaken and are able to swallow to restore the liver glycogen and prevent recurrence of hypoglycemia; -Even if the treatment awakens the person, tell their doctor right away- their dose of diabetes medication may need to be changed; -Hypoglycemia may happen again after receiving GlucaGen treatment. Early symptoms of hypoglycemia may include: anxiety, depressed mood, irritability, abnormal behavior, personality changes, restlessness. Review of the resident's Physician's Orders, dated 05/07/24, showed Lantus SoloStar (Insulin Glargine) (long acting insulin) subq Solution Pen-Injector 100 unit/ml, inject 45 units subcutaneously every morning and at bedtime for diabetes mellitus. Review of the prescribing information for Lantus, long-acting human insulin showed: Warnings and Precautions: Hyperglycemia or hypoclycemia- Make any changes to the insulin regimen under close medical supervision. Hypoglycemia: most common adverse reaction associated with insulins. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. May impair concentration ability. Review of the resident's quarterly MDS, dated [DATE], showed: -No rejection of care; -Insulin administered daily. Review of the resident's MAR, dated 07/01/24, showed the resident's blood glucose at 9:00 P.M. was 403 (the medical record showed no documentation staff notified the physician as ordered). Review of the resident's physician note, dated 07/02/24, showed the following: -Uncontrolled diabetes mellitus type 1; -GlucaGen Hypoglycemia Kit Injection Solution Reconstituted (Glucagon HCI (rDNA)), inject 1 milligram (mg)/ml subcutaneously as needed for hypoglycemia; for blood glucose less than 70 and if the resident is unresponsive, may repeat every 15 minutes; -Humalog injection solution 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime related to type 1 diabetes mellitus; -If blood glucose is 151 - 200 = administer 3 units; -201 - 250 = 5 units; -251 - 300 = 7 units; -301 - 350 = 9 units; -351 - 400 = 11 units; call primary physician for blood glucose greater than 400; -Levemir FlexPen Subcutaneous Solution Pen-injector 100 units/ml inject 28 unit subq two times a day related to type 1 diabetes; Note: This medication list is not the same as the medications on the physician's orders; the resident was not on sliding scale insulin and the resident was on Lantus at a different dose and not Levemir. Per the physician this was probably an old note that came forward. The orders from 4/16/24 and 5/7/24 were accurate and current. Review of the resident's July 2024 MAR showed the following: -On 07/02/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 437; -On 07/03/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 461; -On 07/04/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 498; -On 07/04/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 426; -On 07/04/24 at 9:00 P.M., the resident's blood glucose was 500; -On 07/05/24 at 7:00 A.M., the resident's blood glucose was 445; -On 07/05/24 at 5:00 P.M., the resident's blood glucose was 101. Staff documented the resident refused his/her ordered Humalog insulin; -On 07/07/24 at 11:00 A.M., the resident's blood glucose was 46. Staff documented the resident's ordered Humalog was not administered, no insulin required (the resident's administration order was not on a sliding scale for administration and did not have hold parameters). Review of the resident's medical record showed no documentation staff notified the physician as ordered for any of the instances from 07/02/24-07/7/24 when the resident's blood sugar was over 400. There was no documentation staff contacted the physician when the resident refused insulin or when staff omitted insulin when the resident's blood glucose was 46. Review of the resident's Progress Notes, dated 07/08/24 at 4:25 P.M., showed the following: -LPN B documented the resident currently refusing glucose check, call placed to legal guardian with permission to hold resident's cigarettes and/or vape until resident is compliant with medication. Resident educated on restriction and resident said he/she would do whatever he/she wanted. Legal guardian aware, will continue to monitor; -On 07/08/24 at 9:00 P.M., the resident's blood glucose was marked with an X, and that the resident refused his/her ordered Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's refusal for a blood glucose check or administration of Lantus insulin. Review of the resident's July 2024 MAR showed the following: -On 07/09/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 406; -On 07/10/24 at 12:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/10/24 at 5:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/11/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 32 and staff held the resident's ordered Lantus insulin, see progress notes. Review of the resident's Progress Notes, dated 7/11/24 at 7:52 A.M., showed LPN B documented the resident glucose reading of 32, difficult to arouse. Glucagon injection administered as ordered as well as Boost (liquid nutritional supplement taken by mouth). Review of the resident's July 2024 MAR showed on 07/11/24 at 8:00 A.M., LPN B documented holding the resident's ordered Humalog insulin, see progress note (resident's blood sugar at 7:00 A.M. was 32). Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's high and low blood glucose levels, refusals of Humalog insulin, administration of Glucagon, or holding administration of insulin documented on the MAR between 7/9/24 and 7/11/24. Review of the resident's July 2024 MAR showed the following: -On 07/11/24 at 4:00 P.M., staff documented the resident's blood glucose was 342; -On 07/11/24 at 9:00 P.M., the documentation box for the resident's blood glucose check was blank indicating staff did not complete the ordered procedure with no documented reason why; -On 07/11/24 at bedtime, the administration box for the resident's ordered Lantus insulin was blank, indicating staff had not administered the ordered medication with no documentation reason why. Review of the resident's Progress Notes, for 07/11/24, showed no documentation regarding why the resident's blood glucose checks were not completed as ordered or why the resident's bedtime dose of Lantus insulin was not administered as ordered. There was no documentation staff notified the physician. Review of the resident's July 2024 MAR showed on 07/12/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 58 and staff held the resident's morning Lantus. Refer to progress note. Review of the resident's Progress Notes, for 07/12/24, showed no documentation regarding staff holding the resident's morning Lantus insulin due to the resident's low blood glucose or notification of the physician. Review of the resident's July 2024 MAR showed the following: -On 07/13/24 at 7:00 A.M., staff documented the resident's blood glucose was 44 and staff held the resident's ordered morning Humalog insulin, that it was not required, and the resident's ordered morning Lantus insulin was documented as not required; -On 07/13/24 at 4:00 P.M., staff documented the resident's blood glucose was 30 and the resident's ordered evening Humalog insulin as hold see progress note. Review of the resident's Progress Notes, dated 7/13/24 at 5:27 P.M., showed resident rechecked and blood glucose was 47; resident was still eating and drinking, will recheck. There was no documentation of notification to the physician of the resident's very low blood glucose levels or staff holding the resident's insulin. Review of the resident's July 2024 MAR showed the following: -On 07/14/24 at 7:00 A.M., staff documented the resident refused his/her ordered morning Humalog insulin; no documented reason why; -On 07/14/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/14/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin and referred to the progress note; -On 07/14/24 at 9:00 P.M., LPN B documented the resident's blood glucose was 57 and he/she did not administer the resident's ordered bedtime Lantus insulin, refer to progress note. Review of the resident's Progress Notes, dated 7/14/24, showed the following: -No documentation to show a follow up blood glucose was obtained after the 11:00 A.M. reading of 40; -No documentation regarding staff holding the resident's ordered Humalog insulin at 12:00 P.M.; -No documentation to show a follow up blood glucose was obtained after the 9:00 P.M. reading of 57; -No documentation regarding staff holding the resident's ordered bedtime Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's low blood glucose or staff holding ordered insulin. Review of the resident's July 2024 MAR showed the following: -On 07/15/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 537; the medical record showed no documentation LPN B notified the physician as ordered; -On 07/16/24 at 12:00 P.M., staff documented the resident's blood glucose was 133; staff documented not administering the resident's ordered Humalog insulin, that it was not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/16/24 at 5:00 P.M., staff documented the resident's blood glucose was 275; staff documented not administering the resident's ordered Humalog, insulin not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/17/24 at 8:00 A.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 07/17/24, showed no documentation as to why staff held the resident's ordered Humalog insulin for 8:00 A.M. administration. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 11:00 A.M., staff documented the resident's blood glucose was 59; -On 07/17/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin, insulin not required; (the resident was not on a sliding scale insulin administration). Review of the resident's Progress Notes, dated 7/17/24 at 1:51 P.M., showed the following: -Staff administered Glucagon; -No documentation of follow-up blood glucose monitoring, physician notification, documentation of the resident's condition or response to Glucagon. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 4:00 P.M., staff documented the resident's blood glucose was 265; -On 07/17/24 at 5:00 P.M., blood glucose of 245, staff documented not administering the resident's ordered Humalog insulin, the insulin was not required; (the resident was not on a sliding scale insulin administration); -On 07/18/24 at 7:00 A.M., staff documented the resident's blood glucose was 36; the resident refused his/her 8:00 A.M. Humalog. No documentation staff notified the resident's physician of the resident's low blood sugar. Review of the resident's July 2024 MAR showed the following: -On 07/18/24 at 9:00 P.M., the resident's blood glucose check box was blank indicating staff had not completed the procedure; -On 07/19/24 at 8:00 A.M., staff documented the resident refused his/her morning Humalog insulin, blood glucose was 166; -On 07/19/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/19/24 at 12:00 P.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 7/19/24 at 12:23 P.M., showed repeat blood glucose 85 on recheck. Resident's lunch tray arrived and resident going to eat lunch. Review of the resident's July 2024 MAR showed on 07/19/24 at 5:00 P.M., staff documented holding the resident's ordered evening Humalog insulin, see progress note. Blood glucose was 253. Review of the resident's Progress Notes, dated 07/19/24 at 5:36 P.M., showed the resident was refusing to eat dinner. No documentation to show staff notified the physician. (Staff held the resident's insulin at 5:00 P.M.) Review of the resident's July 2024 MAR showed the following: -On 07/25/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 60; -On 07/25/24 at 9:00 P.M., staff documented the resident's blood glucose not taken because the resident was sleeping. Staff documented not administering the resident's ordered bedtime Lantus insulin because the resident was sleeping. Review of the resident's Progress Notes showed the following: -On 07/26/24 at 6:03 A.M., staff documented the resident was asleep during (9:00 P.M.) medication pass this shift (night shift); staff and nurse attempted three times to awaken resident so he/she could receive a blood glucose check, insulin and bedtime medications. Resident was hard to wake up; on second try, he/she threw back the covers and never got up. (There was no documentation staff assessed the resident for signs or symptoms of hypoglycemia when the resident was difficult to arouse. Staff did not document notifying the resident's physician staff had not completed the blood glucose or administered the resident's Lantus insulin.) -On 07/27/24 at 11:00 A.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, inject 1 mg subq every 15 minutes as needed for blood glucose less 70 and the resident is unresponsive; -On 07/27/24 at 11:13 A.M., staff documented the physician was notified of the resident's drop in blood glucose to 22 and Glucagon administered along with snacks as the resident was not speaking to nurses any more. After administration of Glucagon injection and snack, resident came back to talking and staff educated the resident on the need to eat protein and not skip meals during the day; -On 07/27/24 at 11:24 A.M., staff documented the resident's physician called and said to continue insulin as ordered. He said the snacks and Gucagon given should keep the resident's blood glucose up and to resume orders and check as needed; -On 07/27/24 at 12:31 P.M., staff documented, upon coming to get blood glucose, resident informed staff that he/she only ate his/her cookie off his/her meal tray. Checking blood glucose before giving his/her insulin. Review of the resident's July 2024 MAR showed staff documented on 07/27/24 at 12:00 P.M., the resident's blood glucose was 45. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 12:44 P.M., staff documented the resident had a the meal tray and resident reported she did not like the meal and only ate the cookie. Staff gave the resident's insulin at noon. A meal alternative was brought to the resident at his/her request. When staff brought the resident the peanut butter sandwich, the resident refused to eat the sandwich. Upon refusal, the DON was notified and had a conversation with the resident. The resident refused the DON's instructions and refused to cooperate. The resident threw the sandwich out the door. -On 07/27/24 at 1:08 P.M., resident's blood glucose low and refusing to eat. Directed charge nurse to contact physician and guardian and to follow physician's orders. (There was no further documentation to show staff contacted the physician, new order, or response from the physician. There was no documentation of additional blood glucose testing.) Review of the resident's July 2024 MAR showed on 07/27/24 at 9:00 P.M., staff documented the resident's ordered bedtime Lantus insulin was not given because the resident refused. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 9:04 P.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, Inject 1 mg subcutaneously every 15 minutes as needed for blood glucose less 70 and the resident was unresponsive. Staff educated the resident regarding refusing to eat after insulin given. Resident educated on importance of eating when insulin given. Resident understands protein is needed when blood glucose is low. Resident encouraged to be complaint with diabetes regimen. Resident voices understanding. Resident tearful at this time. Resident able to vent and verbalize feelings. Will continue to monitor. Resident educated when staff administered Glucagon related to low blood glucose and being unresponsive. There was no documentation staff notified the resident's physician. There was no documentation the resident's blood glucose was below 70 or the resident was unresponsive. -On 07/27/24 at 9:25 P.M., staff documented resident refused Lantus insulin at this time due to blood glucose of 86 and has been low off and on all day; will recheck and reattempt later, currently eating a snack. (No documentation of any further blood glucose checks) -On 07/28/24 at 10:57 A.M., staff documented called to resident's hall for hypoglycemic emergency. Checked resident's blood glucose, result was 33. Review of the resident's July 2024 MAR showed on 7/28/24 at 11:00 A.M. (3 minutes prior to the progress note above) showed the resident's blood glucose result was 262. Review of the resident's Progress Notes showed the following: -On 07/28/24 at 10:57 A.M., staff documented the resident's blood glucose dropped to 31, trying to get snack in resident. Resident refused to comply with food or water. Resident is diaphoretic (sweating). -On 07/28/24 at 10:59 A.M., staff documented the resident was given snack, resident is more verbal and can eat and drink; -On 07/28/24 at 11:00 A.M., staff documented administering Glucagon; resident still unable to verbally communicate, eat or drink. Unable to reach physician via call, responded in text message and notified DON; -On 07/28/24 at 11:14 A.M., staff documented the resident's blood glucose was 86; offered another snack of protein, resident complied. Physician updated; -On 07/28/24 at 11:22 A.M., staff documented blood glucose recheck resulted 74; -On 07/28/24, bedtime liberalized pass no specific time documented, staff documented not administering the resident's ordered bedtime Lantus because the resident refused; -On 07/29/24 at 11:43 A.M., staff documented the resident's physician was notified the resident's blood glucose was 102 and is to be given 14 units of insulin. Physician said to still give the 14 units but only once fork is in his/her hand to eat lunch. During an interview on 07/25/24 at 10:45 A.M. and 07/30/24 at 12:30 P.M., the resident said the following: -He/She wanted to go to an endocrinologist (physician that specializes in treating health conditions related to hormones, including diabetes) but no one would let him/her go; -Staff do not administer his/her bedtime insulin most of the time until midnight or 1:00 A.M. and it upsets him/her because he/she has to stay up even if he/she was tired. If he/she goes to bed, the staff will document he/she refused his/her scheduled insulin and not give the insulin; -LPN B refuses to give his/her Humalog insulin unless his/her blood glucose was over 400 and has the Certified Medication Technician (CMT's) trained to refuse to give him/her the Humalog as well. He/She does not feel good when staff will not administer the insulin; -The Assistant Director of Nursing (ADON) was the only staff that gave the insulin like it was supposed to be given and he/she feels better then. Since staff do not give the insulin consistently, and he/she does get the doses, his/her blood glucose will bottom out; -He/She had never refused his/her insulin because he/she does not want to die; -If staff charted he/she refused, it was because the staff were too scared to give it to him/her; -He/She thinks staff are putting food in his/her mouth when he/she was not fully coherent when his/her blood glucose was low, because he/she wakes up with food in his/her mouth; -He/She was scared staff were going to cause him/her to aspirate (choke), and get pneumonia; -Staff held his/her insulin this weekend (no date given) because his/her blood glucose dropped into the 40s; -LPN M held his/her Lantus because he/she was scared the resident would bottom out in his/her sleep; -Staff will refuse to give his/her insulin and chart that he/she refused it; -Staff also told his/her guardian he/she was refusing to eat, but he/she doesn't remember doing that; -When his/her blood glucose was low, staff have told him/her he/she was argumentative and would not cooperate; -He/She gets upset for being punished when he/she is not aware of his/her actions. The staff had taken away smoking privileges and talked to him/her about refusing to eat like it was a behavior, but his/her blood sugar was low at the time causing her to react like this; -The resident voiced concerns of being fearful when his/her blood glucose levels were not controlled, the resident said he/she thought staff were going to cause him/her to go into a diabetic coma, diabetic ketoacidosis, or die from holding his/her insulin. During an interview on 07/25/24 at 10:31 A.M., LPN B said the following: -The resident does not get Humalog insulin unless his/her blood glucose was above 400, it was ordered that way; -The order specifically said not to give the Humalog unless the resident was over 400 or the resident will bottom out (blood glucose will go too low); -The resident's physician had not given parameters to hold the resident's insulin that he/she knew of; -Sometimes he/she will do what he/she needs to, or document what he/she needs to, because the physicians aren't at the facility and do not realize the resident will bottom out; -He/She was not going to give the resident insulin if he/she knew it will cause the resident harm; -The resident does pretty well until his/her blood glucose gets below 40; -Sometimes at 40, the resident can still eat and talk so you can give the Glucagon tablets or snacks; -The resident's physician will specifically say not to hold the resident's Lantus and instruct staff to administer it after the resident starts eating. (Review of the resident's medical record showed the resident had no order to hold Humalog insulin and no order for Glucagon tablets.) During an interview on 07/25/24 at 11:05 A.M., the ADON said the resident gets nervous to take the Humalog insulin if his/her blood glucose was under 200, because he/she bottoms out. The resident will always take the insulin and they watch him/her closely because his/her blood glucose will go low very quickly. 2. Review of Resident #11's Admission MDS, dated [DATE], showed it was very important for the resident to have snacks available between meals. Review of the resident's Care Plan, dated 04/24/24, showed the following: -At risk for unstable blood sugars and ineffective therapeutic regimen related to diagnosis of DM II (type of diabetes where the body doesn't make enough insulin or doesn't use insulin well); -Follow up with physician as needed; -Medication provided as prescribed. Review of the resident's POS dated 07/2024, showed the following: -Diagnoses included DM II; -Blood glucose monitoring before meals (AC) and at bedtime (HS); -Insulin Aspart (rapid acting insulin) Flexpen subq solution pen injector 100 u/ml, inject 15 units subq three times a day for DM II, notify physician if blood glucose is over 350 mg/dL; (stop date 07/09/24); -Humalog [NAME] kwikpen subq solution pen-injector 100 u/ml, inject 15 units subq three times a day for DM II (7/9/24); -Humalog kwikpen subq solution pen-injector 200 units/mL, inject as per sliding scale: (for blood glucose results of 0-150, administer zero units of insulin, 151-200=two units, 201-250=four units, 251-300=six units, 301-350=eight units, 351-400=10 units, 401-450=12 units, if above 500 call physician) subq three times a day (7/9/24). Review of resident's MAR, dated 07/02/24, showed the resident's blood glucose at lunch was 353 mg/dL and was 400 mg/dL at supper. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered for either of these readings. Review of resident's MAR, dated 07/03/24, showed the resident's blood glucose at supper was 417 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/06/24, showed resident's blood glucose at lunch was 401 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/08/24, showed resident's blood glucose at supper was 351mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/18/24, showed the following: -The administration box for the resident's ordered 4:30 P.M. blood glucose check was blank, indicating the procedure had not been completed; -The administration box for the resident's ordered 5:00 P.M. Humalog [NAME] 15 unit administration was blank, indicating the ordered medication had not been administered; -The administration box for the resident's ordered 5:00 P.M. humalog sliding scale insulin blank, indicating staff did not administer the sliding scale insulin. Review of the resident's medical record showed no documentation to explain why the resident's blood glucose check and ordered insulin had not been obtained or administered. Review of the resident's quarterly MDS, dated [DATE], show [TRUNCATED]

Refer to Event ID C0JV13 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 05/29/24. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in resident rooms. The facility census was 102. Review of the facility policy Synergy Cleaning dated 8/1/24 showed the following: -The purpose is to provide a safe and clean environment for residents; -Clean horizontal services, including window sills; -Spot check floors, clean any spills or trouble areas and pick up any trash. Identify any odors and attend to them immediately; -Sweep floors, move furniture and beds away from walls; -Wet mop floors, move furniture and beds away from walls. During an interview on 7/24/24 at 11:25 A.M. Resident #4 said his/her sheets were not changed on shower days and he/she would have to ask staff several times to get them changed. During an interview on 7/24/24 at 11:28 A.M., Resident #21's visitor said he/she had observed urine stained sheets on the resident's bed for a week and a half and staff had not changed them. He/She frequently smelled a urine odor in the facility and the floors were sticky. Observation on 7/24/24 at 11:28 A.M. showed the fitted sheet on Resident #21's bed stained with dried urine. The room smelled of urine. During an interview on 7/25/24 at 4:50 P.M., Certified Nurse Assistant (CNA) C said the facility did not always have enough linens. Observation on 7/24/24 at 10:12 A.M., showed the floor near the nurse's station between C and D halls with a wet brown area on the floor. The floor around the desk was visibly soiled with dirt and debris. Observation on 7/24/24 at 10:15 A.M., showed the floor in occupied resident room [ROOM NUMBER] was sticky and soiled with brown dirt and debris. Observations on 7/24/24 at 10:47 A.M. and 7/25/24 at 1:15 P.M., showed the floor in occupied resident room [ROOM NUMBER] and in the adjoining bathroom sticky and soiled with dirt. The floor was discolored with a gray film. The window sill was dirty with dust and debris. Observation on 7/24/24 at 12:09 P.M., showed the floor in occupied resident room [ROOM NUMBER] located on D hall was dirty and sticky. During an interview on 7/25/24 at 9:18 A.M., Housekeeper I said the following: -He/She was one of four members of the cleaning crew; -Housekeeping staff came into the facility daily and worked from 8:00 A.M. to 10 :00 A.M.; -Two staff were assigned to clean each hall, and they also cleaned the front of the building; -Housekeeping staff cleaned the bathrooms and showers as needed; -They emptied trash and swept and mopped the floors daily; -They only cleaned half of D hall (400 hall; as some residents cleaned their own rooms); -Housekeeping staff did not clean the A hall (occupied, behavior unit) at all. Sometimes facility staff helped clean A hall. During an interview on 7/25/24 at 9:35 A.M. the Housekeeping Supervisor said the following: -Housekeeping was in the building from 7:00 A.M. to 10:00 A.M. daily; -There were four housekeepers who came into the facility at a time and they cleaned resident rooms; -The department heads were responsible for the shower rooms and whatever else was needed. During an interview on 7/30/24 at 3:15 P.M. the Director of Nursing said the following: -CNA's were responsible for changing the residents' linens; -Linens should not have dried urine stains on them; -Staff should change linens on shower days and as needed. She would expect them to change linens within 15-20 minutes of a requested change; -Staff should sweep and mop the floors daily and as needed. MO239086

Refer to Event ID C0JV13 Based on observation, interview, and record review, the facility failed to ensure eight residents, in a review of 29 sampled residents, were treated in a manner to maintain dignity and respect when they failed to communicate with four residents (Residents #2, #7, #9, #10, and #6) in a respectful manner, and provide one resident (Resident #5), who was incontinent, with incontinence briefs when in bed. The resident reported staff told him/her to urinate in his/her bed and they would clean the resident up later. The facility also failed to provide adequate hygiene for one resident (Resident #3) to ensure removal of unwanted facial and underarm hair prior to the resident going out to a physician's appointment. The resident was observed crying and said she was sad and embarrassed by her appearance and that other residents made fun of her. The facility census was 102. Review of the facility policy, Privacy/Room Courtesy Policy, dated 12/28/23, showed the following: -Employees will be cognizant that the facility is their home; -Residents and their rooms/personal space should be treated with respect. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -Moderate cognitive impairment; -No behaviors or rejection of care; -Understood and understands; -It was very important to the resident to make choices about daily decisions like choosing clothing to wear, type of bathing, taking care of personal belongings, etc; -Dependent on staff for shower/bathing Review of the resident's Care Plan, revised 6/6/24, showed the following: -The resident was highly functional and able to complete her activities of daily living (ADL) tasks with set up and supervision to maintain her hygiene; -Allow time to complete task and intervene as needed; -Monitor for decline in function; -Provide assistance, supervision, set up and cues as needed. Observation on 7/24/24, at 10:27 A.M., showed the resident sat at a table in the dining room. The resident had facial hair approximately 0.5 inch long on her upper lip, chin and neck. The resident had on a sleeveless shirt and her arm pit hair was thick and over 1 inch long. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just got back from an appointment with the physician. She was so embarrassed because of how she looked. She did not think she should have to have facial hair and arm pit hair. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by how she looked. Other residents made fun of the hair on her face and arm pits. Observation on 7/25/24 at 11:15 A.M., showed the resident was in the dining room. The resident had the same facial hair and her nails were long with a brown substance under them. The resident's arm pits were not exposed. 2. Review of Resident #2's Preadmission Screening and Resident Review (PASARR; a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis to ensure appropriate placement and to ensure that their individual needs are being met in the appropriate placement environment), dated 9/16/18, showed the following: -Diagnoses included severe bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), intellectual disability, borderline intellectual functioning, borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), anti-social personality disorder (a mental health disorder characterized by disregard for other people), and history of brain injury; -History of physical and sexual abuse as a child, self-harm, and suicide attempts. Review of the resident's Care Plan, last revised 7/15/24, showed the following: -The resident was at risk for injury to self and others and impaired social interaction related to behaviors of verbal and physical aggression toward staff and peers; -Received counseling with outside service; -The resident will remain free of serious injury to self and others and will maintain appropriate social interactions now through next review; -On 7/3/24, the resident was verbally aggressive with peer. A code green (behavioral emergency) was called. Immediate staff intervention and separation from peer. The resident was allowed to vent and verbalize. Staff educated the resident to seek staff to assist with concerns and the resident voiced understanding. Staff also discussed the resident's coping skills and the resident voiced understanding. Staff were able to redirect the resident with no invasive measures. The resident was calm and cooperative at this time; -Administer antipsychotic medications as ordered; -Social services to follow up as needed. (The resident's care plan did not include a history of making false allegations or how staff were to respond to the resident's allegations.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder, and borderline personality disorder; -No hallucinations, delusions, behaviors, or rejection of care; -Received antipsychotic and antidepressant medications routinely. Observation on 7/25/24, at 11:00 A.M., showed the following: -The resident was in the 100 hall by the dining area. He/She walked behind the state agency (SA) staff and talked about needing an appointment. The resident did not speak directly to the SA staff, and there were other residents and staff in the area; -The Administrator walked up to the resident with a posture to make himself taller than the resident. In a stern, intimidating voice, the Administrator asked the resident, What are you talking about? Are you just saying stuff because the state is back here? -The resident put his/her head down and stuttering said he/she just needed an appointment and walked away. During an interview on 7/30/24 at 12:00 P.M., the resident said the following: -The Administrator made him/her feel bad when he/she tried to speak with the SA staff; he/she wanted to tell him (the Administrator) off; -The Administrator took away his/her privileges to go out on the main unit all the time. He/She felt like he/she couldn't talk to the SA staff or he/she would be in trouble; -His/Her roommate raped him/her (previously investigated); -He/She told staff the other day he/she wanted to hurt himself/herself; -The staff were rude to him/her and did not treat him/her with respect, more like a dog and they want me to go away. SA staff reported allegations of rape and self-harm to the facility Administrator on 7/30/24, at 1:00 P.M. During an interview on 7/30/24, at 1:40 P.M., the Administrator said the resident made the allegation of rape previously and it was reported and investigated. Observation on 7/30/24 at 1:40 P.M., showed the following: -The Administrator shared the documentation of the previous investigation; -The Administrator then played an audio recording with his voice and the resident's voice; -On the recording, the Administrator asked the resident in a stern, intimidating voice if he/she had been raped, if he/she had a plan to hurt himself/herself, or had any other concerns or issues. The resident responded to each question in a quiet and wavering voice no to each question. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Verbal behaviors. Review of the resident's undated Care Plan showed the following: -The resident had the potential to be verbally aggressive; -Assess the resident's understanding of the situation, allow time for the resident to express himself/herself and feelings towards the situation; -Assess the resident's coping skills. During an interview on 07/24/25 at 12:48 P.M., the resident said the following: -Staff were rude; -Staff do not listen to the resident. Observation on 07/25/24 at 11:56 P.M., showed the following: -The resident's call light was on; -Certified Nurse Assistant (CNA) E opened the resident's door, stood in the doorway, and asked the resident what he/she wanted; -The resident asked CNA E to take his/her roommate to the dining room as it was time for lunch and his/her roommate could not reach his/her call light; -CNA E responded in a loud, rude tone and said the resident could not make his/her roommate go as it was his/her room, too; -The resident attempted to explain that his/her roommate did not have call light in reach to call when he/she was ready to go; -CNA E interrupted the resident and said in a loud, rude tone, that he/she (CNA E) could not make the roommate go, and he/she didn't know what more the resident expected him/her to do; -The resident responded by explaining his/her roommate did not have a call light. The resident asked how his/her roommate was supposed to let staff know when he/she was ready to go to the dining room; -CNA E responded in a loud, rude tone that he/she had been walking the hall and checked on the resident every five minutes; the resident's roommate will tell him/her (CNA E) when he/she was ready to go; -The resident was visibly upset and began to speak. CNA E spoke over the resident in a loud, rude tone, and said he/she (CNA E) could not make the roommate go; -The resident responded that he/she hated this room and his/her new roommate and he/she should have never been moved, but nobody listened to him/her; -CNA E rolled his/her eyes, and said in a loud, rude tone, I'll let the DON know. -CNA E shut the resident's room door; -CNA E never fully entered the room, did not speak to the resident's roommate, and did not check to ensure the roommate had a call light in reach. -The resident's roommate did not respond or speak during the interaction. During an interview on 07/30/24 at 4:03 P.M., CNA E said the following: -Staff should speak to residents in a calm, pleasant tone; -Staff should not argue, be rude or raise their voice when speaking to residents. Staff should not talk over residents or roll their eyes when residents are speaking; -He/She had never been loud, rude or defensive when speaking to residents. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent for toileting hygiene; -Always incontinent. Review of the resident's undated Care Plan showed the following: -He/She has episodes of incontinence and required assistance with toileting and hygiene; -He/She used disposable briefs; -The resident has a potential psychosocial well-being problem related to diagnoses of schizoaffective disorder and bipolar. Observation on 07/24/24 at 10:25 A.M. showed the following: -The resident sat on the edge of the bed and wore only a sweatshirt; -The resident was not wearing an incontinence brief; -The bed sheets under the resident and the two incontinence pads on the resident's bed were soaked in urine. During an interview on 07/24/24 at 10:28 A.M., the resident said the following: -Staff was very busy; -He/She was unable to walk to the bathroom on his/her own; -Staff tell him/her to urinate in the bed and they will clean him/her up later; -Urinating in the bed and not wearing an incontinence brief made him/her feel dirty and embarrassed. Observation on 07/25/24 at 9:19 A.M. showed the resident asleep in bed. He/She was not wearing an incontinence brief. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the resident's undated care plan, showed the following: -Resident has a potential psychosocial well-being problem; -The resident needs assistance, encouragement, and support to identify problems that cannot be controlled; -The resident needs assistance, supervision, and support to identify causative and contributing factors; -The resident has post traumatic stress disorder (PTSD) and may flare up without any trigger; -The resident will be able to identify triggers and utilize positive coping skills. During an interview on 07/25/24 at 10:41 A.M., the resident said the following: -Staff never notify the residents of the alternate entree for the meal. The residents have to go to the kitchen window to ask, but then staff yell at them for bothering the kitchen staff; -The kitchen staff yell in a loud/rude voice to Go away!, You can't be at the window!, We're busy!; -If he/she asked multiple staff about the alternate entree, the staff get annoyed, and tell the resident he/she was not telling the truth about asking other staff; -He/She did not appreciate when staff spoke to him/her in this way, and didn't feel like it was appropriate or polite; -When the staff yelled, raised their voices, or spoke in a rude tone, it made him/her feel very irritated and increased his/her agitation. It made him/her want to raise his/her voice back, but he didn't out of fear of being told he/she was having behaviors and to go back to his/her room. 6. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the residents undated care plan, showed the following: -The resident has a potential psychosocial well-being problem; -The resident will verbalize feelings related to emotional state; -The resident has a mood problem related to diagnoses of bipolar and depression; -Allow resident time to voice feelings and concerns. During an interview on 07/25/24 at 10:45 A.M., the resident said the following: -Kitchen staff regularly raised their voices and spoke in a rude tone when talking with residents; -He/She was told to tell the kitchen staff prior to meal time if he/she wanted an alternative, but when he/she went to the kitchen window, staff yelled at him/her and told him/her to Go away!; -When the staff yelled, it hurt his/her feelings and made him/her want to cry and yell back. He/She did not do this out of fear of being told he/she was having a behavior, told to go back to his/her room, or threatened to send him/her back to the behavior unit. 7. Review of Resident #6's Care Plan, dated 09/15/23, showed the following: -Communication problem related to hearing impairment; -Use communication techniques which enhance interaction, allow adequate time to respond, do not rush, repeat as necessary, face when speaking and make eye contact; -Diagnosis of depression. Resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Monitor/report signs/symptoms of shame, worthlessness, agitation or anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the resident had no behaviors or rejection of care. Review of the resident's POS, dated 07/2024, showed diagnoses included neurocognitive disorder with Lewy Bodies (progressive brain disease that causes a gradual decline in mental abilities), major depressive disorder and anxiety. During an interview on 07/25/24 at 11:28 A.M., the resident said the following: -Staff could be short and rude with their tone of voice; -One staff was sarcastic and loud when he/she asked for hygiene items; -It made him/her sad and he/she felt like wanting to hit the staff. During an interview on 07/25/24 at 11:31 A.M., a visitor said he/she overheard staff being rude with the resident. One day a staff yelled at the resident (who had requested razors), Well if we aint got it, we can't give it to you! 8. During an interview on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing (DON) said the following: -Staff were to ensure female residents did not have facial hair and arm pit hair if the resident did not want facial hair and arm pit hair; -Staff were to assist the residents to keep their fingernails trimmed and clean; -Staff should not tell residents to soil themselves or their bed; -Staff should treat residents with dignity and respect at all times; -Staff should not raise their voice at, yell at, or roll their eyes at residents. During an interview on 08/02/24 at 10:05 A.M., the Administrator said the following: -He expected staff to treat all residents with dignity and respect; -Staff should not raise their voice at, yell at, or roll their eyes at residents. MO237998 MO238302 MO238414 MO239086

Refer to Event ID C0JV13 Based on observation, interview and record review, the facility failed to ensure two female residents (Residents #4 and #3) received the necessary services to maintain grooming and hygiene including bathing, removal of facial and underarm hair, and nail care. The failure caused one resident to be tearful and expressed being sad and embarrassed, stating other residents made fun her. This deficient practice impacted two residents (Residents #4 and #3) in a review 29 sampled residents. The facility census was 102. Review of the facility policy Personal Care, Hygiene and Grooming, dated 11/1/22, showed the most important aspect of maintaining good health was good hygiene. Personal hygiene, also referred to as a personal care, included bathing and showering, hair care, nail care, oral hygiene and dental care and shaving; -Residents are bathed according to preferences, including the time of day, and day of the week, bed bath, tub bath, or shower or partial bath; -Nail care includes keeping nails trimmed and filed, no jagged or broken nails, cleaning underneath to remove debris; -Nail care on residents with DIABETES will be provided by the nurse; -All residents are to be shaved daily unless they have specified otherwise or have a trimmed beard; -Check female residents for shaving needs including excessive chin hairs. Review of the facility's Shower Policy, dated 12/23/23, showed the following: -Shower schedules will consist of two assigned days in a seven-day calendar week; -Bathing should include washing hair, shaving, fingernail/toenail trim, and assessment of skin. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -No behaviors or rejection of care; -Understood and understands; -Dependent on staff for shower/bathing. Review of the resident's Care Plan, revised 6/6/24, showed the following: -Resident was highly functional and able to complete activities of daily living (ADLs) task with set up and supervision to maintain hygiene; -Allow time to complete task and intervene as needed; -Provide assistance, supervision, set up and cues as needed. Review of the facility shower schedule showed the resident's shower days were Tuesday and Friday. Review of the resident's shower record found in Point Click Care (PCC), dated July 2024, showed the following: -The resident had two scheduled bath days per week; -Staff documented bathing was completed on 07/02/24 (only once for the week), 07/09/24 (only once for the week), 07/16/24 (only once for the week), and 07/23/24. There was no documentation the resident refused any showers. Observation on 7/24/24, at 10:27 A.M., showed the resident in the dining room sitting at a table. The resident had facial hair approximately one half inch long on her upper lip, chin, and neck. The resident wore a sleeveless shirt and had thick hair, over an inch long in her arm pit. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just returned from an appointment with the physician and was so embarrassed because of how she looked. She did not like having facial hair or hair in her arm pits. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by this and other residents made fun of the hair on her face and in her arm pits. She would like her fingernails to be trimmed and clean. She did not get two showers a week, staff only had time to do one. Observation on 7/25/24, at 11:15 A.M., showed the resident in the dining room with other residents with the same facial hair and dirty fingernails. The resident wore a shirt that covered her underarms. 2. Review of Resident #4's admission MDS dated [DATE], showed the following: -No behaviors or rejection of care; -Dependent for bathing and personal hygiene. Review of the resident's care plan dated 6/25/24 showed the following: -Extensive assist with ADLs including hygiene; -Provide assistance as needed. Review of the facility shower schedule (specifying the days showers would be given) did not include the resident's name. Review of the resident's shower record found in Point Click Care (PCC), dated 07/24, showed the following: -The resident had two scheduled bath days weekly; -Staff documented bathing as completed on 07/01/24 (only once for the week), 07/08/24 (only once for the week), 07/15/24, and 07/18/24. Observation and interview on 07/24/24 showed the following: -At 10:20 A.M., the resident sat in her broda chair (specialized reclining chair) in her room. The resident had numerous long, white hairs noted on her chin and shorter hair on her upper lip; -At 4:30 P.M., the resident lay in bed and the facial hair remained. The resident said staff did not bathe or shave her. Observation on 07/25/24 at 10:35 A.M., showed the resident with the same facial hair. During an interview on 07/25/24 at 10:40 A.M., the resident said she had not received one shower or bed bath since her admission to the facility. Staff only washed the urine from her body. She wished staff would use a topical hair remover or something to get rid of her facial hair. She was accustomed to getting assistance from staff with shaving at her prior placement. She did not like hair on her face and had never refused to let staff shower, bathe, or shave her. During an interview on 7/25/24 at 4:50 P.M., certified nurse aide (CNA) C said the following: -Residents should be shaved on shower days and as needed; -She would shave residents when they requested, however Resident #4 had never asked to be shaved. During an interview on 07/25/24 at 3:50 P.M., CNA D said the following: -Showers are completed daily except Sundays; -If a resident refused their shower, it could be made up on another day; -Staff documented showers in PCC. 3. During an interviews on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing said CNAs should shave residents on shower days and as needed. Staff are expected to ensure residents do not have facial hair and arm pit hair if they do not want facial hair and arm pit hair. Staff are expected to assist the residents to keep their fingernails trimmed and clean. Residents are scheduled to receive at least two showers a week. During an interview on 08/02/24 at 10:05 A.M., the Administrator said he expected nursing staff to assist residents with bathing and shaving as needed.

Based on interview and record review, the facility failed to provide adequate supervision for two residents (Resident #5 and #7) in a review of 12 sampled residents. Staff failed to monitor Resident #5 who was left outside from approximately 10:00 A.M. to 12:00 P.M. The resident sat in a wheelchair in the facility courtyard in direct sunlight with temperatures of 87 degrees Fahrenheit (F) and a 91 degree F heat index. The resident was assessed to have altered mental status, was difficult to arouse, and had low oxygen saturation. The resident was sent to the hospital where he/she was admitted with diagnoses of encephalopathy (chemical imbalance in the blood caused by illness) and possible heat stroke (severe heat-related illness that occurs when the body can not regulate its temperature). Additionally, the facility failed to ensure a smoking apron was worn for resident safety, per Resident #7's smoking assessment. The facility census was 103. The administrator was notified on 6/14/24 at 1:15 P.M of the Immediate Jeopardy (IJ) which began on 6/12/24. The IJ was removed on 6/17/24, per surveyor onsite verification. Review of the facility policy, Inclement Weather/Severe Heat Precautions, undated, showed the following: -The purpose of the policy was to identify potentially harmful weather or outside temperatures that may pose harm to the resident; -The facility will identify the following environmental risks that may cause harm to the resident: -Excessive heat greater than 98 degrees F (as deemed by the medical director); -Heat advisory; -The administrator, Director of Nursing (DON), or designee will determine the weather status before residents exit the facility on walks, on outside pass (OSP) or out of the facility smoke time; -Summer temperature threshold: Courtyards should be shut down when the temperature reaches or exceeds 90 degrees F. High temperatures can lead to heat exhaustion and heat stroke; -The administrator would have to give permission to open the courtyard if temperatures are above 90 degrees F in the summer, administrator does have the ability to allow residents to go out and smoke if it is over this temperature and come right back in with staff. They should be outside 10 to 15 minutes maximum in extreme temperatures; -During heatwaves, consider closing the courtyard or limiting access during peak heat hours, typically between 10:00 A.M. and 4:00 P.M., when the sun is at it's strongest. Always ensure the residents have access to adequate hydration and shaded areas and avoid outdoor activities during extreme weather conditions. Regularly review and adhere to local weather advisories and health guidelines to make informed decisions. During an interview on 6/13/24 at 3:22 P.M. the administrator said he/she was told the facility did not have a smoking policy. Review of a list of residents who smoke, dated 6/13/24 and provided by the facility, showed Resident #5 and Resident #7 were smokers. Resident smoking times were 6:30 A.M., 9:30 A.M., 12:00 P.M., 3:00 P.M., 7:30 P.M. and 9:00 P.M. The resident designated smoking area was the back courtyard. Review of the facility's resident council minutes, dated 5/2/24, showed grievance five read as follows: Residents would like to be taken back into the building after smoking and not left outside waiting for staff to take them back inside. 1. Review of Resident #5's care plan, dated 2/2/23 and last revised 6/6/24, showed the following: -At risk for injury and alteration in health related to being a smoker; -Will maintain safety while following smoking protocol; -Supervised while smoking; -Smoking per facility protocol; -Resident will wear a smoking apron while smoking; -At risk for falls related to impaired balance and psychotropic medication (four falls since 2/24/23); -Resident required supervision with cueing, encouragement and one staff assist for support with transferring due to unsteady gait and lower extremity issues requiring braces (4/4/23). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 3/10/24, showed the following: -Moderately impaired cognition; -No behaviors, wandering or rejection of care; -Dependent of one staff for transfers and mobility; -Range of motion limitation of both lower extremities; -Shortness of breath at rest and with exertion; -Used supplemental oxygen; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Resident required supervision with cueing, encouragement and one staff assist for support with transferring due to an unsteady gait and lower extremity issues requiring braces (4/4/23); -Tobacco use was not addressed. Review of the resident's smoking assessment, dated 4/19/24, showed the following: -Resident was currently a smoker; -Cognitively intact; -The resident will wear a smoking apron while smoking; -All residents will be supervised when smoking. Review of the resident's Physician Order Sheet (POS), dated 6/2024, showed the following: -Diagnoses included congestive heart failure (CHF-heart does not pump blood adequately), chronic obstructive pulmonary disease (COPD-difficulty breathing), type II diabetes mellitus (uncontrolled blood glucose), atrial fibrillation (irregular, often rapid heart rate), seizure disorder (uncontrolled jerking or blank stare) and obesity; -Up with assist/walker and out of bed to chair/wheelchair; -Bilateral leg braces applied when up and removed when in bed; -Oxygen at 2 liters per minute (LPM) via nasal cannula (tubing that supplies oxygen through the nostrils) to maintain SpO2 (blood oxygen saturation) above 90-92% every day and night shift. Review of the wunderground weather data for 6/12/24 showed the following: -At 9:54 A.M., temperature (T): 81 degrees F., dew point 63 degrees F., humidity 54% and winds [NAME] Southwest at eight miles per hour (mph), condition hazy; -At 10:54 A.M., T: 83 degrees F., dew point 63 degrees F., humidity 51% and winds southwest at nine mph, condition fair; -At 11:54 A.M., T: 87 degrees F., dew point 64 degrees F., humidity 46% and winds west southwest at ten mph, condition fair. During an interview on 6/13/24 at 11:00 A.M., Certified Nurse Assistant (CNA) D said the following: -He/She had assisted Resident #5 outside at the 9:30 A.M. smoke break and he/she brought him/her back in around 9:50 A.M.; he/she did not know if the resident went back outside; -The resident had not refused to return indoors on 6/12/24; -When he/she saw the resident on 6/12/24, the resident was trying to speak, he/she would open his/her eyes but was not able to follow commands. The resident was unable to drink so he/she put some water in a straw and tried to give some liquid by placing water in the resident's mouth. The resident's skin and legs were always red, but were redder than normal and they felt hot; -He/she did not know if the resident had anything to drink while he/she was outside. During an interview on 6/13/24 at 1:33 P.M. CNA E said the following: -He/She worked on B hall, which was not the resident's hall, on 6/12/24; -The resident was fine at breakfast and went outside for the 9:30 A.M. smoke break; -CNA E went out about 11:00 A.M. or so for his/her smoke break and saw the resident sitting in the sun on the patio by the door; -It felt hot outside to CNA E, but the resident said he/she enjoyed being out in the sun; -The resident's speech was okay and there was no sign of sunburn at that time; -CNA E was outside approximately five to six minutes and when he/she went back inside, the resident remained outside. There was no staff outside; -He/She did not see a smoking apron on the resident on 6/12/24 at 11:00 A.M. During an interview on 6/18/24 at 10:30 A.M. Resident #13 said he/she was friends with Resident #5 and they were both smokers. He/She recalled the day the resident was left outside. They had gone out to smoke around 9:30 A.M. smoke break time and Resident #5 remained outside when Resident #13 went back inside after the smoke break. The resident was still outside in the sun when he/she went out at noon for the next smoke break. He/She alerted the unit manager the resident was not doing well. When he/she first saw the resident his/her head was shaking, eyes were closed and he/she could not talk. Review of the resident's progress notes, dated 6/12/24, showed the following: -At 11:53 A.M., late entry authored by the Director of Nursing (DON): Staff approached this writer stating resident was off baseline. Resident noted to be sitting in wheelchair, eyes opening and closing. Resident grabbing at handrail. Resident not able to answer questions. Vitals taken: blood pressure-136/58 (normal 120/80), heart rate-90 (normal 60-100 beats per minute), temperature-100.2 ( normal 98.6) degrees F, respiration rate-18 (normal 12-18 breaths per minute), and SpO2-86% (normal 92 to 100%) on room air. Oxygen applied at 2 LPM via nasal cannula. SpO2 rechecked at 95%. Cool wash cloths applied to resident. 911 called. Guardian aware; -At 11:59 A.M., authored by Licensed Practical Nurse (LPN) A: This writer made aware resident noted to have altered mental status. Immediate assessment completed by nursing staff. Resident difficult to arouse with low Sp02 at 86% on room air. Oxygen applied, Emergency Medical Services (EMS) notified, resident sent to hospital for evaluation and treatment. Resident's legal guardian made aware of resident transfer to ER. Review of the resident's EMS report, dated 6/12/24, showed the following: -On scene: 12:19 P.M.; -Upon arrival the resident was found sitting in a wheelchair next to the nurse's station. The resident was slumped down into the wheelchair with eyes closed, breathing and had a strong radial pulse. The resident was very red in the face and hot to touch. The nurse that was present said the resident had told them earlier that his/her room was very cold and he/she wanted to get warmer. The resident was left outside in the heat and was not attended to for two hours. The current temp was 91 degrees F. When staff went to check on the resident, they found the resident in the condition that we find him/her in at this time; -Resident was unresponsive with head tilted back in the wheelchair, eyes closed and does not respond to verbal stimuli. Resident's face very red, along with all extremities. Tongue dry, skin red and hot to touch. Resident appears to have loss of bowel and incontinence in the wheelchair with gross edema (swelling) of the lower limbs; -LPN gave EMS update and said the resident was complaining of his/her room being cold, so staff let him/her go outside. Staff found the resident like this just before calling. EMS asked how long the resident was outside in the heat and the LPN replied about two hours; -Resident had to be lifted with a mechanical lift to be placed on the stretcher. The resident was transferred to the hospital. During an interview on 6/20/24 at 8:45 A.M., Emergency Medical Services (EMS) staff who responded to the call from the facility regarding the resident's change in condition on 6/12/24, said the following: -EMS was called to the facility for a resident with altered mental status; -The outside temperature upon EMS arrival was 89 degrees F; -Upon arrival the resident was leaned back in his/her wheelchair near the nurse's station; -The resident's face, neck and arms were very red. The resident's mouth and tongue were very dry and he/she appeared dehydrated; -Facility staff had placed cold washcloths under the resident's arms and to the back of his/her neck; -The resident could not answer questions or follow commands; -The nurse said the resident complained of his/her room being cold and staff let the resident go outside. The resident had been outside for approximately two hours. When EMS staff asked if the resident had been outside unattended, the staff members did not answer his/her question; -EMS staff got the resident to the ambulance where they started intravenous fluids and placed cold packs to the resident's groin and under his/her arms; -Upon arrival to the hospital, the resident was alert to his/her name only. Review of the resident's hospital records, dated 6/13/24, showed the following: -Assessment and plan: Acute metabolic encephalopathy (chemical imbalance in the blood caused by illness):; -Suspect possible heat stroke (severe heat-related illness that occurs when the body can not regulate its temperature); -Continue intravenous (IV) fluids and IV antibiotics. During an interview on 6/13/24 at 11:46 A.M. Unit Manager A said the following: -He/She was letting residents out for the noon smoke break when a resident said he/she needed to check on Resident #5. He/She wheeled the resident, who sat in his/her wheelchair on the patio in the sun, inside and parked him/her next to the handrail by the nurse's desk. The resident was breathing, moving his/her hands and grabbing at the handrail. The resident would not say his/her name or speak. While CNA D checked the resident's temperature, he/she went to get the DON who responded, assessed the resident, and instructed someone to call 911; -Residents were not currently supervised by staff when they smoked; -He/She said residents need to be supervised when they go out to smoke. He/She was currently working on a facility policy for approval. During an interview on 6/13/24 at 11:12 A.M. LPN B said the following: -He/She was the charge nurse for the resident on 6/12/24; -He/She knew the resident was a smoker and went out for every smoke break; -He/She did not know the resident was outside for two hours yesterday until Unit Manager A notified him/her; -Staff do have to help the resident to open the door, however, he/she propels himself/herself in the wheelchair; -There was no sign in/out sheet for when residents went outside unless they went out in front of the facility; -The CNAs who took the residents outside would be responsible for ensuring the resident was safe and returned back inside; -Staff monitored smokers but did not necessarily remain outside with them the entire time. During an interview on 6/13/24 at 12:10 P.M. the DON said Unit Manager A knocked on his/her door and said they needed a nurse. He/She responded to the resident who sat in his/her wheelchair near the nurse's desk. The resident was trying to grab the hand rail on the wall. His/Her eyes were open and the resident looked at the DON. He/She asked the resident to squeeze his/her hands but the resident did not. His/Her temperature was 100.1 F., he/she was not speaking, and only mumbled, which was not his/her baseline. Staff called EMS and placed washcloths on the resident's forehead and underarms. Staff applied oxygen. The resident normally talked and was able to propel himself/herself. She had asked staff what happened. CNA D reported the resident wanted to stay outside after the first smoke break. There were no cameras for video footage of the area. She did not have a weather policy During an interview on 6/13/24 at 4:40 P.M. CNA D said that when EMS arrived he/she and EMS staff asked the resident to stand. The two assisted the resident to stand, the resident was weak and started to go down so they lowered him/her to the floor. They transferred the resident with a mechanical lift to move the resident to a stretcher. The resident was normally a two person transfer. During an interview on 6/13/24 at 4:35 P.M. the Assistant Director of Nursing (ADON) said the following: -He/She had given report on the resident to the EMS team when they arrived; -He/She let them know that the resident had been outside. During an interview on 6/14/24 at 8:40 A.M. the resident said he/she did recall the incident of being left outside for about two hours in the sun. It was very hot. He/She did not recall who took him/her outside that day, but it was hot and he/she wanted to come back inside, but there was no one to assist him/her. Staff did not come to check on him/her while he/she was outside, and staff did not stay outside when he/she or others went out to smoke. During an interview on 6/13/24 at 11:00 A.M., CNA D said the following: -Residents were allowed to go outside and they usually let staff know when they go out on their own; -No residents had been left outside that he/she knew of; -If residents have to be assisted outside by staff, he/she would check on them every five minutes, as it was just too hot for them to be outside for very long; -The resident wore a smoking apron some of the time; -He/She was not aware of any weather limitations (extreme heat or cold) regarding not allowing the resident outside; -He/She did not report to anyone when he/she took a resident outside; -Residents who were outside did not have a way to call staff for help. A lot of them just come and go on their own; -He/She would not let residents sit outside in the heat very long (10-20 minutes); -The resident usually sat on the patio, right in the sun. During interviews on 6/14/24 at 1:15 P.M. and 6/18/24 at 6:00 P.M., the DON said the following: -The resident can propel himself/herself in the wheelchair but could not open the door; -A resident should not be left unattended outside for two hours; -It would be important for staff to know if residents were outside; -She would expect staff to check on residents who were outside whether they were independent or dependent per their two-hour face checks. During an interview on 6/13/24 at 3:22 P.M. the resident's physician said the following: -He was not notified of the incident with the resident until the state agency phoned the office and he looked up the hospital records which listed heat exposure and UTI as admitting diagnoses; -He would have expected to be notified; -He would not expect this particular resident to be left outside in direct sun for two hours as he/she and most other residents could not tolerate that; -The encephalopathy diagnosis could very possibly be related to the heat exposure but also could be the UTI or a combination of both; -The resident should not have been left outside unattended for one or two hours. Observation on 6/13/24 at 11:00 A.M. showed the door leading to the courtyard was a large glass door. A code pad was attached to the wall adjacent to the door. Staff had to enter a code to allow residents outdoors. The door would open without a code and would alarm alerting staff that someone had gone outdoors. The door could be opened from the outside allowing residents to re-enter if they did not require someone to open/hold the door or required assistance getting over the threshold in their wheelchair. The door led to a concrete patio (unshaded) with two sidewalks (one to the left and one straight ahead) which extended from it and into the courtyard. The sidewalk straight ahead led to two other patios (one covered and one uncovered) where tables were arranged. 2. Review of Resident #7's smoking assessment, dated 3/14/24, showed the following: -Currently was a smoker; -Cognitively intact; -The resident will wear a smoking apron while smoking; -All residents will be supervised when smoking. Review of the resident's POS, dated 6/2024, showed diagnoses included COPD, mild intellectual disabilities, and unspecified convulsions. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Inattention: comes and goes, changes in severity; -Disorganized thinking: comes and goes, changes in severity; -Range of motion impairment to both lower extremities; -Used a wheelchair; -Independent with transfer from bed to chair to bed; -Sit to stand transfer: Supervision or touch assistance/steadying as resident completes; -Shortness of breath at rest, with exertion and lying flat; -Tobacco use was not addressed. Observation on 6/18/24 at 3:10 P.M. showed the resident outside smoking with other residents. He/She did not wear a smoking apron. 3. During an interview on 6/13/24 at 1:33 P.M. CNA E said the following: -There were no residents who physically needed help smoking their cigarettes; -He/She had not been educated on restrictions for residents being outside; -Residents should be supervised when smoking as they could drop their cigarettes. During an interview on 6/13/24 at 11:46 A.M. Unit Manager A said the concerns for residents who were not supervised while smoking would include catching themselves on fire, burning themselves and any number of medical emergencies. During an interview on 6/13/24 at 4:20 P.M. Certified Medication Technician (CMT) F said the following: -Resident cigarettes and lighters were kept in the lock box; -If residents smoked independently, they either have a lighter or staff hand them one as they go out; -Staff either light dependent smokers cigarettes for them or an independent resident, who was already outside, would light them. -The door leading to the smoking area opens from the outside; -The door alarmed if someone went out, to alert staff; -Staff would know if a dependent resident wanted to come back in either by staff who were outside or other residents would let staff know. During an interview on 6/18/24 at 6:00 P.M. the DON said the following: -He/She would expect staff to supervise residents while they smoked if the smoking assessment and care plan listed staff supervision as interventions; -Residents should wear smoking aprons if their smoking assessments determined that as an intervention; -It would be important for residents who required a smoking apron while smoking to be supervised by staff at all times; -Staff should supervise all smokers at all times. During an interview on 6/18/24 at 6:35 P.M., the administrator said the following: -Staff should know when a resident was outside; -Staff should monitor residents closely if residents were outside in hot/cold temperatures; -He/She would expect residents to wear smoking aprons if it was care planned for the resident; -Staff should be outside at all times when residents were outside smoking. 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). MO#237510 MO#237509

Based on observation, interview, and record review, staff failed to ensure four Residents (Resident #4, #9, #10, and #11) were free from verbal abuse when one resident (Resident #8) yelled and cursed at these residents on multiple occasions and staff told the residents to go to their rooms and ignore Resident #8 which caused the residents increased anxiety and fear they would have increased behaviors if Resident #8 continued to yell and curse at them. Resident #4 said he/she was concerned he/she was going to act out towards the resident. Resident #8 caused an increase in his/her anxiety, he/she was having difficulties calming down, and wanting to harm the other resident; Resident #10 said Resident #8 made him/her upset and angry and if something wasn't done to address the resident's behaviors he/she was going to end up in a fight with Resident #8. Resident #9 said he/she was worried about acting out or being aggressive towards the resident because it upset him/her so much. Resident #11 said he/she was always on edge (feeling nervous or unable to calm down), because Resident #8 cursed at him/her daily. The facility census was 103. Review of the facility policy Abuse and Neglect, dated 12/29/23, showed the following: -Class II neglect was failure of an employee to provide reasonable or necessary services to a resident according to the individual treatment/habilitation plan, if feasible or according to acceptable standards of care. This includes action or behavior, which may cause psychological harm to a resident due to intimidation causing fear or otherwise cause undue anxiety; -The policy and procedure will include how to assess, prevent, and manage aggressive, violent, and or catastrophic reactions of residents in a way that protects both residents and staff; -Prevention and Identification: -The facility will identify and correct, providing interventions in which abuse, neglect or misappropriation may occur. This will include assessment of the physical environment, which may make abuse or neglect more likely to occur, supervisors should identify inappropriate behaviors such as derogatory language and neglectful care. Prevention will also include assessment, care planning, and monitoring of residents with needs or behaviors which may lead to conflict; -The policy did not address verbal abuse including a definition of verbal abuse. 1. Review of Resident #8's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/8/24, showed the following: -Adequate hearing and clear speech; -Cognitively intact; -Makes self-understood and understands others; -No behavioral symptoms exhibited. Review of the resident's nursing note, dated 6/16/24 at 10:31 A.M., showed the resident was noted to be verbally aggressive towards staff and peers. Allowed to vent and verbalize. Review of the resident's progress note, dated 6/16/24 at 9:06 A.M., showed the resident was noted to be verbally aggressive towards peers, immediate separation and staff intervention, allowed to vent and verbalize. Review of the resident's nursing note, dated 6/17/24 at 3:00 P.M., showed the resident continued with verbal aggression towards peers and was physical towards facility property. Long-term psychiatric management notified and an order given to send to the resident to the emergency room . Observation on 6/18/24 at 12:12 P.M., showed the resident seated in a chair in the hall as other residents watched television in the common area nearby. Resident #8 yelled at the residents from the chair and said, You need to fucking make me shut up! Unit Manger G shut the door to the common area. 2. Review of Resident #4's admission MDS, dated [DATE], showed the following: -Adequate hearing and clear speech; -Cognitively intact; -Makes self-understood and understands others. Review of Resident #4's hospital discharge instructions following an inpatient psychiatric evaluation for a suicide attempt, dated 6/14/24, showed the following: -Triggers and stressors: behaviors and circumstances that put the resident at emotional risk include people that bully and people that are attention seeking. During an interview on 6/18/24 at 11:05 A.M., the resident said the following: -Resident #8 called him/her and the other residents names. Resident #8 also cursed at them; -Staff told the other residents to either go to their rooms or ignore Resident #8; -Resident #8 had behaviors daily and this had been going on for months; -Resident #4 was just readmitted to the facility following a psychiatric evaluation, he/she was concerned he/she was going to act out towards Resident #8 if something wasn't done to address Resident #8's behaviors; -Resident #8 caused an increase in his/her anxiety, he/she was having difficulties calming down, he/she was wanting to harm the other resident; -Resident #4 pleaded for something to be done to address Resident #8's behaviors. 3. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Adequate hearing and clear speech; -Cognitively intact; -Makes self-understood and understands others. During an interview on 6/18/24 at 11:35 A.M. the resident said the following: -Resident #8 would tell him/her to fuck off and called him/her a bitch; -Resident #8 stood outside his/her door and would yell and curse at him/her; -Staff never redirected Resident #8 for his/her behaviors. The resident disrupted day to day activities; -Staff told him/her to go to his/her room when Resident #8 became disruptive, it was like staff punished him/her because of Resident #8's behaviors; -He/She was worried about acting out or being aggressive towards the resident because it upset him/her so much; -The resident became tearful during the interview and said he/she was afraid of Resident #8 and did not feel safe with him/her here. 4. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -Adequate hearing and clear speech; -Cognitively intact; -Makes self-understood and understands others. During an interview on 6/18/24 at 11:38 A.M. the resident said the following: -Resident #8 cursed at the other residents and tried to start fights daily; -Staff told the other residents to move away from Resident #8 or to go to their rooms when Resident #8 acted out; -Staff punished other residents for Resident #8's behaviors. He/She was going to end up in a fight with Resident #8 if something wasn't done to address his/her behaviors, it made him/her upset and angry, he/she couldn't take it anymore. 5. Review of Resident #11's admission MDS, dated [DATE], showed the following: -Adequate hearing and clear speech; -Makes self-understood and understands others; -The resident's cognition was not assessed in the MDS assessment; During an interview on 6/18/24 at 11:45 A.M., the resident said the following: -Resident #8 called him/her a bitch yesterday. He/She was so tired of being cursed at, it happened daily; -He/She was always on edge (feeling nervous or unable to calm down), because of Resident #8. Resident #8 was upsetting the entire hall; -All the other residents were told to go their rooms until Resident #8 could calm down, it wasn't fair. 6. During interview on 6/18/24 at 12:10 P.M. and 7/3/24 at 8:50 A.M., Unit Manager G said the following: -Resident #8 was highly attention seeking; -He/She tried to ignore the resident when he/she acted out and tried to get other residents to do the same; -Resident #8 cursed at other residents to get a rise out of them; -He/She had to calm the other residents down because they were upset because of comments Resident #8 had made towards them or because of his/her behaviors; -He/She tried to send Resident #8 to his/her room when he/she was cursing at other residents but that was not always effective; -The resident's behaviors were borderline on being abusive, if he/she could get the other residents to ignore Resident #8 and just walk by when he/she cursed at them, Resident #8 would usually stop. During an interview on 6/18/24 at 5:00 P.M. and 6:15 P.M., the Director of Nursing (DON) said the following: -She expected staff to intervene if a resident was cursing and yelling at other residents; -If Resident #8 continued to have behaviors directed towards other residents, unit staff should notify her or the Administrator, -The other residents should not be told to ignore Resident #8, as tension could build up between the residents; -She did not consider the resident's actions abuse since this was a resident using profanity, staff should just redirect and educate the resident that this behavior was inappropriate. During an interview on 6/18/24 at 6:30 P.M. and 7/2/24 at 9:46 A.M., the Administrator said Resident #8 had a lot of attention seeking behaviors. It was not appropriate for staff to tell other residents to go to their rooms because Resident #8 was having behaviors. It was not appropriate for the other residents to be cursed and yelled at. Since it was a peer and they lived together he did not consider the resident's actions to be abuse. The residents did use profanity.

Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). Staff administered injectable Glucagon (medication to treat very low blood glucose) three times when the resident was assessed as lethargic and difficult to arouse and did not notify the physician twice. The facility administered oral Glucagon without a physician's order and did not monitor the resident's blood glucose after giving Glucagon tablets. The facility failed to have a safe and effective system of insulin administration for diabetic residents. Facility staff withheld insulin without the direction of the physician, failed to follow physician orders, failed to ensure fast acting insulin was administered timely with meals, failed to notify the physician if a resident's blood glucose was outside of parameters, and failed to document blood glucose readings and administration of insulin. The census was 102. The administrator was notified of the Immediate Jeopardy (IJ) on 07/25/24 at 4:05 P.M. which began on 7/1/24. The IJ was removed on 8/2/24 as confirmed by surveyor onsite verification. Review of the facility's Medication Administration policy, last revised 03/28/24, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident; -A medication is administered outside the time frame ordered is considered late, the primary care physician should be contacted, and communication and interventions should be documented in the electronic medical record (EMR); -Blood glucose readings outside the parameters established by the physician and or Medical Director are to he reported immediately to the primary care physician for interventions. Documentation should be reflected in the progress note regarding communication made; -Whenever a medication is not given, the Unit Nurse/Certified Medication Technician (CMT) must document the in the EMR/medication administration record (MAR), and document in the EMR, in the resident's chart, and on the 24-Hour Report: a. Date and time; b. Why the medication was not given, such as dose refused or ordered to be held by the physician; -If medications are ordered to be withheld, the Unit Nurse must document on the electronic medication administration record (EMAR) and a nursing progress note the following: a. Reason withheld; b. Start and stop dates for withholding the medication; b. Nursing documentation/ initials. -The policy did not address physician notification if a resident refused an ordered medication or procedure. Review of the facility Blood Glucose Monitoring Policy, last revised 03/28/24, showed the following: -Charge nurses will keep a list of diabetics; -Blood glucose samples will be taken according to the methods and times described in the physician's orders; -The policy did not address hyperglycemic or hypoglycemic results, physician notifications, parameters or when to recheck a blood glucose. During an interview on 07/25/24 at 3:30 P.M., the Director of Nursing (DON) said the facility did not have a policy for how to treat hyperglycemia or hypoglycemia. 1. Review of Resident #1's care plan, dated 02/14/24, showed the following: -Diagnoses include type 1 diabetes mellitus (DM) (disease requiring insulin replacement to control blood sugar in the body), schizophrenia (mental condition that causes a false sense of reality and can cause individuals to have delusions or fragmented thoughts and can cause them to think, feel and behave differently), and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior); -The resident manipulated his/her blood glucose levels by withholding food to decrease levels and eating sweets to increase levels; -The resident will not have signs and symptoms of hyperglycemia or hypoglycemia through review date; -Educate the resident on the importance of controlling blood glucose levels; -Educate the resident on the risks of manipulating blood glucose levels; -Monitor the resident's blood glucose levels and administer insulin per physician orders. Review of the resident's admission Minimum Data Set (MDS), a federally required assessment completed by staff, dated 02/23/24, showed the following: -Cognitively intact; -Understands and is understood; -No behaviors or rejection of care; -Insulin injections daily. Review of the resident's Physician's Orders, dated 04/16/24, showed: -Humalog injection solution (Insulin Lispro) (rapid acting insulin) 100 units/milliliter (u/ml), inject 14 units subcutaneously (subq) (beneath or under the skin) with meals for diabetes mellitus type 1, for blood glucose greater than 400 call primary care physician; -GlucaGen HypoKit Injection Solution Reconstituted (Glucagon) inject 1 milligram (mg) subcutaneously every 15 minutes as needed for blood glucose less than 70 and unresponsive; -Blood glucose checks before meals and at bedtime. Notify the physician for blood glucose less than 60 or greater than 400; -No order for Glucagon tablets. Review of the prescribing information for GlucaGen, located on the Food and Drug Administration's website showed: -Used to treat severe hypoglycemic reactions; -Patients should be given supplemental carbohydrates as soon as they awaken and are able to swallow to restore the liver glycogen and prevent recurrence of hypoglycemia; -Even if the treatment awakens the person, tell their doctor right away- their dose of diabetes medication may need to be changed; -Hypoglycemia may happen again after receiving GlucaGen treatment. Early symptoms of hypoglycemia may include: anxiety, depressed mood, irritability, abnormal behavior, personality changes, restlessness. Review of the resident's Physician's Orders, dated 05/07/24, showed Lantus SoloStar (Insulin Glargine) (long acting insulin) subq Solution Pen-Injector 100 unit/ml, inject 45 units subcutaneously every morning and at bedtime for diabetes mellitus. Review of the prescribing information for Lantus, long-acting human insulin showed: Warnings and Precautions: Hyperglycemia or hypoclycemia- Make any changes to the insulin regimen under close medical supervision. Hypoglycemia: most common adverse reaction associated with insulins. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. May impair concentration ability. Review of the resident's quarterly MDS, dated [DATE], showed: -No rejection of care; -Insulin administered daily. Review of the resident's MAR, dated 07/01/24, showed the resident's blood glucose at 9:00 P.M. was 403 (the medical record showed no documentation staff notified the physician as ordered). Review of the resident's physician note, dated 07/02/24, showed the following: -Uncontrolled diabetes mellitus type 1; -GlucaGen Hypoglycemia Kit Injection Solution Reconstituted (Glucagon HCI (rDNA)), inject 1 milligram (mg)/ml subcutaneously as needed for hypoglycemia; for blood glucose less than 70 and if the resident is unresponsive, may repeat every 15 minutes; -Humalog injection solution 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime related to type 1 diabetes mellitus; -If blood glucose is 151 - 200 = administer 3 units; -201 - 250 = 5 units; -251 - 300 = 7 units; -301 - 350 = 9 units; -351 - 400 = 11 units; call primary physician for blood glucose greater than 400; -Levemir FlexPen Subcutaneous Solution Pen-injector 100 units/ml inject 28 unit subq two times a day related to type 1 diabetes; Note: This medication list is not the same as the medications on the physician's orders; the resident was not on sliding scale insulin and the resident was on Lantus at a different dose and not Levemir. Per the physician this was probably an old note that came forward. The orders from 4/16/24 and 5/7/24 were accurate and current. Review of the resident's July 2024 MAR showed the following: -On 07/02/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 437; -On 07/03/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 461; -On 07/04/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 498; -On 07/04/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 426; -On 07/04/24 at 9:00 P.M., the resident's blood glucose was 500; -On 07/05/24 at 7:00 A.M., the resident's blood glucose was 445; -On 07/05/24 at 5:00 P.M., the resident's blood glucose was 101. Staff documented the resident refused his/her ordered Humalog insulin; -On 07/07/24 at 11:00 A.M., the resident's blood glucose was 46. Staff documented the resident's ordered Humalog was not administered, no insulin required (the resident's administration order was not on a sliding scale for administration and did not have hold parameters). Review of the resident's medical record showed no documentation staff notified the physician as ordered for any of the instances from 07/02/24-07/7/24 when the resident's blood sugar was over 400. There was no documentation staff contacted the physician when the resident refused insulin or when staff omitted insulin when the resident's blood glucose was 46. Review of the resident's Progress Notes, dated 07/08/24 at 4:25 P.M., showed the following: -LPN B documented the resident currently refusing glucose check, call placed to legal guardian with permission to hold resident's cigarettes and/or vape until resident is compliant with medication. Resident educated on restriction and resident said he/she would do whatever he/she wanted. Legal guardian aware, will continue to monitor; -On 07/08/24 at 9:00 P.M., the resident's blood glucose was marked with an X, and that the resident refused his/her ordered Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's refusal for a blood glucose check or administration of Lantus insulin. Review of the resident's July 2024 MAR showed the following: -On 07/09/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 406; -On 07/10/24 at 12:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/10/24 at 5:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/11/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 32 and staff held the resident's ordered Lantus insulin, see progress notes. Review of the resident's Progress Notes, dated 7/11/24 at 7:52 A.M., showed LPN B documented the resident glucose reading of 32, difficult to arouse. Glucagon injection administered as ordered as well as Boost (liquid nutritional supplement taken by mouth). Review of the resident's July 2024 MAR showed on 07/11/24 at 8:00 A.M., LPN B documented holding the resident's ordered Humalog insulin, see progress note (resident's blood sugar at 7:00 A.M. was 32). Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's high and low blood glucose levels, refusals of Humalog insulin, administration of Glucagon, or holding administration of insulin documented on the MAR between 7/9/24 and 7/11/24. Review of the resident's July 2024 MAR showed the following: -On 07/11/24 at 4:00 P.M., staff documented the resident's blood glucose was 342; -On 07/11/24 at 9:00 P.M., the documentation box for the resident's blood glucose check was blank indicating staff did not complete the ordered procedure with no documented reason why; -On 07/11/24 at bedtime, the administration box for the resident's ordered Lantus insulin was blank, indicating staff had not administered the ordered medication with no documentation reason why. Review of the resident's Progress Notes, for 07/11/24, showed no documentation regarding why the resident's blood glucose checks were not completed as ordered or why the resident's bedtime dose of Lantus insulin was not administered as ordered. There was no documentation staff notified the physician. Review of the resident's July 2024 MAR showed on 07/12/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 58 and staff held the resident's morning Lantus. Refer to progress note. Review of the resident's Progress Notes, for 07/12/24, showed no documentation regarding staff holding the resident's morning Lantus insulin due to the resident's low blood glucose or notification of the physician. Review of the resident's July 2024 MAR showed the following: -On 07/13/24 at 7:00 A.M., staff documented the resident's blood glucose was 44 and staff held the resident's ordered morning Humalog insulin, that it was not required, and the resident's ordered morning Lantus insulin was documented as not required; -On 07/13/24 at 4:00 P.M., staff documented the resident's blood glucose was 30 and the resident's ordered evening Humalog insulin as hold see progress note. Review of the resident's Progress Notes, dated 7/13/24 at 5:27 P.M., showed resident rechecked and blood glucose was 47; resident was still eating and drinking, will recheck. There was no documentation of notification to the physician of the resident's very low blood glucose levels or staff holding the resident's insulin. Review of the resident's July 2024 MAR showed the following: -On 07/14/24 at 7:00 A.M., staff documented the resident refused his/her ordered morning Humalog insulin; no documented reason why; -On 07/14/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/14/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin and referred to the progress note; -On 07/14/24 at 9:00 P.M., LPN B documented the resident's blood glucose was 57 and he/she did not administer the resident's ordered bedtime Lantus insulin, refer to progress note. Review of the resident's Progress Notes, dated 7/14/24, showed the following: -No documentation to show a follow up blood glucose was obtained after the 11:00 A.M. reading of 40; -No documentation regarding staff holding the resident's ordered Humalog insulin at 12:00 P.M.; -No documentation to show a follow up blood glucose was obtained after the 9:00 P.M. reading of 57; -No documentation regarding staff holding the resident's ordered bedtime Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's low blood glucose or staff holding ordered insulin. Review of the resident's July 2024 MAR showed the following: -On 07/15/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 537; the medical record showed no documentation LPN B notified the physician as ordered; -On 07/16/24 at 12:00 P.M., staff documented the resident's blood glucose was 133; staff documented not administering the resident's ordered Humalog insulin, that it was not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/16/24 at 5:00 P.M., staff documented the resident's blood glucose was 275; staff documented not administering the resident's ordered Humalog, insulin not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/17/24 at 8:00 A.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 07/17/24, showed no documentation as to why staff held the resident's ordered Humalog insulin for 8:00 A.M. administration. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 11:00 A.M., staff documented the resident's blood glucose was 59; -On 07/17/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin, insulin not required; (the resident was not on a sliding scale insulin administration). Review of the resident's Progress Notes, dated 7/17/24 at 1:51 P.M., showed the following: -Staff administered Glucagon; -No documentation of follow-up blood glucose monitoring, physician notification, documentation of the resident's condition or response to Glucagon. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 4:00 P.M., staff documented the resident's blood glucose was 265; -On 07/17/24 at 5:00 P.M., blood glucose of 245, staff documented not administering the resident's ordered Humalog insulin, the insulin was not required; (the resident was not on a sliding scale insulin administration); -On 07/18/24 at 7:00 A.M., staff documented the resident's blood glucose was 36; the resident refused his/her 8:00 A.M. Humalog. No documentation staff notified the resident's physician of the resident's low blood sugar. Review of the resident's July 2024 MAR showed the following: -On 07/18/24 at 9:00 P.M., the resident's blood glucose check box was blank indicating staff had not completed the procedure; -On 07/19/24 at 8:00 A.M., staff documented the resident refused his/her morning Humalog insulin, blood glucose was 166; -On 07/19/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/19/24 at 12:00 P.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 7/19/24 at 12:23 P.M., showed repeat blood glucose 85 on recheck. Resident's lunch tray arrived and resident going to eat lunch. Review of the resident's July 2024 MAR showed on 07/19/24 at 5:00 P.M., staff documented holding the resident's ordered evening Humalog insulin, see progress note. Blood glucose was 253. Review of the resident's Progress Notes, dated 07/19/24 at 5:36 P.M., showed the resident was refusing to eat dinner. No documentation to show staff notified the physician. (Staff held the resident's insulin at 5:00 P.M.) Review of the resident's July 2024 MAR showed the following: -On 07/25/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 60; -On 07/25/24 at 9:00 P.M., staff documented the resident's blood glucose not taken because the resident was sleeping. Staff documented not administering the resident's ordered bedtime Lantus insulin because the resident was sleeping. Review of the resident's Progress Notes showed the following: -On 07/26/24 at 6:03 A.M., staff documented the resident was asleep during (9:00 P.M.) medication pass this shift (night shift); staff and nurse attempted three times to awaken resident so he/she could receive a blood glucose check, insulin and bedtime medications. Resident was hard to wake up; on second try, he/she threw back the covers and never got up. (There was no documentation staff assessed the resident for signs or symptoms of hypoglycemia when the resident was difficult to arouse. Staff did not document notifying the resident's physician staff had not completed the blood glucose or administered the resident's Lantus insulin.) -On 07/27/24 at 11:00 A.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, inject 1 mg subq every 15 minutes as needed for blood glucose less 70 and the resident is unresponsive; -On 07/27/24 at 11:13 A.M., staff documented the physician was notified of the resident's drop in blood glucose to 22 and Glucagon administered along with snacks as the resident was not speaking to nurses any more. After administration of Glucagon injection and snack, resident came back to talking and staff educated the resident on the need to eat protein and not skip meals during the day; -On 07/27/24 at 11:24 A.M., staff documented the resident's physician called and said to continue insulin as ordered. He said the snacks and Gucagon given should keep the resident's blood glucose up and to resume orders and check as needed; -On 07/27/24 at 12:31 P.M., staff documented, upon coming to get blood glucose, resident informed staff that he/she only ate his/her cookie off his/her meal tray. Checking blood glucose before giving his/her insulin. Review of the resident's July 2024 MAR showed staff documented on 07/27/24 at 12:00 P.M., the resident's blood glucose was 45. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 12:44 P.M., staff documented the resident had a the meal tray and resident reported she did not like the meal and only ate the cookie. Staff gave the resident's insulin at noon. A meal alternative was brought to the resident at his/her request. When staff brought the resident the peanut butter sandwich, the resident refused to eat the sandwich. Upon refusal, the DON was notified and had a conversation with the resident. The resident refused the DON's instructions and refused to cooperate. The resident threw the sandwich out the door. -On 07/27/24 at 1:08 P.M., resident's blood glucose low and refusing to eat. Directed charge nurse to contact physician and guardian and to follow physician's orders. (There was no further documentation to show staff contacted the physician, new order, or response from the physician. There was no documentation of additional blood glucose testing.) Review of the resident's July 2024 MAR showed on 07/27/24 at 9:00 P.M., staff documented the resident's ordered bedtime Lantus insulin was not given because the resident refused. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 9:04 P.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, Inject 1 mg subcutaneously every 15 minutes as needed for blood glucose less 70 and the resident was unresponsive. Staff educated the resident regarding refusing to eat after insulin given. Resident educated on importance of eating when insulin given. Resident understands protein is needed when blood glucose is low. Resident encouraged to be complaint with diabetes regimen. Resident voices understanding. Resident tearful at this time. Resident able to vent and verbalize feelings. Will continue to monitor. Resident educated when staff administered Glucagon related to low blood glucose and being unresponsive. There was no documentation staff notified the resident's physician. There was no documentation the resident's blood glucose was below 70 or the resident was unresponsive. -On 07/27/24 at 9:25 P.M., staff documented resident refused Lantus insulin at this time due to blood glucose of 86 and has been low off and on all day; will recheck and reattempt later, currently eating a snack. (No documentation of any further blood glucose checks) -On 07/28/24 at 10:57 A.M., staff documented called to resident's hall for hypoglycemic emergency. Checked resident's blood glucose, result was 33. Review of the resident's July 2024 MAR showed on 7/28/24 at 11:00 A.M. (3 minutes prior to the progress note above) showed the resident's blood glucose result was 262. Review of the resident's Progress Notes showed the following: -On 07/28/24 at 10:57 A.M., staff documented the resident's blood glucose dropped to 31, trying to get snack in resident. Resident refused to comply with food or water. Resident is diaphoretic (sweating). -On 07/28/24 at 10:59 A.M., staff documented the resident was given snack, resident is more verbal and can eat and drink; -On 07/28/24 at 11:00 A.M., staff documented administering Glucagon; resident still unable to verbally communicate, eat or drink. Unable to reach physician via call, responded in text message and notified DON; -On 07/28/24 at 11:14 A.M., staff documented the resident's blood glucose was 86; offered another snack of protein, resident complied. Physician updated; -On 07/28/24 at 11:22 A.M., staff documented blood glucose recheck resulted 74; -On 07/28/24, bedtime liberalized pass no specific time documented, staff documented not administering the resident's ordered bedtime Lantus because the resident refused; -On 07/29/24 at 11:43 A.M., staff documented the resident's physician was notified the resident's blood glucose was 102 and is to be given 14 units of insulin. Physician said to still give the 14 units but only once fork is in his/her hand to eat lunch. During an interview on 07/25/24 at 10:45 A.M. and 07/30/24 at 12:30 P.M., the resident said the following: -He/She wanted to go to an endocrinologist (physician that specializes in treating health conditions related to hormones, including diabetes) but no one would let him/her go; -Staff do not administer his/her bedtime insulin most of the time until midnight or 1:00 A.M. and it upsets him/her because he/she has to stay up even if he/she was tired. If he/she goes to bed, the staff will document he/she refused his/her scheduled insulin and not give the insulin; -LPN B refuses to give his/her Humalog insulin unless his/her blood glucose was over 400 and has the Certified Medication Technician (CMT's) trained to refuse to give him/her the Humalog as well. He/She does not feel good when staff will not administer the insulin; -The Assistant Director of Nursing (ADON) was the only staff that gave the insulin like it was supposed to be given and he/she feels better then. Since staff do not give the insulin consistently, and he/she does get the doses, his/her blood glucose will bottom out; -He/She had never refused his/her insulin because he/she does not want to die; -If staff charted he/she refused, it was because the staff were too scared to give it to him/her; -He/She thinks staff are putting food in his/her mouth when he/she was not fully coherent when his/her blood glucose was low, because he/she wakes up with food in his/her mouth; -He/She was scared staff were going to cause him/her to aspirate (choke), and get pneumonia; -Staff held his/her insulin this weekend (no date given) because his/her blood glucose dropped into the 40s; -LPN M held his/her Lantus because he/she was scared the resident would bottom out in his/her sleep; -Staff will refuse to give his/her insulin and chart that he/she refused it; -Staff also told his/her guardian he/she was refusing to eat, but he/she doesn't remember doing that; -When his/her blood glucose was low, staff have told him/her he/she was argumentative and would not cooperate; -He/She gets upset for being punished when he/she is not aware of his/her actions. The staff had taken away smoking privileges and talked to him/her about refusing to eat like it was a behavior, but his/her blood sugar was low at the time causing her to react like this; -The resident voiced concerns of being fearful when his/her blood glucose levels were not controlled, the resident said he/she thought staff were going to cause him/her to go into a diabetic coma, diabetic ketoacidosis, or die from holding his/her insulin. During an interview on 07/25/24 at 10:31 A.M., LPN B said the following: -The resident does not get Humalog insulin unless his/her blood glucose was above 400, it was ordered that way; -The order specifically said not to give the Humalog unless the resident was over 400 or the resident will bottom out (blood glucose will go too low); -The resident's physician had not given parameters to hold the resident's insulin that he/she knew of; -Sometimes he/she will do what he/she needs to, or document what he/she needs to, because the physicians aren't at the facility and do not realize the resident will bottom out; -He/She was not going to give the resident insulin if he/she knew it will cause the resident harm; -The resident does pretty well until his/her blood glucose gets below 40; -Sometimes at 40, the resident can still eat and talk so you can give the Glucagon tablets or snacks; -The resident's physician will specifically say not to hold the resident's Lantus and instruct staff to administer it after the resident starts eating. (Review of the resident's medical record showed the resident had no order to hold Humalog insulin and no order for Glucagon tablets.) During an interview on 07/25/24 at 11:05 A.M., the ADON said the resident gets nervous to take the Humalog insulin if his/her blood glucose was under 200, because he/she bottoms out. The resident will always take the insulin and they watch him/her closely because his/her blood glucose will go low very quickly. 2. Review of Resident #11's admission MDS, dated [DATE], showed it was very important for the resident to have snacks available between meals. Review of the resident's Care Plan, dated 04/24/24, showed the following: -At risk for unstable blood sugars and ineffective therapeutic regimen related to diagnosis of DM II (type of diabetes where the body doesn't make enough insulin or doesn't use insulin well); -Follow up with physician as needed; -Medication provided as prescribed. Review of the resident's POS dated 07/2024, showed the following: -Diagnoses included DM II; -Blood glucose monitoring before meals (AC) and at bedtime (HS); -Insulin Aspart (rapid acting insulin) Flexpen subq solution pen injector 100 u/ml, inject 15 units subq three times a day for DM II, notify physician if blood glucose is over 350 mg/dL; (stop date 07/09/24); -Humalog [NAME] kwikpen subq solution pen-injector 100 u/ml, inject 15 units subq three times a day for DM II (7/9/24); -Humalog kwikpen subq solution pen-injector 200 units/mL, inject as per sliding scale: (for blood glucose results of 0-150, administer zero units of insulin, 151-200=two units, 201-250=four units, 251-300=six units, 301-350=eight units, 351-400=10 units, 401-450=12 units, if above 500 call physician) subq three times a day (7/9/24). Review of resident's MAR, dated 07/02/24, showed the resident's blood glucose at lunch was 353 mg/dL and was 400 mg/dL at supper. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered for either of these readings. Review of resident's MAR, dated 07/03/24, showed the resident's blood glucose at supper was 417 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/06/24, showed resident's blood glucose at lunch was 401 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/08/24, showed resident's blood glucose at supper was 351mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/18/24, showed the following: -The administration box for the resident's ordered 4:30 P.M. blood glucose check was blank, indicating the procedure had not been completed; -The administration box for the resident's ordered 5:00 P.M. Humalog [NAME] 15 unit administration was blank, indicating the ordered medication had not been administered; -The administration box for the resident's ordered 5:00 P.M. humalog sliding scale insulin blank, indicating staff did not administer the sliding scale insulin. Review of the resident's medical record showed no documentation [TRUNCATED]

Based on interview and record review, the facility failed to provide care per policy or in accordance with professional standards of practice to six insulin dependent diabetic residents of 29 sampled residents, (Resident #1, #11, #6, #17, #14, and #16). The facility failed to notify Resident #1's physician when the resident experienced hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) blood glucose readings and was documented as refusing blood glucose tests and insulin. Staff failed to obtain parameters for when to notify the physician of hypoglycemic blood glucose readings. The resident's blood glucose readings ranged from 30 to 537 milligrams per deciliter (mg/dl) (normal range 80-120 mg/dl). Staff administered injectable Glucagon (medication to treat very low blood glucose) three times when the resident was assessed as lethargic and difficult to arouse and did not notify the physician twice. The facility administered oral Glucagon without a physician's order and did not monitor the resident's blood glucose after giving Glucagon tablets. The facility failed to have a safe and effective system of insulin administration for diabetic residents. Facility staff withheld insulin without the direction of the physician, failed to follow physician orders, failed to ensure fast acting insulin was administered timely with meals, failed to notify the physician if a resident's blood glucose was outside of parameters, and failed to document blood glucose readings and administration of insulin. The census was 102. The administrator was notified of the Immediate Jeopardy (IJ) on 07/25/24 at 4:05 P.M. which began on 7/1/24. The IJ was removed on 8/2/24 as confirmed by surveyor onsite verification. Review of the facility's Medication Administration policy, last revised 03/28/24, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident; -A medication is administered outside the time frame ordered is considered late, the primary care physician should be contacted, and communication and interventions should be documented in the electronic medical record (EMR); -Blood glucose readings outside the parameters established by the physician and or Medical Director are to he reported immediately to the primary care physician for interventions. Documentation should be reflected in the progress note regarding communication made; -Whenever a medication is not given, the Unit Nurse/Certified Medication Technician (CMT) must document the in the EMR/medication administration record (MAR), and document in the EMR, in the resident's chart, and on the 24-Hour Report: a. Date and time; b. Why the medication was not given, such as dose refused or ordered to be held by the physician; -If medications are ordered to be withheld, the Unit Nurse must document on the electronic medication administration record (EMAR) and a nursing progress note the following: a. Reason withheld; b. Start and stop dates for withholding the medication; b. Nursing documentation/ initials. -The policy did not address physician notification if a resident refused an ordered medication or procedure. Review of the facility Blood Glucose Monitoring Policy, last revised 03/28/24, showed the following: -Charge nurses will keep a list of diabetics; -Blood glucose samples will be taken according to the methods and times described in the physician's orders; -The policy did not address hyperglycemic or hypoglycemic results, physician notifications, parameters or when to recheck a blood glucose. During an interview on 07/25/24 at 3:30 P.M., the Director of Nursing (DON) said the facility did not have a policy for how to treat hyperglycemia or hypoglycemia. 1. Review of Resident #1's care plan, dated 02/14/24, showed the following: -Diagnoses include type 1 diabetes mellitus (DM) (disease requiring insulin replacement to control blood sugar in the body), schizophrenia (mental condition that causes a false sense of reality and can cause individuals to have delusions or fragmented thoughts and can cause them to think, feel and behave differently), and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior); -The resident manipulated his/her blood glucose levels by withholding food to decrease levels and eating sweets to increase levels; -The resident will not have signs and symptoms of hyperglycemia or hypoglycemia through review date; -Educate the resident on the importance of controlling blood glucose levels; -Educate the resident on the risks of manipulating blood glucose levels; -Monitor the resident's blood glucose levels and administer insulin per physician orders. Review of the resident's admission Minimum Data Set (MDS), a federally required assessment completed by staff, dated 02/23/24, showed the following: -Cognitively intact; -Understands and is understood; -No behaviors or rejection of care; -Insulin injections daily. Review of the resident's Physician's Orders, dated 04/16/24, showed: -Humalog injection solution (Insulin Lispro) (rapid acting insulin) 100 units/milliliter (u/ml), inject 14 units subcutaneously (subq) (beneath or under the skin) with meals for diabetes mellitus type 1, for blood glucose greater than 400 call primary care physician; -GlucaGen HypoKit Injection Solution Reconstituted (Glucagon) inject 1 milligram (mg) subcutaneously every 15 minutes as needed for blood glucose less than 70 and unresponsive; -Blood glucose checks before meals and at bedtime. Notify the physician for blood glucose less than 60 or greater than 400; -No order for Glucagon tablets. Review of the prescribing information for GlucaGen, located on the Food and Drug Administration's website showed: -Used to treat severe hypoglycemic reactions; -Patients should be given supplemental carbohydrates as soon as they awaken and are able to swallow to restore the liver glycogen and prevent recurrence of hypoglycemia; -Even if the treatment awakens the person, tell their doctor right away- their dose of diabetes medication may need to be changed; -Hypoglycemia may happen again after receiving GlucaGen treatment. Early symptoms of hypoglycemia may include: anxiety, depressed mood, irritability, abnormal behavior, personality changes, restlessness. Review of the resident's Physician's Orders, dated 05/07/24, showed Lantus SoloStar (Insulin Glargine) (long acting insulin) subq Solution Pen-Injector 100 unit/ml, inject 45 units subcutaneously every morning and at bedtime for diabetes mellitus. Review of the prescribing information for Lantus, long-acting human insulin showed: Warnings and Precautions: Hyperglycemia or hypoclycemia- Make any changes to the insulin regimen under close medical supervision. Hypoglycemia: most common adverse reaction associated with insulins. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. May impair concentration ability. Review of the resident's quarterly MDS, dated [DATE], showed: -No rejection of care; -Insulin administered daily. Review of the resident's MAR, dated 07/01/24, showed the resident's blood glucose at 9:00 P.M. was 403 (the medical record showed no documentation staff notified the physician as ordered). Review of the resident's physician note, dated 07/02/24, showed the following: -Uncontrolled diabetes mellitus type 1; -GlucaGen Hypoglycemia Kit Injection Solution Reconstituted (Glucagon HCI (rDNA)), inject 1 milligram (mg)/ml subcutaneously as needed for hypoglycemia; for blood glucose less than 70 and if the resident is unresponsive, may repeat every 15 minutes; -Humalog injection solution 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime related to type 1 diabetes mellitus; -If blood glucose is 151 - 200 = administer 3 units; -201 - 250 = 5 units; -251 - 300 = 7 units; -301 - 350 = 9 units; -351 - 400 = 11 units; call primary physician for blood glucose greater than 400; -Levemir FlexPen Subcutaneous Solution Pen-injector 100 units/ml inject 28 unit subq two times a day related to type 1 diabetes; Note: This medication list is not the same as the medications on the physician's orders; the resident was not on sliding scale insulin and the resident was on Lantus at a different dose and not Levemir. Per the physician this was probably an old note that came forward. The orders from 4/16/24 and 5/7/24 were accurate and current. Review of the resident's July 2024 MAR showed the following: -On 07/02/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 437; -On 07/03/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 461; -On 07/04/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 498; -On 07/04/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 426; -On 07/04/24 at 9:00 P.M., the resident's blood glucose was 500; -On 07/05/24 at 7:00 A.M., the resident's blood glucose was 445; -On 07/05/24 at 5:00 P.M., the resident's blood glucose was 101. Staff documented the resident refused his/her ordered Humalog insulin; -On 07/07/24 at 11:00 A.M., the resident's blood glucose was 46. Staff documented the resident's ordered Humalog was not administered, no insulin required (the resident's administration order was not on a sliding scale for administration and did not have hold parameters). Review of the resident's medical record showed no documentation staff notified the physician as ordered for any of the instances from 07/02/24-07/7/24 when the resident's blood sugar was over 400. There was no documentation staff contacted the physician when the resident refused insulin or when staff omitted insulin when the resident's blood glucose was 46. Review of the resident's Progress Notes, dated 07/08/24 at 4:25 P.M., showed the following: -LPN B documented the resident currently refusing glucose check, call placed to legal guardian with permission to hold resident's cigarettes and/or vape until resident is compliant with medication. Resident educated on restriction and resident said he/she would do whatever he/she wanted. Legal guardian aware, will continue to monitor; -On 07/08/24 at 9:00 P.M., the resident's blood glucose was marked with an X, and that the resident refused his/her ordered Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's refusal for a blood glucose check or administration of Lantus insulin. Review of the resident's July 2024 MAR showed the following: -On 07/09/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 406; -On 07/10/24 at 12:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/10/24 at 5:00 P.M., staff documented the resident refused his/her ordered Humalog insulin; -On 07/11/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 32 and staff held the resident's ordered Lantus insulin, see progress notes. Review of the resident's Progress Notes, dated 7/11/24 at 7:52 A.M., showed LPN B documented the resident glucose reading of 32, difficult to arouse. Glucagon injection administered as ordered as well as Boost (liquid nutritional supplement taken by mouth). Review of the resident's July 2024 MAR showed on 07/11/24 at 8:00 A.M., LPN B documented holding the resident's ordered Humalog insulin, see progress note (resident's blood sugar at 7:00 A.M. was 32). Review of the resident's medical record showed no documentation staff notified the resident's physician of the resident's high and low blood glucose levels, refusals of Humalog insulin, administration of Glucagon, or holding administration of insulin documented on the MAR between 7/9/24 and 7/11/24. Review of the resident's July 2024 MAR showed the following: -On 07/11/24 at 4:00 P.M., staff documented the resident's blood glucose was 342; -On 07/11/24 at 9:00 P.M., the documentation box for the resident's blood glucose check was blank indicating staff did not complete the ordered procedure with no documented reason why; -On 07/11/24 at bedtime, the administration box for the resident's ordered Lantus insulin was blank, indicating staff had not administered the ordered medication with no documentation reason why. Review of the resident's Progress Notes, for 07/11/24, showed no documentation regarding why the resident's blood glucose checks were not completed as ordered or why the resident's bedtime dose of Lantus insulin was not administered as ordered. There was no documentation staff notified the physician. Review of the resident's July 2024 MAR showed on 07/12/24 at 7:00 A.M., LPN B documented the resident's blood glucose was 58 and staff held the resident's morning Lantus. Refer to progress note. Review of the resident's Progress Notes, for 07/12/24, showed no documentation regarding staff holding the resident's morning Lantus insulin due to the resident's low blood glucose or notification of the physician. Review of the resident's July 2024 MAR showed the following: -On 07/13/24 at 7:00 A.M., staff documented the resident's blood glucose was 44 and staff held the resident's ordered morning Humalog insulin, that it was not required, and the resident's ordered morning Lantus insulin was documented as not required; -On 07/13/24 at 4:00 P.M., staff documented the resident's blood glucose was 30 and the resident's ordered evening Humalog insulin as hold see progress note. Review of the resident's Progress Notes, dated 7/13/24 at 5:27 P.M., showed resident rechecked and blood glucose was 47; resident was still eating and drinking, will recheck. There was no documentation of notification to the physician of the resident's very low blood glucose levels or staff holding the resident's insulin. Review of the resident's July 2024 MAR showed the following: -On 07/14/24 at 7:00 A.M., staff documented the resident refused his/her ordered morning Humalog insulin; no documented reason why; -On 07/14/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/14/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin and referred to the progress note; -On 07/14/24 at 9:00 P.M., LPN B documented the resident's blood glucose was 57 and he/she did not administer the resident's ordered bedtime Lantus insulin, refer to progress note. Review of the resident's Progress Notes, dated 7/14/24, showed the following: -No documentation to show a follow up blood glucose was obtained after the 11:00 A.M. reading of 40; -No documentation regarding staff holding the resident's ordered Humalog insulin at 12:00 P.M.; -No documentation to show a follow up blood glucose was obtained after the 9:00 P.M. reading of 57; -No documentation regarding staff holding the resident's ordered bedtime Lantus insulin. Review of the resident's medical record showed no documentation staff notified the physician of the resident's low blood glucose or staff holding ordered insulin. Review of the resident's July 2024 MAR showed the following: -On 07/15/24 at 11:00 A.M., LPN B documented the resident's blood glucose was 537; the medical record showed no documentation LPN B notified the physician as ordered; -On 07/16/24 at 12:00 P.M., staff documented the resident's blood glucose was 133; staff documented not administering the resident's ordered Humalog insulin, that it was not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/16/24 at 5:00 P.M., staff documented the resident's blood glucose was 275; staff documented not administering the resident's ordered Humalog, insulin not required; (the resident was not on a sliding scale insulin administration); staff had not administered the resident's insulin as ordered; -On 07/17/24 at 8:00 A.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 07/17/24, showed no documentation as to why staff held the resident's ordered Humalog insulin for 8:00 A.M. administration. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 11:00 A.M., staff documented the resident's blood glucose was 59; -On 07/17/24 at 12:00 P.M., staff documented not administering the resident's ordered Humalog insulin, insulin not required; (the resident was not on a sliding scale insulin administration). Review of the resident's Progress Notes, dated 7/17/24 at 1:51 P.M., showed the following: -Staff administered Glucagon; -No documentation of follow-up blood glucose monitoring, physician notification, documentation of the resident's condition or response to Glucagon. Review of the resident's July 2024 MAR showed the following: -On 07/17/24 at 4:00 P.M., staff documented the resident's blood glucose was 265; -On 07/17/24 at 5:00 P.M., blood glucose of 245, staff documented not administering the resident's ordered Humalog insulin, the insulin was not required; (the resident was not on a sliding scale insulin administration); -On 07/18/24 at 7:00 A.M., staff documented the resident's blood glucose was 36; the resident refused his/her 8:00 A.M. Humalog. No documentation staff notified the resident's physician of the resident's low blood sugar. Review of the resident's July 2024 MAR showed the following: -On 07/18/24 at 9:00 P.M., the resident's blood glucose check box was blank indicating staff had not completed the procedure; -On 07/19/24 at 8:00 A.M., staff documented the resident refused his/her morning Humalog insulin, blood glucose was 166; -On 07/19/24 at 11:00 A.M., staff documented the resident's blood glucose was 40; -On 07/19/24 at 12:00 P.M., staff documented holding the resident's ordered Humalog insulin, see progress note. Review of the resident's Progress Notes, dated 7/19/24 at 12:23 P.M., showed repeat blood glucose 85 on recheck. Resident's lunch tray arrived and resident going to eat lunch. Review of the resident's July 2024 MAR showed on 07/19/24 at 5:00 P.M., staff documented holding the resident's ordered evening Humalog insulin, see progress note. Blood glucose was 253. Review of the resident's Progress Notes, dated 07/19/24 at 5:36 P.M., showed the resident was refusing to eat dinner. No documentation to show staff notified the physician. (Staff held the resident's insulin at 5:00 P.M.) Review of the resident's July 2024 MAR showed the following: -On 07/25/24 at 4:00 P.M., LPN B documented the resident's blood glucose was 60; -On 07/25/24 at 9:00 P.M., staff documented the resident's blood glucose not taken because the resident was sleeping. Staff documented not administering the resident's ordered bedtime Lantus insulin because the resident was sleeping. Review of the resident's Progress Notes showed the following: -On 07/26/24 at 6:03 A.M., staff documented the resident was asleep during (9:00 P.M.) medication pass this shift (night shift); staff and nurse attempted three times to awaken resident so he/she could receive a blood glucose check, insulin and bedtime medications. Resident was hard to wake up; on second try, he/she threw back the covers and never got up. (There was no documentation staff assessed the resident for signs or symptoms of hypoglycemia when the resident was difficult to arouse. Staff did not document notifying the resident's physician staff had not completed the blood glucose or administered the resident's Lantus insulin.) -On 07/27/24 at 11:00 A.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, inject 1 mg subq every 15 minutes as needed for blood glucose less 70 and the resident is unresponsive; -On 07/27/24 at 11:13 A.M., staff documented the physician was notified of the resident's drop in blood glucose to 22 and Glucagon administered along with snacks as the resident was not speaking to nurses any more. After administration of Glucagon injection and snack, resident came back to talking and staff educated the resident on the need to eat protein and not skip meals during the day; -On 07/27/24 at 11:24 A.M., staff documented the resident's physician called and said to continue insulin as ordered. He said the snacks and Gucagon given should keep the resident's blood glucose up and to resume orders and check as needed; -On 07/27/24 at 12:31 P.M., staff documented, upon coming to get blood glucose, resident informed staff that he/she only ate his/her cookie off his/her meal tray. Checking blood glucose before giving his/her insulin. Review of the resident's July 2024 MAR showed staff documented on 07/27/24 at 12:00 P.M., the resident's blood glucose was 45. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 12:44 P.M., staff documented the resident had a the meal tray and resident reported she did not like the meal and only ate the cookie. Staff gave the resident's insulin at noon. A meal alternative was brought to the resident at his/her request. When staff brought the resident the peanut butter sandwich, the resident refused to eat the sandwich. Upon refusal, the DON was notified and had a conversation with the resident. The resident refused the DON's instructions and refused to cooperate. The resident threw the sandwich out the door. -On 07/27/24 at 1:08 P.M., resident's blood glucose low and refusing to eat. Directed charge nurse to contact physician and guardian and to follow physician's orders. (There was no further documentation to show staff contacted the physician, new order, or response from the physician. There was no documentation of additional blood glucose testing.) Review of the resident's July 2024 MAR showed on 07/27/24 at 9:00 P.M., staff documented the resident's ordered bedtime Lantus insulin was not given because the resident refused. Review of the resident's Progress Notes showed the following: -On 07/27/24 at 9:04 P.M., staff documented administering GlucaGen Hypoglycemia Kit Injection Solution, Inject 1 mg subcutaneously every 15 minutes as needed for blood glucose less 70 and the resident was unresponsive. Staff educated the resident regarding refusing to eat after insulin given. Resident educated on importance of eating when insulin given. Resident understands protein is needed when blood glucose is low. Resident encouraged to be complaint with diabetes regimen. Resident voices understanding. Resident tearful at this time. Resident able to vent and verbalize feelings. Will continue to monitor. Resident educated when staff administered Glucagon related to low blood glucose and being unresponsive. There was no documentation staff notified the resident's physician. There was no documentation the resident's blood glucose was below 70 or the resident was unresponsive. -On 07/27/24 at 9:25 P.M., staff documented resident refused Lantus insulin at this time due to blood glucose of 86 and has been low off and on all day; will recheck and reattempt later, currently eating a snack. (No documentation of any further blood glucose checks) -On 07/28/24 at 10:57 A.M., staff documented called to resident's hall for hypoglycemic emergency. Checked resident's blood glucose, result was 33. Review of the resident's July 2024 MAR showed on 7/28/24 at 11:00 A.M. (3 minutes prior to the progress note above) showed the resident's blood glucose result was 262. Review of the resident's Progress Notes showed the following: -On 07/28/24 at 10:57 A.M., staff documented the resident's blood glucose dropped to 31, trying to get snack in resident. Resident refused to comply with food or water. Resident is diaphoretic (sweating). -On 07/28/24 at 10:59 A.M., staff documented the resident was given snack, resident is more verbal and can eat and drink; -On 07/28/24 at 11:00 A.M., staff documented administering Glucagon; resident still unable to verbally communicate, eat or drink. Unable to reach physician via call, responded in text message and notified DON; -On 07/28/24 at 11:14 A.M., staff documented the resident's blood glucose was 86; offered another snack of protein, resident complied. Physician updated; -On 07/28/24 at 11:22 A.M., staff documented blood glucose recheck resulted 74; -On 07/28/24, bedtime liberalized pass no specific time documented, staff documented not administering the resident's ordered bedtime Lantus because the resident refused; -On 07/29/24 at 11:43 A.M., staff documented the resident's physician was notified the resident's blood glucose was 102 and is to be given 14 units of insulin. Physician said to still give the 14 units but only once fork is in his/her hand to eat lunch. During an interview on 07/25/24 at 10:45 A.M. and 07/30/24 at 12:30 P.M., the resident said the following: -He/She wanted to go to an endocrinologist (physician that specializes in treating health conditions related to hormones, including diabetes) but no one would let him/her go; -Staff do not administer his/her bedtime insulin most of the time until midnight or 1:00 A.M. and it upsets him/her because he/she has to stay up even if he/she was tired. If he/she goes to bed, the staff will document he/she refused his/her scheduled insulin and not give the insulin; -LPN B refuses to give his/her Humalog insulin unless his/her blood glucose was over 400 and has the Certified Medication Technician (CMT's) trained to refuse to give him/her the Humalog as well. He/She does not feel good when staff will not administer the insulin; -The Assistant Director of Nursing (ADON) was the only staff that gave the insulin like it was supposed to be given and he/she feels better then. Since staff do not give the insulin consistently, and he/she does get the doses, his/her blood glucose will bottom out; -He/She had never refused his/her insulin because he/she does not want to die; -If staff charted he/she refused, it was because the staff were too scared to give it to him/her; -He/She thinks staff are putting food in his/her mouth when he/she was not fully coherent when his/her blood glucose was low, because he/she wakes up with food in his/her mouth; -He/She was scared staff were going to cause him/her to aspirate (choke), and get pneumonia; -Staff held his/her insulin this weekend (no date given) because his/her blood glucose dropped into the 40s; -LPN M held his/her Lantus because he/she was scared the resident would bottom out in his/her sleep; -Staff will refuse to give his/her insulin and chart that he/she refused it; -Staff also told his/her guardian he/she was refusing to eat, but he/she doesn't remember doing that; -When his/her blood glucose was low, staff have told him/her he/she was argumentative and would not cooperate; -He/She gets upset for being punished when he/she is not aware of his/her actions. The staff had taken away smoking privileges and talked to him/her about refusing to eat like it was a behavior, but his/her blood sugar was low at the time causing her to react like this; -The resident voiced concerns of being fearful when his/her blood glucose levels were not controlled, the resident said he/she thought staff were going to cause him/her to go into a diabetic coma, diabetic ketoacidosis, or die from holding his/her insulin. During an interview on 07/25/24 at 10:31 A.M., LPN B said the following: -The resident does not get Humalog insulin unless his/her blood glucose was above 400, it was ordered that way; -The order specifically said not to give the Humalog unless the resident was over 400 or the resident will bottom out (blood glucose will go too low); -The resident's physician had not given parameters to hold the resident's insulin that he/she knew of; -Sometimes he/she will do what he/she needs to, or document what he/she needs to, because the physicians aren't at the facility and do not realize the resident will bottom out; -He/She was not going to give the resident insulin if he/she knew it will cause the resident harm; -The resident does pretty well until his/her blood glucose gets below 40; -Sometimes at 40, the resident can still eat and talk so you can give the Glucagon tablets or snacks; -The resident's physician will specifically say not to hold the resident's Lantus and instruct staff to administer it after the resident starts eating. (Review of the resident's medical record showed the resident had no order to hold Humalog insulin and no order for Glucagon tablets.) During an interview on 07/25/24 at 11:05 A.M., the ADON said the resident gets nervous to take the Humalog insulin if his/her blood glucose was under 200, because he/she bottoms out. The resident will always take the insulin and they watch him/her closely because his/her blood glucose will go low very quickly. 2. Review of Resident #11's Admission MDS, dated [DATE], showed it was very important for the resident to have snacks available between meals. Review of the resident's Care Plan, dated 04/24/24, showed the following: -At risk for unstable blood sugars and ineffective therapeutic regimen related to diagnosis of DM II (type of diabetes where the body doesn't make enough insulin or doesn't use insulin well); -Follow up with physician as needed; -Medication provided as prescribed. Review of the resident's POS dated 07/2024, showed the following: -Diagnoses included DM II; -Blood glucose monitoring before meals (AC) and at bedtime (HS); -Insulin Aspart (rapid acting insulin) Flexpen subq solution pen injector 100 u/ml, inject 15 units subq three times a day for DM II, notify physician if blood glucose is over 350 mg/dL; (stop date 07/09/24); -Humalog [NAME] kwikpen subq solution pen-injector 100 u/ml, inject 15 units subq three times a day for DM II (7/9/24); -Humalog kwikpen subq solution pen-injector 200 units/mL, inject as per sliding scale: (for blood glucose results of 0-150, administer zero units of insulin, 151-200=two units, 201-250=four units, 251-300=six units, 301-350=eight units, 351-400=10 units, 401-450=12 units, if above 500 call physician) subq three times a day (7/9/24). Review of resident's MAR, dated 07/02/24, showed the resident's blood glucose at lunch was 353 mg/dL and was 400 mg/dL at supper. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered for either of these readings. Review of resident's MAR, dated 07/03/24, showed the resident's blood glucose at supper was 417 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/06/24, showed resident's blood glucose at lunch was 401 mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/08/24, showed resident's blood glucose at supper was 351mg/dL. Review of the resident's medical record showed no documentation the resident's physician was notified as ordered. Review of resident's MAR, dated 07/18/24, showed the following: -The administration box for the resident's ordered 4:30 P.M. blood glucose check was blank, indicating the procedure had not been completed; -The administration box for the resident's ordered 5:00 P.M. Humalog [NAME] 15 unit administration was blank, indicating the ordered medication had not been administered; -The administration box for the resident's ordered 5:00 P.M. humalog sliding scale insulin blank, indicating staff did not administer the sliding scale insulin. Review of the resident's medical record showed no documentation to explain why the resident's blood glucose check and ordered insulin had not been obtained or administered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #7, and #8), of 15 sampled residents with mental disorders received individualized treatment and services to meet their needs. Resident #7 had verbal and physical behaviors towards others. The resident also displayed suicidal ideation and attempted suicide when he/she tied a cord around his/her neck with intent to hang himself/herself and end his/her life. Resident #8 who had a history of suicide attempts, told his/her guardian he/she wanted to hang himself/herself while at the facility, and was sent out for a mental health evaluation. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services, including counseling to address the residents' psychosocial well-being. The facility census was 98. Review of the facility policy, Behavioral Health Management and Interventions, dated 11/1/22, showed the following: -As a part of the initial assessment staff will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., bipolar disorder or schizophrenia) -As a part of the comprehensive assessment, staff will evaluate, based on input from the resident, and representative review of medical record and general observations; -The staff will identify, document, and inform the medical practitioner about specific details regarding changes in an individual's mental status, behavior and cognition; -Onset, duration, intensity, and frequency of behavioral symptoms, any precipitating or relevant factors, or environmental triggers; -New onset of behavior will be documented regardless of the degree of risk to the resident or others; -The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition; -The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly, safety strategies will be implemented immediately if necessary to protect the resident and others from harm; -The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice; -The resident and the representative will be involved in the development and implementation of the care plan; -Interventions will be individualized to provide the highest level of well-being for the resident; -Interventions and approaches will be based on assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior and will be documented on the care plan and modified when appropriate; -Any resident with behavior that has been identified that would present a potential danger to either himself or other residents will be placed on increased visual monitoring unless other immediate interventions are needed; -If necessary, in an emergent situation, the physician or psychiatrist will be notified of the emergent need of the behavior and emergency transfer/discharge policies will be implemented. 1. Review of Resident #7's PASARR (Pre-admission and Resident Review)/Mental Illness Update, Level II Evaluation, dated 3/11/24, showed the following: -Diagnoses included psychotic disorder (a mental disorder characterized by a disconnection from reality), bipolar disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), impulse control disorder ( a behavioral condition that make it difficult to control action or reactions which can cause harm to others or oneself) and borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships); -The resident has made comments about suicidal ideation with plans throughout hospitalization and to his/her guardian; -The individual needs or continues to need the following supports and services individualized support plan (ISP) individualized treatment plan (ITP), behavioral support plan from department of mental health (DMH) or community of mental health center and/or developmental disability regional office; -Behaviors to be addressed in the nursing facility plan of care included aggression, wandering depression, anxiety, and suicidal ideation; -Provision of the structured environment to include supervision for the safety of self and others, history of aggression and suicidal ideations; -Crisis interventions services to include suicidal precautions, assault precautions, and elopement precautions. Review of the resident's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/24/24, showed the following: -The resident was cognitively intact; -Able to make self-understood and able to understand others; -No behavioral symptoms exhibited; -Psychological therapy by any licensed mental health professional was marked as none. Review of the resident's nurses note dated 3/29/24 at 12:00 A.M. showed the following: -The resident was noted to be verbally aggressive towards peers, immediate separation and the resident was allowed to vent and verbalize; -The resident requested as needed (PRN) medication, Zyprexa (antipsychotic used to treat mental disorders) 10 milligrams (mg) administered by mouth (PO) as ordered. Staff educated the resident on therapeutic communication. Review of the resident's nurses note, dated 4/2/24 at 11:30 P.M., showed the following: -Received call from the crisis center the resident had contacted the suicide crisis center and said he/she was suicidal; -The nurse offered Zyprexa at which time the resident became verbally aggressive towards the nurse, the resident began punching walls and tables, the resident continued saying he/she was going to commit suicide or do whatever it took to get out of here. Staff contacted the administrator and 1:1 initiated. The resident continued to escalate at which time code green (behavioral emergency) was called and the resident became increasingly aggressive; -Long-term psych called with no answer, physician on call notified and order to send the resident to the hospital. Emergency medical services (EMS) arrived, and the resident continued to be verbally aggressive and attempted to refuse transport, eventually became compliant and agreed to transport. Review of the resident's nurses note dated 4/3/24 at 6:50 P.M., showed the resident returned from the hospital with no new orders. Review of the resident's nurses note dated 4/6/24 at 11:14 P.M. showed the following: -A code green was called, the resident was extremely agitated and verbally abusive towards another resident and staff, multiple attempts to let resident vent and then to redirect were unsuccessful; -Received a new order for Haldol (antipsychotic) mg by mouth or intramuscular (IM) every eight hours for agitation. Administered Haldol by mouth. The resident was currently resting quietly in bed with no further behaviors. Review of the resident's care plan dated 4/8/24 showed the following: -The resident was at risk to injury to self and others related to verbally aggressive behaviors and behaviors of self-harm; -Allow time to voice feelings and concerns as needed, follow-up with guardian as needed, frequent checks for safety, provide means to release tension and redirect anger, redirect as needed and removed from situation as needed. Review of the resident's nurses note dated 5/1/24 at 7:30 P.M. showed the following: -Staff noted the resident was verbally aggressive and attempted to be physically aggressive, immediately separated the resident from his/her peers; -The resident was allowed to vent and verbalize, and Benadryl (an antihistamine) administered, and the resident tolerated it well; -Staff educated the resident on therapeutic communication and coping skills with understanding voiced. Review of the resident's physician order sheets (POS) dated May 2024 showed an order for Benadryl 25 mg, to be administered PO every eight hours PRN for agitation/anxiety (start date 4/29/24). Review of the resident's MAR dated May 2024 showed on 5/1/24 staff administered Benadryl 25 mg at 8:30 P.M. Review of the resident's nurses note dated 5/19/24 at 11: 21 P.M. showed the following: -The resident was verbally aggressive towards staff and said, I'm going to kill myself tonight. I'm done. I can't take it anymore. Allowed the resident to vent feelings, multiple attempts to redirect the resident were unsuccessful; -The resident continued to make suicidal threats, spoke to the guardian who said to send the resident to the hospital. Review of the resident's hospital discharge instructions dated 5/20/24 showed the following: -The resident was examined, and any medical condition stabilized; -Follow-up with the primary care physician in the next four days. Review of the resident's nurses note date dated 5/25/24 at 10:39 P.M. showed the following: -The resident said he/she tried to strangle himself/herself, but the string broke, a red mark was noted around the resident's neck; -The string from the resident's sweat pants was broken into two pieces. The resident was very anxious and emotional and said he/she didn't want to live anymore. The resident refused any PRN medications and said the (medications) didn't help; -The resident was transferred to the hospital via facility transportation. During an interview on 5/29/24 at 2:15 P.M. the resident said the following: -On 5/25/24 he/she wanted to end his/her life. He/She took a string and tied it to the top of the door to his/her room where the doorstop was attached, then dropped down to strangle himself/herself, but the string broke; -He/She had tried to talk to staff about this and they wouldn't listen. He/She felt his/her medications weren't working. He/She also wanted to hurt others; -He/She needed counseling, someone to talk to. The facility told him/her they were trying to get counseling set up for him/her. During an interview on 5/29/24 at 1:30 P.M. the resident's guardian said the following: -The resident actively attempted suicide on 5/25/24 and used the elastic band from his/her pants; -The last few conversations with the resident he/she had to end the conversation because the resident was so verbally aggressive; -He/She would expect the facility to follow the PASARR for services; -The resident made comments about suicide more for attention, but comments of suicide or wanting to harm himself/herself should never be dismissed. The resident had attempted suicide in the past; -Any verbalization of suicide should be taken seriously; -He/She would expect the resident to have counseling services, the resident needed one on one validation and did not like to be in a group; -The resident was very unpredictable. 2. Review of the resident's face sheet showed Resident #8 admitted to the facility on [DATE]. Review of the residents PASARR, dated 10/4/18, showed the following: -Diagnoses included severe bipolar disorder, pedophilia (sexual feelings towards children), intellectual disability mild, borderline personality disorder and anti-social personality (disregard for the rights and feelings of others, and to show no regard for right and wrong); -The resident had a history of physical and sexual abuse, history of suicidal ideation and suicidal attempts, attempts to hang himself/herself, overdose, cut wrists and a long history of fire setting and history of arson; -Problematic behaviors include impatient/demanding, disturbs other residents, physically threatening, talks of suicide/ideation, suicide threats and injuries self; -Staff work with client to give supportive structure. Staff monitor and provide safety; -Guardian is requesting nursing home placement due to client's recent suicidal ideation and threats. Client has had suicidal attempts in the past and must be monitored; -The resident needs continued services, structured socialization activities to diminish tendencies toward isolation and withdrawal, development of appropriate personal support networks, implementation of systemic plans to change inappropriate behaviors, provision of a structured environment, Department of Mental Health regional office referral continued services. Review of the resident's nurses note, dated 4/30/24 at 2:02 A.M., showed the following: -The resident became upset and agitated with roommate for calling him/her names and being rude; -The resident requested a new roommate and chose not to sleep in his/her room; -The resident decided to sleep in the common area in a recliner because he/she didn't want to go back in his/her room. Review of the resident's nurses note, dated 5/1/24 at 9:16 P.M., showed the following: -A code green was called, the resident noted to be verbally aggressive towards staff and physical aggressive towards property, immediate staff interventions and separation, resident allowed to vent and verbalize feelings. Resident said he/she was upset about being asked to clean up dirty cups in rooms as well as wanting to return to a previous facility; -Education provided to resident on appropriate behaviors with understanding voiced. Review of the resident's care plan dated 5/5/24 showed the following: -The resident was at risk to self and others and impaired social interaction related to behaviors of verbal and physical aggression towards staff and peers; -Administer antipsychotic medications as ordered; -Social services to follow-up as needed. Review of the resident's nurses note, dated 5/16/24 at 2:24 A.M., showed the resident was readmitted to the special care unit from an inpatient psychiatric evaluation. The resident was appropriate for placement and needs could be met. During an interview on 5/29/24 at 4:06 P.M. the resident said the following: -He/She didn't like it at the facility and wanted to move; -He/She was not receiving any counseling services. During an interview on 6/5/24 at 9:25 A.M. the resident's guardian said the following: -On 5/2/24 the resident called him/her and said he/she wanted to hang himself/herself; -He/She notified the facility immediately and requested the resident be sent out for a mental health evaluation; -The resident had a long history of mental illness and suicide attempts. He/She would expect the resident to receive counseling services to meet his/her mental health needs. 3. During an interview on 5/28/24 at 4:45 P.M., Licensed Practical Nurse (LPN) A said the following: -It was baseline for Resident #7 to make suicidal comments. The plan was usually to hang himself/herself; -He/She was familiar with the resident prior to working at this facility and the resident had attempted to hang himself/herself before; -Interventions the staff used were to keep him/her busy, take him/her on outings, administer as needed (PRN) medications and send out for psychiatric evaluations. -Resident #8 sent out for a mental health evaluation because of suicidal ideation, he/she was not sure if the resident had a plan, he/she thought medications were changed when the resident was sent out, but not sure of any other changes or interventions put in place; -The facility was working on getting counseling set up for the residents with mental health issues, he/she was not sure exactly how long they had been working on this, it had been awhile. During an interview on 5/28/24 at 3:45 P.M. Unit Manager F (for the behavioral unit) said the following: -He/She tried to keep Resident #7 busy, if the resident was busy he/she didn't make suicidal comments; -The resident will say that he/she doesn't want to live anymore, but did not have a plan. The resident had not attempted suicide since he/she admitted to the facility; -The facility was not yet set up with counseling or any services with the Department of Mental Health; -He/She had groups on the hall and would pass out handouts about stress and control. He/She left it up to the residents if they wanted to attend groups; -Resident #8 called his/her guardian and told the guardian that he/she wanted to hurt himself/herself so he/she was sent out for a mental health evaluation. The resident had never made comments about suicide prior to that; -He/She was not sure who updated the care plans with interventions, possible corporate. During an interview on 5/29/24 at 1:50 P.M. and 6/6/24 at 10:00 A.M., the Administrator said the following: -She felt Resident #7's comments regarding suicide were attention seeking, but expected staff to always take these comments seriously and notify her so she could give direction; -The last time Resident #7 went out to the hospital (5/25/24), the resident had reported he/she had a cord or string around his/her neck and it broke, he/she verbalized actually wanting to harm himself/herself. The resident was immediately sent out for evaluation; -No new interventions have been put in place regarding suicidal ideation as each time she spoke to the resident about suicidal comments he/she had made towards staff, the resident would change it around and say he/she didn't want to hurt himself/herself, but that the issue was about pain or a medication pass (not actually an intent to harm himself/herself); -The facility was trying to get the resident set up with counseling, but currently the counseling service they had a contract with didn't have any open spots; -The behavioral unit opened in November of 2023, the facility had not been able to provide counseling services or mental health services to those specific residents. Counseling services were being provided to the general population, but not on the unit. The counseling service they currently had, only had limited spots and those were filled with the residents in the general population who had mental health issues. They have been working on getting these services set up. The only service they have provided while waiting on these services was church on Sunday, which could help with spiritual guidance, no other services were provided; -The facility had a daily nursing meeting, during the meeting new interventions were discussed. If any new interventions were put in place the care plan coordinator was emailed (as he/she was corporate staff and did not work onsite at the facility) with new interventions and he/she would update the care plan in the EMR.

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #7, and #8), of 15 sampled residents with mental disorders received individualized treatment and services to meet their needs. Resident #7 had verbal and physical behaviors towards others. The resident also displayed suicidal ideation and attempted suicide when he/she tied a cord around his/her neck with intent to hang himself/herself and end his/her life. Resident #8 who had a history of suicide attempts, told his/her guardian he/she wanted to hang himself/herself while at the facility, and was sent out for a mental health evaluation. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services, including counseling to address the residents' psychosocial well-being. The facility census was 98. Review of the facility policy, Behavioral Health Management and Interventions, dated 11/1/22, showed the following: -As a part of the initial assessment staff will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., bipolar disorder or schizophrenia) -As a part of the comprehensive assessment, staff will evaluate, based on input from the resident, and representative review of medical record and general observations; -The staff will identify, document, and inform the medical practitioner about specific details regarding changes in an individual's mental status, behavior and cognition; -Onset, duration, intensity, and frequency of behavioral symptoms, any precipitating or relevant factors, or environmental triggers; -New onset of behavior will be documented regardless of the degree of risk to the resident or others; -The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition; -The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly, safety strategies will be implemented immediately if necessary to protect the resident and others from harm; -The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice; -The resident and the representative will be involved in the development and implementation of the care plan; -Interventions will be individualized to provide the highest level of well-being for the resident; -Interventions and approaches will be based on assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior and will be documented on the care plan and modified when appropriate; -Any resident with behavior that has been identified that would present a potential danger to either himself or other residents will be placed on increased visual monitoring unless other immediate interventions are needed; -If necessary, in an emergent situation, the physician or psychiatrist will be notified of the emergent need of the behavior and emergency transfer/discharge policies will be implemented. 1. Review of Resident #7's PASARR (Pre-Admission and Resident Review)/Mental Illness Update, Level II Evaluation, dated 3/11/24, showed the following: -Diagnoses included psychotic disorder (a mental disorder characterized by a disconnection from reality), bipolar disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), impulse control disorder ( a behavioral condition that make it difficult to control action or reactions which can cause harm to others or oneself) and borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships); -The resident has made comments about suicidal ideation with plans throughout hospitalization and to his/her guardian; -The individual needs or continues to need the following supports and services individualized support plan (ISP) individualized treatment plan (ITP), behavioral support plan from department of mental health (DMH) or community of mental health center and/or developmental disability regional office; -Behaviors to be addressed in the nursing facility plan of care included aggression, wandering depression, anxiety, and suicidal ideation; -Provision of the structured environment to include supervision for the safety of self and others, history of aggression and suicidal ideations; -Crisis interventions services to include suicidal precautions, assault precautions, and elopement precautions. Review of the resident's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/24/24, showed the following: -The resident was cognitively intact; -Able to make self-understood and able to understand others; -No behavioral symptoms exhibited; -Psychological therapy by any licensed mental health professional was marked as none. Review of the resident's nurses note dated 3/29/24 at 12:00 A.M. showed the following: -The resident was noted to be verbally aggressive towards peers, immediate separation and the resident was allowed to vent and verbalize; -The resident requested as needed (PRN) medication, Zyprexa (antipsychotic used to treat mental disorders) 10 milligrams (mg) administered by mouth (PO) as ordered. Staff educated the resident on therapeutic communication. Review of the resident's nurses note, dated 4/2/24 at 11:30 P.M., showed the following: -Received call from the crisis center the resident had contacted the suicide crisis center and said he/she was suicidal; -The nurse offered Zyprexa at which time the resident became verbally aggressive towards the nurse, the resident began punching walls and tables, the resident continued saying he/she was going to commit suicide or do whatever it took to get out of here. Staff contacted the administrator and 1:1 initiated. The resident continued to escalate at which time code green (behavioral emergency) was called and the resident became increasingly aggressive; -Long-term psych called with no answer, physician on call notified and order to send the resident to the hospital. Emergency medical services (EMS) arrived, and the resident continued to be verbally aggressive and attempted to refuse transport, eventually became compliant and agreed to transport. Review of the resident's nurses note dated 4/3/24 at 6:50 P.M., showed the resident returned from the hospital with no new orders. Review of the resident's nurses note dated 4/6/24 at 11:14 P.M. showed the following: -A code green was called, the resident was extremely agitated and verbally abusive towards another resident and staff, multiple attempts to let resident vent and then to redirect were unsuccessful; -Received a new order for Haldol (antipsychotic) mg by mouth or intramuscular (IM) every eight hours for agitation. Administered Haldol by mouth. The resident was currently resting quietly in bed with no further behaviors. Review of the resident's care plan dated 4/8/24 showed the following: -The resident was at risk to injury to self and others related to verbally aggressive behaviors and behaviors of self-harm; -Allow time to voice feelings and concerns as needed, follow-up with guardian as needed, frequent checks for safety, provide means to release tension and redirect anger, redirect as needed and removed from situation as needed. Review of the resident's nurses note dated 5/1/24 at 7:30 P.M. showed the following: -Staff noted the resident was verbally aggressive and attempted to be physically aggressive, immediately separated the resident from his/her peers; -The resident was allowed to vent and verbalize, and Benadryl (an antihistamine) administered, and the resident tolerated it well; -Staff educated the resident on therapeutic communication and coping skills with understanding voiced. Review of the resident's physician order sheets (POS) dated May 2024 showed an order for Benadryl 25 mg, to be administered PO every eight hours PRN for agitation/anxiety (start date 4/29/24). Review of the resident's MAR dated May 2024 showed on 5/1/24 staff administered Benadryl 25 mg at 8:30 P.M. Review of the resident's nurses note dated 5/19/24 at 11: 21 P.M. showed the following: -The resident was verbally aggressive towards staff and said, I'm going to kill myself tonight. I'm done. I can't take it anymore. Allowed the resident to vent feelings, multiple attempts to redirect the resident were unsuccessful; -The resident continued to make suicidal threats, spoke to the guardian who said to send the resident to the hospital. Review of the resident's hospital discharge instructions dated 5/20/24 showed the following: -The resident was examined, and any medical condition stabilized; -Follow-up with the primary care physician in the next four days. Review of the resident's nurses note date dated 5/25/24 at 10:39 P.M. showed the following: -The resident said he/she tried to strangle himself/herself, but the string broke, a red mark was noted around the resident's neck; -The string from the resident's sweat pants was broken into two pieces. The resident was very anxious and emotional and said he/she didn't want to live anymore. The resident refused any PRN medications and said the (medications) didn't help; -The resident was transferred to the hospital via facility transportation. During an interview on 5/29/24 at 2:15 P.M. the resident said the following: -On 5/25/24 he/she wanted to end his/her life. He/She took a string and tied it to the top of the door to his/her room where the doorstop was attached, then dropped down to strangle himself/herself, but the string broke; -He/She had tried to talk to staff about this and they wouldn't listen. He/She felt his/her medications weren't working. He/She also wanted to hurt others; -He/She needed counseling, someone to talk to. The facility told him/her they were trying to get counseling set up for him/her. During an interview on 5/29/24 at 1:30 P.M. the resident's guardian said the following: -The resident actively attempted suicide on 5/25/24 and used the elastic band from his/her pants; -The last few conversations with the resident he/she had to end the conversation because the resident was so verbally aggressive; -He/She would expect the facility to follow the PASARR for services; -The resident made comments about suicide more for attention, but comments of suicide or wanting to harm himself/herself should never be dismissed. The resident had attempted suicide in the past; -Any verbalization of suicide should be taken seriously; -He/She would expect the resident to have counseling services, the resident needed one on one validation and did not like to be in a group; -The resident was very unpredictable. 2. Review of the resident's face sheet showed Resident #8 admitted to the facility on [DATE]. Review of the residents PASARR, dated 10/4/18, showed the following: -Diagnoses included severe bipolar disorder, pedophilia (sexual feelings towards children), intellectual disability mild, borderline personality disorder and anti-social personality (disregard for the rights and feelings of others, and to show no regard for right and wrong); -The resident had a history of physical and sexual abuse, history of suicidal ideation and suicidal attempts, attempts to hang himself/herself, overdose, cut wrists and a long history of fire setting and history of arson; -Problematic behaviors include impatient/demanding, disturbs other residents, physically threatening, talks of suicide/ideation, suicide threats and injuries self; -Staff work with client to give supportive structure. Staff monitor and provide safety; -Guardian is requesting nursing home placement due to client's recent suicidal ideation and threats. Client has had suicidal attempts in the past and must be monitored; -The resident needs continued services, structured socialization activities to diminish tendencies toward isolation and withdrawal, development of appropriate personal support networks, implementation of systemic plans to change inappropriate behaviors, provision of a structured environment, Department of Mental Health regional office referral continued services. Review of the resident's nurses note, dated 4/30/24 at 2:02 A.M., showed the following: -The resident became upset and agitated with roommate for calling him/her names and being rude; -The resident requested a new roommate and chose not to sleep in his/her room; -The resident decided to sleep in the common area in a recliner because he/she didn't want to go back in his/her room. Review of the resident's nurses note, dated 5/1/24 at 9:16 P.M., showed the following: -A code green was called, the resident noted to be verbally aggressive towards staff and physical aggressive towards property, immediate staff interventions and separation, resident allowed to vent and verbalize feelings. Resident said he/she was upset about being asked to clean up dirty cups in rooms as well as wanting to return to a previous facility; -Education provided to resident on appropriate behaviors with understanding voiced. Review of the resident's care plan dated 5/5/24 showed the following: -The resident was at risk to self and others and impaired social interaction related to behaviors of verbal and physical aggression towards staff and peers; -Administer antipsychotic medications as ordered; -Social services to follow-up as needed. Review of the resident's nurses note, dated 5/16/24 at 2:24 A.M., showed the resident was readmitted to the special care unit from an inpatient psychiatric evaluation. The resident was appropriate for placement and needs could be met. During an interview on 5/29/24 at 4:06 P.M. the resident said the following: -He/She didn't like it at the facility and wanted to move; -He/She was not receiving any counseling services. During an interview on 6/5/24 at 9:25 A.M. the resident's guardian said the following: -On 5/2/24 the resident called him/her and said he/she wanted to hang himself/herself; -He/She notified the facility immediately and requested the resident be sent out for a mental health evaluation; -The resident had a long history of mental illness and suicide attempts. He/She would expect the resident to receive counseling services to meet his/her mental health needs. 3. During an interview on 5/28/24 at 4:45 P.M., Licensed Practical Nurse (LPN) A said the following: -It was baseline for Resident #7 to make suicidal comments. The plan was usually to hang himself/herself; -He/She was familiar with the resident prior to working at this facility and the resident had attempted to hang himself/herself before; -Interventions the staff used were to keep him/her busy, take him/her on outings, administer as needed (PRN) medications and send out for psychiatric evaluations. -Resident #8 sent out for a mental health evaluation because of suicidal ideation, he/she was not sure if the resident had a plan, he/she thought medications were changed when the resident was sent out, but not sure of any other changes or interventions put in place; -The facility was working on getting counseling set up for the residents with mental health issues, he/she was not sure exactly how long they had been working on this, it had been awhile. During an interview on 5/28/24 at 3:45 P.M. Unit Manager F (for the behavioral unit) said the following: -He/She tried to keep Resident #7 busy, if the resident was busy he/she didn't make suicidal comments; -The resident will say that he/she doesn't want to live anymore, but did not have a plan. The resident had not attempted suicide since he/she admitted to the facility; -The facility was not yet set up with counseling or any services with the Department of Mental Health; -He/She had groups on the hall and would pass out handouts about stress and control. He/She left it up to the residents if they wanted to attend groups; -Resident #8 called his/her guardian and told the guardian that he/she wanted to hurt himself/herself so he/she was sent out for a mental health evaluation. The resident had never made comments about suicide prior to that; -He/She was not sure who updated the care plans with interventions, possible corporate. During an interview on 5/29/24 at 1:50 P.M. and 6/6/24 at 10:00 A.M., the Administrator said the following: -She felt Resident #7's comments regarding suicide were attention seeking, but expected staff to always take these comments seriously and notify her so she could give direction; -The last time Resident #7 went out to the hospital (5/25/24), the resident had reported he/she had a cord or string around his/her neck and it broke, he/she verbalized actually wanting to harm himself/herself. The resident was immediately sent out for evaluation; -No new interventions have been put in place regarding suicidal ideation as each time she spoke to the resident about suicidal comments he/she had made towards staff, the resident would change it around and say he/she didn't want to hurt himself/herself, but that the issue was about pain or a medication pass (not actually an intent to harm himself/herself); -The facility was trying to get the resident set up with counseling, but currently the counseling service they had a contract with didn't have any open spots; -The behavioral unit opened in November of 2023, the facility had not been able to provide counseling services or mental health services to those specific residents. Counseling services were being provided to the general population, but not on the unit. The counseling service they currently had, only had limited spots and those were filled with the residents in the general population who had mental health issues. They have been working on getting these services set up. The only service they have provided while waiting on these services was church on Sunday, which could help with spiritual guidance, no other services were provided; -The facility had a daily nursing meeting, during the meeting new interventions were discussed. If any new interventions were put in place the care plan coordinator was emailed (as he/she was corporate staff and did not work onsite at the facility) with new interventions and he/she would update the care plan in the EMR.

Based on observation, interview and record review, the facility failed to ensure two female residents (Residents #4 and #3) received the necessary services to maintain grooming and hygiene including bathing, removal of facial and underarm hair, and nail care. The failure caused one resident to be tearful and expressed being sad and embarrassed, stating other residents made fun her. This deficient practice impacted two residents (Residents #4 and #3) in a review 29 sampled residents. The facility census was 102. Review of the facility policy Personal Care, Hygiene and Grooming, dated 11/1/22, showed the most important aspect of maintaining good health was good hygiene. Personal hygiene, also referred to as a personal care, included bathing and showering, hair care, nail care, oral hygiene and dental care and shaving; -Residents are bathed according to preferences, including the time of day, and day of the week, bed bath, tub bath, or shower or partial bath; -Nail care includes keeping nails trimmed and filed, no jagged or broken nails, cleaning underneath to remove debris; -Nail care on residents with DIABETES will be provided by the nurse; -All residents are to be shaved daily unless they have specified otherwise or have a trimmed beard; -Check female residents for shaving needs including excessive chin hairs. Review of the facility's Shower Policy, dated 12/23/23, showed the following: -Shower schedules will consist of two assigned days in a seven-day calendar week; -Bathing should include washing hair, shaving, fingernail/toenail trim, and assessment of skin. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -No behaviors or rejection of care; -Understood and understands; -Dependent on staff for shower/bathing. Review of the resident's Care Plan, revised 6/6/24, showed the following: -Resident was highly functional and able to complete activities of daily living (ADLs) task with set up and supervision to maintain hygiene; -Allow time to complete task and intervene as needed; -Provide assistance, supervision, set up and cues as needed. Review of the facility shower schedule showed the resident's shower days were Tuesday and Friday. Review of the resident's shower record found in Point Click Care (PCC), dated July 2024, showed the following: -The resident had two scheduled bath days per week; -Staff documented bathing was completed on 07/02/24 (only once for the week), 07/09/24 (only once for the week), 07/16/24 (only once for the week), and 07/23/24. There was no documentation the resident refused any showers. Observation on 7/24/24, at 10:27 A.M., showed the resident in the dining room sitting at a table. The resident had facial hair approximately one half inch long on her upper lip, chin, and neck. The resident wore a sleeveless shirt and had thick hair, over an inch long in her arm pit. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just returned from an appointment with the physician and was so embarrassed because of how she looked. She did not like having facial hair or hair in her arm pits. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by this and other residents made fun of the hair on her face and in her arm pits. She would like her fingernails to be trimmed and clean. She did not get two showers a week, staff only had time to do one. Observation on 7/25/24, at 11:15 A.M., showed the resident in the dining room with other residents with the same facial hair and dirty fingernails. The resident wore a shirt that covered her underarms. 2. Review of Resident #4's admission MDS dated [DATE], showed the following: -No behaviors or rejection of care; -Dependent for bathing and personal hygiene. Review of the resident's care plan dated 6/25/24 showed the following: -Extensive assist with ADLs including hygiene; -Provide assistance as needed. Review of the facility shower schedule (specifying the days showers would be given) did not include the resident's name. Review of the resident's shower record found in Point Click Care (PCC), dated 07/24, showed the following: -The resident had two scheduled bath days weekly; -Staff documented bathing as completed on 07/01/24 (only once for the week), 07/08/24 (only once for the week), 07/15/24, and 07/18/24. Observation and interview on 07/24/24 showed the following: -At 10:20 A.M., the resident sat in her broda chair (specialized reclining chair) in her room. The resident had numerous long, white hairs noted on her chin and shorter hair on her upper lip; -At 4:30 P.M., the resident lay in bed and the facial hair remained. The resident said staff did not bathe or shave her. Observation on 07/25/24 at 10:35 A.M., showed the resident with the same facial hair. During an interview on 07/25/24 at 10:40 A.M., the resident said she had not received one shower or bed bath since her admission to the facility. Staff only washed the urine from her body. She wished staff would use a topical hair remover or something to get rid of her facial hair. She was accustomed to getting assistance from staff with shaving at her prior placement. She did not like hair on her face and had never refused to let staff shower, bathe, or shave her. During an interview on 7/25/24 at 4:50 P.M., certified nurse aide (CNA) C said the following: -Residents should be shaved on shower days and as needed; -She would shave residents when they requested, however Resident #4 had never asked to be shaved. During an interview on 07/25/24 at 3:50 P.M., CNA D said the following: -Showers are completed daily except Sundays; -If a resident refused their shower, it could be made up on another day; -Staff documented showers in PCC. 3. During an interviews on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing said CNAs should shave residents on shower days and as needed. Staff are expected to ensure residents do not have facial hair and arm pit hair if they do not want facial hair and arm pit hair. Staff are expected to assist the residents to keep their fingernails trimmed and clean. Residents are scheduled to receive at least two showers a week. During an interview on 08/02/24 at 10:05 A.M., the Administrator said he expected nursing staff to assist residents with bathing and shaving as needed.

Based on observation, interview and record review, the facility failed to ensure two female residents (Residents #4 and #3) received the necessary services to maintain grooming and hygiene including bathing, removal of facial and underarm hair, and nail care. The failure caused one resident to be tearful and expressed being sad and embarrassed, stating other residents made fun her. This deficient practice impacted two residents (Residents #4 and #3) in a review 29 sampled residents. The facility census was 102. Review of the facility policy Personal Care, Hygiene and Grooming, dated 11/1/22, showed the most important aspect of maintaining good health was good hygiene. Personal hygiene, also referred to as a personal care, included bathing and showering, hair care, nail care, oral hygiene and dental care and shaving; -Residents are bathed according to preferences, including the time of day, and day of the week, bed bath, tub bath, or shower or partial bath; -Nail care includes keeping nails trimmed and filed, no jagged or broken nails, cleaning underneath to remove debris; -Nail care on residents with DIABETES will be provided by the nurse; -All residents are to be shaved daily unless they have specified otherwise or have a trimmed beard; -Check female residents for shaving needs including excessive chin hairs. Review of the facility's Shower Policy, dated 12/23/23, showed the following: -Shower schedules will consist of two assigned days in a seven-day calendar week; -Bathing should include washing hair, shaving, fingernail/toenail trim, and assessment of skin. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -No behaviors or rejection of care; -Understood and understands; -Dependent on staff for shower/bathing. Review of the resident's Care Plan, revised 6/6/24, showed the following: -Resident was highly functional and able to complete activities of daily living (ADLs) task with set up and supervision to maintain hygiene; -Allow time to complete task and intervene as needed; -Provide assistance, supervision, set up and cues as needed. Review of the facility shower schedule showed the resident's shower days were Tuesday and Friday. Review of the resident's shower record found in Point Click Care (PCC), dated July 2024, showed the following: -The resident had two scheduled bath days per week; -Staff documented bathing was completed on 07/02/24 (only once for the week), 07/09/24 (only once for the week), 07/16/24 (only once for the week), and 07/23/24. There was no documentation the resident refused any showers. Observation on 7/24/24, at 10:27 A.M., showed the resident in the dining room sitting at a table. The resident had facial hair approximately one half inch long on her upper lip, chin, and neck. The resident wore a sleeveless shirt and had thick hair, over an inch long in her arm pit. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just returned from an appointment with the physician and was so embarrassed because of how she looked. She did not like having facial hair or hair in her arm pits. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by this and other residents made fun of the hair on her face and in her arm pits. She would like her fingernails to be trimmed and clean. She did not get two showers a week, staff only had time to do one. Observation on 7/25/24, at 11:15 A.M., showed the resident in the dining room with other residents with the same facial hair and dirty fingernails. The resident wore a shirt that covered her underarms. 2. Review of Resident #4's admission MDS dated [DATE], showed the following: -No behaviors or rejection of care; -Dependent for bathing and personal hygiene. Review of the resident's care plan dated 6/25/24 showed the following: -Extensive assist with ADLs including hygiene; -Provide assistance as needed. Review of the facility shower schedule (specifying the days showers would be given) did not include the resident's name. Review of the resident's shower record found in Point Click Care (PCC), dated 07/24, showed the following: -The resident had two scheduled bath days weekly; -Staff documented bathing as completed on 07/01/24 (only once for the week), 07/08/24 (only once for the week), 07/15/24, and 07/18/24. Observation and interview on 07/24/24 showed the following: -At 10:20 A.M., the resident sat in her broda chair (specialized reclining chair) in her room. The resident had numerous long, white hairs noted on her chin and shorter hair on her upper lip; -At 4:30 P.M., the resident lay in bed and the facial hair remained. The resident said staff did not bathe or shave her. Observation on 07/25/24 at 10:35 A.M., showed the resident with the same facial hair. During an interview on 07/25/24 at 10:40 A.M., the resident said she had not received one shower or bed bath since her admission to the facility. Staff only washed the urine from her body. She wished staff would use a topical hair remover or something to get rid of her facial hair. She was accustomed to getting assistance from staff with shaving at her prior placement. She did not like hair on her face and had never refused to let staff shower, bathe, or shave her. During an interview on 7/25/24 at 4:50 P.M., certified nurse aide (CNA) C said the following: -Residents should be shaved on shower days and as needed; -She would shave residents when they requested, however Resident #4 had never asked to be shaved. During an interview on 07/25/24 at 3:50 P.M., CNA D said the following: -Showers are completed daily except Sundays; -If a resident refused their shower, it could be made up on another day; -Staff documented showers in PCC. 3. During an interviews on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing said CNAs should shave residents on shower days and as needed. Staff are expected to ensure residents do not have facial hair and arm pit hair if they do not want facial hair and arm pit hair. Staff are expected to assist the residents to keep their fingernails trimmed and clean. Residents are scheduled to receive at least two showers a week. During an interview on 08/02/24 at 10:05 A.M., the Administrator said he expected nursing staff to assist residents with bathing and shaving as needed.

Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #6, #7 and #8) in a review of seven sampled residents and two additional residents (Resident #9 and #10), received care and services in accordance with professional standards of practice. The facility failed to ensure Residents #6, #7, and #8 received their ordered morning medications on time, failed to report abnormal blood pressures for Resident #9 and #10 to a nurse and failed to secure medication cards (with medication in them) before leaving a medication cart unattended in the hallway. The facility census was 91. Review of the facility Medication Administration Policy, dated 11/30/22, showed the following: -The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing. and administering of all medications, to meet the needs of each resident; -When getting the medication out of the resident's drawer, check to make sure it is the: a. Right resident b. Right medication c. Right dose d. Right time e. Right route -Check the label of the medication against the order on the resident's electronic medical record (EMR)/medication administration record (MAR), making sure that everything matches including the: a. Name of the medication b. Dose c. Route d. Times to be given; -The policy did not include liberal time parameters or leaving medications unattended. The Director of Nursing (DON) said the liberal medication administration time schedule included the following: -Liberal A.M. (Lib A) medications were to be administered between 6:00 A.M. and 10:00 A.M.; -Liberal Day medications were to be administered between 7:00 A.M. and 10:00 A.M.; -Liberal Early AM medications were to be administered between 5:00 A.M. and 6:00 A.M.; -Liberal Afternoon (Lib N) medications were to be administered between 4:00 P.M. and 5:00 P.M.; -Liberal evening (Lib E) medications were to be administered between 4:00 P.M. and 8:00 P.M. The DON said there was no policy regarding blood pressure parameters to be reported to the nurse. Multiple requests for a medication storage policy made with no policy provided. 1. Review of the staffing schedule for 3/27/24, day shift (6:00 A.M. to 6:00 P.M.), showed there were two staff scheduled to administer medications (Certified Medication Technician (CMT) C and CMT D). One for A-hall (CMT C) and one for B-hall (CMT B). There was a spot for a third CMT but no identified staff to fill that spot. 2. Review of the resident roster showed twenty residents were on A-hall and twenty-eight on B-hall. 1. Review of Resident #5's March 2024 Physician Order Sheet (POS) showed the following: -Diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), edema (swelling caused by a collection of fluid in the spaces that surround the body's tissues and organs), hypotension (low blood pressure), type 2 diabetes mellitus (too much sugar in blood), right artificial knee joint, and pain in left toe; -Oral Pain Scale: Record every shift; 0-1 no pain, 2-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-9 very severe pain and 10 worst possible pain; -Bumetanide (diuretic) 0.5 milligrams (mg), give two tablets by mouth two times a day; -Hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg, give one tablet by mouth four times a day for chronic knee pain; -Metformin (diabetes) 500 mg, give two tablets by mouth two times a day; -Midodrine (blood pressure) 5 mg, give one tablet by mouth three times a day; -Sennosides-Docusate (constipation) 8.6-50 mg, give one tablet by mouth two times a day. Review of the resident's March 2024 Medication Administration Record (MAR) showed the following: -Bumetanide 0.5 mg, give two tablets by mouth two times a day at 8:00 A.M. and 5:00 P.M.; -Hydrocodone-acetaminophen 5-325 mg, give one tablet by mouth four times a day for chronic knee pain at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.; -Pain level to be documented at 8:00 A.M., 1200 P.M., 4:00 P.M., and 8:00 P.M.; -Metformin 500 mg, give two tablets by mouth two times a day at 7:00 A.M. and 8:00 P.M.; -Midodrine 5mg, give one tablet by mouth three times a day at 7:00 A.M., 12:00 P.M. and 5:00 P.M.; -Sennosides-Docusate 8.6-50 mg, give one tablet by mouth two times a day at 8:00 A.M. and 8:00 P.M. Observation on 3/27/24 at 9:45 A.M., showed Certified Medication Technician (CMT) C prepared and administered the resident's 7 A.M. and 8 A.M. morning medications. The resident's electronic MAR showed these medications were past due (colored red). Review of the resident's pain level summary, dated 3/27/24 at 9:45 A.M. and 9:50 A.M., showed the resident had a numerical pain value of 10. During an interview on 3/28/24 at 8:20 A.M., the resident said he/she had a scheduled pain medication which should be given at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. He/She wished he/she could get his/her pain medication on time. He/She has received his/her morning pain medication as late as 11:00 A.M. on some days. He/She had pain in both knees and his/her buttock and felt his/her pain would be better controlled if he/she would receive his/her scheduled pain medication on time. He/She said it did not seem that his/her pain was being kept in control. 2. Review of Resident #6's March 2024 POS showed the following: -Diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), anxiety disorder, chronic pain and major depressive disorder; -Buspirone (anxiety) HCL, give 10 mg by mouth two times a day; -Cyclobenzaprine (muscle spasms) HCL 10 mg, give one tablet by mouth three times a day; -Diclofenac sodium tablet delayed release (inflammation) 75 mg, give one tablet by mouth two times a day; -Oxycodone with acetaminophen (narcotic pain relief) 5-325 mg, give one tablet by mouth every 12 hours for pain; -Topiramate (headache) 100 mg, give one tablet by mouth two times a day; -Oral pain scale: Record each shift, two times a day for pain management. Review of the resident's March 2024 MAR showed the following: -Buspirone HCL, give 10 mg by mouth two times a day at 8:00 A.M. and 8:00 P.M.; -Cyclobenzaprine HCL 10 mg, give one tablet by mouth three times a day at 7:00 A.M., 12:00 P.M. and 8:00 P.M.; -Diclofenac sodium tablet delayed release 75 mg, give one tablet by mouth two times a day at 7:00 A.M. and 8:00 P.M.; -Oxycodone with acetaminophen 5-325 mg, give one tablet by mouth every 12 hours for pain at 8:00 A.M. and 8:00 P.M.; -Topiramate 100 mg give one tablet by mouth two times a day at 7:00 A.M. and 8:00 P.M. Observation on 3/27/24 at 10:22 A.M. showed CMT C prepared and administered the resident's 7 A.M. and 8 A.M. medications. The resident's electronic MAR showed these medications were past due (colored red). Review of the resident's pain level summary, dated 3/27/24 at 10:30 A.M. and 10:31 A.M., showed the resident had a numerical pain value of 7. During an interview on 3/28/24 at 1:38 P.M., the resident said he/she took scheduled pain medications. His/Her pain medication was usually not given on time. He/She did not feel his/her pain was kept under control. If he/she would get his/her pain medication like it was ordered, he/she felt he/she would be able to get up earlier and be able to get dressed more comfortably. 3. Review of Resident #7's March 2024 POS showed the following: -Diagnoses included rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in joints), osteopathic (a degenerative joint disease, in which the tissues in the joint break down over time), depression, constipation, pain in right shoulder, edema, essential hypertension, pain; -Artificial tear solution (eye dryness), instill one drop in both eyes two times a day; -Eliquis (blood thinner) 5 mg, give one tablet by mouth two times a day; -Lidocaine external patch (pain), apply to neck or shoulder topically every morning and at bedtime; -Lidocaine external patch, apply to neck or shoulder topically every morning and at bedtime; -Lidocaine external patch, apply to right knee topically every morning and at bedtime; -Miralax (constipation) 17 gram by mouth two times a day; -Pregabalin (pain) 150 mg, give one tablet by mouth every morning and at bedtime. Review of the resident's March 2024 MAR showed the following: -Artificial tear solution, instill one drop in both eyes two times a day between (liberal A time and liberal E time) 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.; -Eliquis 5 mg give one tablet by mouth two times a day at 8:00 A.M. and 5:00 P.M.; -Lidocaine external patch, apply to neck or shoulder topically, every morning and at bedtime at 8:00 A.M. and 8:00 P.M.; -Lidocaine external patch, apply to neck or shoulder topically, every morning and at bedtime at 8:00 A.M. and 8:00 P.M.; -Lidocaine external patch, apply to right knee topically every morning and at bedtime at 8:00 A.M. and 8:00 P.M.; -Miralax 17 gram by mouth two times a day between (liberal A time and liberal E time) 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.; -Pregabalin 150 mg, give one tablet by mouth every morning and at bedtime at liberal A time and liberal E time (between 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.). Review of the resident's pain level summary, dated 3/27/24 at 12:24 P.M., 12:25 P.M. and 12:26 P.M., showed the resident had a numerical pain value of 8. Observation on 3/27/24 at 12:34 P.M. showed CMT C prepared and administered the resident's 8 A.M. and 6:00 A.M. to 10:00 A.M. medications ( liberal A medication time frame medications). The resident's electronic MAR showed these medications were past due (colored red). During an interview on 3/27/24 at 12:34 P.M., the resident said he/she has chronic pain and his/her pain never goes below a 5. 4. Review of Resident #8's March 2024 POS showed the following: -Diagnoses included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs); -Carvedilol (heart failure) 6.25 mg, give one tablet by mouth two times a day; -Sennosides-docusate (constipation) 8.6 mg-50 mg, give two tablets by mouth two times a day. Review of the resident's March 2024 MAR showed the following: -Carvedilol 6.25 mg, give one tablet by mouth two times a day at 8:00 A.M. and 4:00 P.M.; -Sennosides-docusate 8.6 mg-50 mg, give two by mouth two times a day at liberal A time and liberal E time (between 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.). Observation on 3/27/24 at 12:41 P.M. showed CMT C prepared and administered the resident's morning medications for 8:00 A.M. and for the 6:00 A.M. to 10:00 A.M. liberal medication time frame. The resident's electronic MAR showed these medications were past due (colored red). 5. Review of Resident #9's March 2024 POS showed the following: -Diagnoses included anemia, essential hypertension, and gastro-esophageal reflux disease (GERD) (stomach disorder); -Ferrous sulfate ( iron supplement) 325 mg, give one tablet by mouth two times a day; -Metoprolol tartate (blood pressure) 25 mg, give one tablet by mouth two times a day; -Sucralfate (antacid) one gram, give one tablet by mouth before meals and at bedtime. Review of the resident's March 2024 MAR showed the following: -Ferrous sulfate 325 mg, give one tablet by mouth two times a day at liberal A time and liberal E time (between 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.); -Metoprolol tartate 25 mg, give one tablet by mouth two times a day at liberal A time and liberal E time (between 6:00 A.M. and 10:00 A.M. and between 4:00 P.M. and 8:00 P.M.); -Sucralfate 1 gram, give one tablet by mouth before meals and bedtime at 7:00 A.M., 11:30 A.M., 5:00 P.M. and 8:00 P.M. Observation on 3/27/24 at 1:00 P.M. showed CMT C prepared and administered the resident's morning medications for 11:30 A.M. and for the 6:00 A.M. to 10:00 A.M. liberal medication time frame. The resident's electronic MAR showed these medications were past due (colored red). 6. Review of Resident #10's March 2024 POS showed the following: -Diagnoses included pulmonary hypertension, hypertensive heart (a condition that affects the blood vessels in the lungs) and chronic kidney disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and with stage five chronic kidney disease (kidneys are getting very close to failure or have already failed) or end stage renal disease (kidneys have already failed); -Losartan potassium (blood pressure) 50 mg, give one tablet by mouth in the morning and hold if systolic blood pressure (SBP) is under 90. Observation on 3/27/24 at 9:23 A.M. showed CMT C obtained the resident's blood pressure and the reading was 185/101 (review of the centers for disease control web site, dated May 18th, 2021, showed a normal blood pressure level to be less than 120/80). Review of the progress notes showed no documentation of the 3/27/24 9:23 A.M. blood pressure reading being reported to the charge nurse or the primary care physician. There was no documentation to show the blood pressure was re-checked. During an phone interview on 4/10/24 at 4:46 P.M., Resident #10's Attending Physician, said the following: -He expected a blood pressure reading of 185/101 to be reported to the nurse; -He expected the blood pressure to be rechecked; -If the blood pressure was still elevated, he expected to be notified. 7. Review of Resident #11's March 2024 POS showed the following: -Diagnoses included essential hypertension; -Amlodipine basylate 10 mg, give one tablet by mouth one time a day; -Sacubitril-valsartan (blood pressure) 24-26 mg, give one tablet by mouth two times a day. Review of the resident's March 2024 MAR showed the following: -Amlodipine basylate 10 mg, give one tablet by mouth one time a day, scheduled for 6:00 A.M. to 10:00 A.M. (liberal A medication time frame); the MAR had a box for staff to check and document the resident's blood pressure at this time; -Sacubitril-valsartan (blood pressure) 24-26 mg, give one tablet by mouth two times a day, scheduled for 8:00 A.M.; the MAR had a box for staff to check and document the resident's blood pressure at this time. Observation on 3/27/24 at 10:49 A.M. showed CMT C obtained the resident's blood pressure and the reading was 161/101. Review of the progress notes showed no documentation of the 3/27/24 at 10:49 A.M. blood pressure reading being reported to the charge nurse or the primary care physician. There was no documentation to show the blood pressure was re-checked. During an phone interview on 4/10/24 at 4:29 P.M., Resident #11's Primary Care Physician (PCP), said the following: -He expected a blood pressure reading of 161/101 to be reported to the nurse; -He expected blood pressure medication to be given and then recheck the resident's blood pressure after one-two hours; -If the blood pressure was still elevated, he then expected to be notified. 8. Observation on 3/27/24 at 10:42 A.M., CMT C prepared medications, from the medication cart in the hallway, to be administered to a resident. He/She left medication cards, (containing medications in the cards), including cards of furosemide (diuretic), potassium (supplement), atenolol (blood pressure medication), tamoxifen (hormone therapy) and Eliquis (anticoagulant (blood thinner)) on top of his/her medication cart, in the hallway, without securing them while giving a resident medication in his/her room. The medications and the medication cart were not within sight when CMT C was in the resident's room; During an interview on 3/27/24 at 1:51 P.M. and 3/29/24 at 3:02 P.M., CMT C said the following: -If a medication is overdue, the residents' electronic MAR turns red. He/She got behind while looking for a resident who was out of the building on outside pass (OSP); -He/She administers medication to approximately fifty (50) residents; -If the residents are compliant, medications can be done (on time); -He/She would report a resident's blood pressure if it was abnormally higher than usual; depending on the resident; -He/She did report Resident #10 and #11's high blood pressure to the nurse; -It was never okay to leave medications unattended on the top of his/her medication cart. During an interview on 3/28/24 at 8:53 A.M., CMT D said he/she was usually responsible for administering medications to about 40 residents. During an interview on 3/27/24 at 2:46 P.M. and 3/28/24 at 1:18 P.M., Licensed Practical Nurse (LPN) B said the following: -Medications should be given on time. Scheduled pain medication should be given on time. Medication should not be given late; -Medication should never be left unattended on top of a medication cart; -Any blood pressure outside of the parameter should be reported to the nurse. If a blood pressure is high, it should be reported to the nurse. He/She would recheck the blood pressure and report it accordingly to the primary care physician. The primary care physician would then be able to say the blood pressure was okay or he/she would like an intervention to be completed. He/She did not receive a report by staff (CMT C) of Resident #10 and #11's blood pressure being high. He/She was the nurse responsible for the residents on both A and B halls this day. During an interview on 3/28/24 at 1:05 P.M. and 3:19 P.M. and 4/09/24 at 10:25 A.M , the DON said the following: -She would expect medication to be given on time; -She would expect scheduled medication to be given on time; -She would expect scheduled pain medication to be given on time;he -She felt there were enough staff currently to assure medications were given on time and under normal circumstances she felt two staff members were enough to pass medications to residents on time; -She was not aware of any complaints from residents or staff members in regards to there being enough staff members to administer medications on time; -She would expect a blood pressure with triple digits in the bottom number to be reported to a nurse; -It is never okay to leave medication on top of an unattended medication cart in the hallway while administering medications to a resident in his/her room. During an interview on 3/28/24 at 3:21 P.M., the Administrator said she would expect medications to be given on time and she would never expect medications to be left on top of a medication cart in the hallway while administering medications to a resident in his/her room. MO 233309

This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 06/18/24. Based on observation, interview, and record review, the facility failed to ensure eight residents, in a review of 29 sampled residents, were treated in a manner to maintain dignity and respect when they failed to communicate with four residents (Residents #2, #7, #9, #10, and #6) in a respectful manner, and provide one resident (Resident #5), who was incontinent, with incontinence briefs when in bed. The resident reported staff told him/her to urinate in his/her bed and they would clean the resident up later. The facility also failed to provide adequate hygiene for one resident (Resident #3) to ensure removal of unwanted facial and underarm hair prior to the resident going out to a physician's appointment. The resident was observed crying and said she was sad and embarrassed by her appearance and that other residents made fun of her. The facility census was 102. Review of the facility policy, Privacy/Room Courtesy Policy, dated 12/28/23, showed the following: -Employees will be cognizant that the facility is their home; -Residents and their rooms/personal space should be treated with respect. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -Moderate cognitive impairment; -No behaviors or rejection of care; -Understood and understands; -It was very important to the resident to make choices about daily decisions like choosing clothing to wear, type of bathing, taking care of personal belongings, etc; -Dependent on staff for shower/bathing Review of the resident's Care Plan, revised 6/6/24, showed the following: -The resident was highly functional and able to complete her activities of daily living (ADL) tasks with set up and supervision to maintain her hygiene; -Allow time to complete task and intervene as needed; -Monitor for decline in function; -Provide assistance, supervision, set up and cues as needed. Observation on 7/24/24, at 10:27 A.M., showed the resident sat at a table in the dining room. The resident had facial hair approximately 0.5 inch long on her upper lip, chin and neck. The resident had on a sleeveless shirt and her arm pit hair was thick and over 1 inch long. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just got back from an appointment with the physician. She was so embarrassed because of how she looked. She did not think she should have to have facial hair and arm pit hair. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by how she looked. Other residents made fun of the hair on her face and arm pits. Observation on 7/25/24 at 11:15 A.M., showed the resident was in the dining room. The resident had the same facial hair and her nails were long with a brown substance under them. The resident's arm pits were not exposed. 2. Review of Resident #2's Preadmission Screening and Resident Review (PASARR; a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis to ensure appropriate placement and to ensure that their individual needs are being met in the appropriate placement environment), dated 9/16/18, showed the following: -Diagnoses included severe bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), intellectual disability, borderline intellectual functioning, borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), anti-social personality disorder (a mental health disorder characterized by disregard for other people), and history of brain injury; -History of physical and sexual abuse as a child, self-harm, and suicide attempts. Review of the resident's Care Plan, last revised 7/15/24, showed the following: -The resident was at risk for injury to self and others and impaired social interaction related to behaviors of verbal and physical aggression toward staff and peers; -Received counseling with outside service; -The resident will remain free of serious injury to self and others and will maintain appropriate social interactions now through next review; -On 7/3/24, the resident was verbally aggressive with peer. A code green (behavioral emergency) was called. Immediate staff intervention and separation from peer. The resident was allowed to vent and verbalize. Staff educated the resident to seek staff to assist with concerns and the resident voiced understanding. Staff also discussed the resident's coping skills and the resident voiced understanding. Staff were able to redirect the resident with no invasive measures. The resident was calm and cooperative at this time; -Administer antipsychotic medications as ordered; -Social services to follow up as needed. (The resident's care plan did not include a history of making false allegations or how staff were to respond to the resident's allegations.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder, and borderline personality disorder; -No hallucinations, delusions, behaviors, or rejection of care; -Received antipsychotic and antidepressant medications routinely. Observation on 7/25/24, at 11:00 A.M., showed the following: -The resident was in the 100 hall by the dining area. He/She walked behind the state agency (SA) staff and talked about needing an appointment. The resident did not speak directly to the SA staff, and there were other residents and staff in the area; -The Administrator walked up to the resident with a posture to make himself taller than the resident. In a stern, intimidating voice, the Administrator asked the resident, What are you talking about? Are you just saying stuff because the state is back here? -The resident put his/her head down and stuttering said he/she just needed an appointment and walked away. During an interview on 7/30/24 at 12:00 P.M., the resident said the following: -The Administrator made him/her feel bad when he/she tried to speak with the SA staff; he/she wanted to tell him (the Administrator) off; -The Administrator took away his/her privileges to go out on the main unit all the time. He/She felt like he/she couldn't talk to the SA staff or he/she would be in trouble; -His/Her roommate raped him/her (previously investigated); -He/She told staff the other day he/she wanted to hurt himself/herself; -The staff were rude to him/her and did not treat him/her with respect, more like a dog and they want me to go away. SA staff reported allegations of rape and self-harm to the facility Administrator on 7/30/24, at 1:00 P.M. During an interview on 7/30/24, at 1:40 P.M., the Administrator said the resident made the allegation of rape previously and it was reported and investigated. Observation on 7/30/24 at 1:40 P.M., showed the following: -The Administrator shared the documentation of the previous investigation; -The Administrator then played an audio recording with his voice and the resident's voice; -On the recording, the Administrator asked the resident in a stern, intimidating voice if he/she had been raped, if he/she had a plan to hurt himself/herself, or had any other concerns or issues. The resident responded to each question in a quiet and wavering voice no to each question. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Verbal behaviors. Review of the resident's undated Care Plan showed the following: -The resident had the potential to be verbally aggressive; -Assess the resident's understanding of the situation, allow time for the resident to express himself/herself and feelings towards the situation; -Assess the resident's coping skills. During an interview on 07/24/25 at 12:48 P.M., the resident said the following: -Staff were rude; -Staff do not listen to the resident. Observation on 07/25/24 at 11:56 P.M., showed the following: -The resident's call light was on; -Certified Nurse Assistant (CNA) E opened the resident's door, stood in the doorway, and asked the resident what he/she wanted; -The resident asked CNA E to take his/her roommate to the dining room as it was time for lunch and his/her roommate could not reach his/her call light; -CNA E responded in a loud, rude tone and said the resident could not make his/her roommate go as it was his/her room, too; -The resident attempted to explain that his/her roommate did not have call light in reach to call when he/she was ready to go; -CNA E interrupted the resident and said in a loud, rude tone, that he/she (CNA E) could not make the roommate go, and he/she didn't know what more the resident expected him/her to do; -The resident responded by explaining his/her roommate did not have a call light. The resident asked how his/her roommate was supposed to let staff know when he/she was ready to go to the dining room; -CNA E responded in a loud, rude tone that he/she had been walking the hall and checked on the resident every five minutes; the resident's roommate will tell him/her (CNA E) when he/she was ready to go; -The resident was visibly upset and began to speak. CNA E spoke over the resident in a loud, rude tone, and said he/she (CNA E) could not make the roommate go; -The resident responded that he/she hated this room and his/her new roommate and he/she should have never been moved, but nobody listened to him/her; -CNA E rolled his/her eyes, and said in a loud, rude tone, I'll let the DON know. -CNA E shut the resident's room door; -CNA E never fully entered the room, did not speak to the resident's roommate, and did not check to ensure the roommate had a call light in reach. -The resident's roommate did not respond or speak during the interaction. During an interview on 07/30/24 at 4:03 P.M., CNA E said the following: -Staff should speak to residents in a calm, pleasant tone; -Staff should not argue, be rude or raise their voice when speaking to residents. Staff should not talk over residents or roll their eyes when residents are speaking; -He/She had never been loud, rude or defensive when speaking to residents. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent for toileting hygiene; -Always incontinent. Review of the resident's undated Care Plan showed the following: -He/She has episodes of incontinence and required assistance with toileting and hygiene; -He/She used disposable briefs; -The resident has a potential psychosocial well-being problem related to diagnoses of schizoaffective disorder and bipolar. Observation on 07/24/24 at 10:25 A.M. showed the following: -The resident sat on the edge of the bed and wore only a sweatshirt; -The resident was not wearing an incontinence brief; -The bed sheets under the resident and the two incontinence pads on the resident's bed were soaked in urine. During an interview on 07/24/24 at 10:28 A.M., the resident said the following: -Staff was very busy; -He/She was unable to walk to the bathroom on his/her own; -Staff tell him/her to urinate in the bed and they will clean him/her up later; -Urinating in the bed and not wearing an incontinence brief made him/her feel dirty and embarrassed. Observation on 07/25/24 at 9:19 A.M. showed the resident asleep in bed. He/She was not wearing an incontinence brief. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the resident's undated care plan, showed the following: -Resident has a potential psychosocial well-being problem; -The resident needs assistance, encouragement, and support to identify problems that cannot be controlled; -The resident needs assistance, supervision, and support to identify causative and contributing factors; -The resident has post traumatic stress disorder (PTSD) and may flare up without any trigger; -The resident will be able to identify triggers and utilize positive coping skills. During an interview on 07/25/24 at 10:41 A.M., the resident said the following: -Staff never notify the residents of the alternate entrée for the meal. The residents have to go to the kitchen window to ask, but then staff yell at them for bothering the kitchen staff; -The kitchen staff yell in a loud/rude voice to Go away!, You can't be at the window!, We're busy!; -If he/she asked multiple staff about the alternate entree, the staff get annoyed, and tell the resident he/she was not telling the truth about asking other staff; -He/She did not appreciate when staff spoke to him/her in this way, and didn't feel like it was appropriate or polite; -When the staff yelled, raised their voices, or spoke in a rude tone, it made him/her feel very irritated and increased his/her agitation. It made him/her want to raise his/her voice back, but he didn't out of fear of being told he/she was having behaviors and to go back to his/her room. 6. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the residents undated care plan, showed the following: -The resident has a potential psychosocial well-being problem; -The resident will verbalize feelings related to emotional state; -The resident has a mood problem related to diagnoses of bipolar and depression; -Allow resident time to voice feelings and concerns. During an interview on 07/25/24 at 10:45 A.M., the resident said the following: -Kitchen staff regularly raised their voices and spoke in a rude tone when talking with residents; -He/She was told to tell the kitchen staff prior to meal time if he/she wanted an alternative, but when he/she went to the kitchen window, staff yelled at him/her and told him/her to Go away!; -When the staff yelled, it hurt his/her feelings and made him/her want to cry and yell back. He/She did not do this out of fear of being told he/she was having a behavior, told to go back to his/her room, or threatened to send him/her back to the behavior unit. 7. Review of Resident #6's Care Plan, dated 09/15/23, showed the following: -Communication problem related to hearing impairment; -Use communication techniques which enhance interaction, allow adequate time to respond, do not rush, repeat as necessary, face when speaking and make eye contact; -Diagnosis of depression. Resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Monitor/report signs/symptoms of shame, worthlessness, agitation or anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the resident had no behaviors or rejection of care. Review of the resident's POS, dated 07/2024, showed diagnoses included neurocognitive disorder with Lewy Bodies (progressive brain disease that causes a gradual decline in mental abilities), major depressive disorder and anxiety. During an interview on 07/25/24 at 11:28 A.M., the resident said the following: -Staff could be short and rude with their tone of voice; -One staff was sarcastic and loud when he/she asked for hygiene items; -It made him/her sad and he/she felt like wanting to hit the staff. During an interview on 07/25/24 at 11:31 A.M., a visitor said he/she overheard staff being rude with the resident. One day a staff yelled at the resident (who had requested razors), Well if we aint got it, we can't give it to you! 8. During an interview on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing (DON) said the following: -Staff were to ensure female residents did not have facial hair and arm pit hair if the resident did not want facial hair and arm pit hair; -Staff were to assist the residents to keep their fingernails trimmed and clean; -Staff should not tell residents to soil themselves or their bed; -Staff should treat residents with dignity and respect at all times; -Staff should not raise their voice at, yell at, or roll their eyes at residents. During an interview on 08/02/24 at 10:05 A.M., the Administrator said the following: -He expected staff to treat all residents with dignity and respect; -Staff should not raise their voice at, yell at, or roll their eyes at residents. MO237998 MO238302 MO238414 MO239086

This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 06/18/24. Based on observation, interview, and record review, the facility failed to ensure eight residents, in a review of 29 sampled residents, were treated in a manner to maintain dignity and respect when they failed to communicate with four residents (Residents #2, #7, #9, #10, and #6) in a respectful manner, and provide one resident (Resident #5), who was incontinent, with incontinence briefs when in bed. The resident reported staff told him/her to urinate in his/her bed and they would clean the resident up later. The facility also failed to provide adequate hygiene for one resident (Resident #3) to ensure removal of unwanted facial and underarm hair prior to the resident going out to a physician's appointment. The resident was observed crying and said she was sad and embarrassed by her appearance and that other residents made fun of her. The facility census was 102. Review of the facility policy, Privacy/Room Courtesy Policy, dated 12/28/23, showed the following: -Employees will be cognizant that the facility is their home; -Residents and their rooms/personal space should be treated with respect. 1. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/6/24, showed the following: -Moderate cognitive impairment; -No behaviors or rejection of care; -Understood and understands; -It was very important to the resident to make choices about daily decisions like choosing clothing to wear, type of bathing, taking care of personal belongings, etc; -Dependent on staff for shower/bathing Review of the resident's Care Plan, revised 6/6/24, showed the following: -The resident was highly functional and able to complete her activities of daily living (ADL) tasks with set up and supervision to maintain her hygiene; -Allow time to complete task and intervene as needed; -Monitor for decline in function; -Provide assistance, supervision, set up and cues as needed. Observation on 7/24/24, at 10:27 A.M., showed the resident sat at a table in the dining room. The resident had facial hair approximately 0.5 inch long on her upper lip, chin and neck. The resident had on a sleeveless shirt and her arm pit hair was thick and over 1 inch long. The resident's finger nails were long with brown debris underneath. During an interview on 7/24/24, at 10:27 A.M., the resident was tearful and said she just got back from an appointment with the physician. She was so embarrassed because of how she looked. She did not think she should have to have facial hair and arm pit hair. Staff would not assist her to shave because they said they were too busy. The resident said she was sad and embarrassed by how she looked. Other residents made fun of the hair on her face and arm pits. Observation on 7/25/24 at 11:15 A.M., showed the resident was in the dining room. The resident had the same facial hair and her nails were long with a brown substance under them. The resident's arm pits were not exposed. 2. Review of Resident #2's Preadmission Screening and Resident Review (PASARR; a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis to ensure appropriate placement and to ensure that their individual needs are being met in the appropriate placement environment), dated 9/16/18, showed the following: -Diagnoses included severe bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), intellectual disability, borderline intellectual functioning, borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), anti-social personality disorder (a mental health disorder characterized by disregard for other people), and history of brain injury; -History of physical and sexual abuse as a child, self-harm, and suicide attempts. Review of the resident's Care Plan, last revised 7/15/24, showed the following: -The resident was at risk for injury to self and others and impaired social interaction related to behaviors of verbal and physical aggression toward staff and peers; -Received counseling with outside service; -The resident will remain free of serious injury to self and others and will maintain appropriate social interactions now through next review; -On 7/3/24, the resident was verbally aggressive with peer. A code green (behavioral emergency) was called. Immediate staff intervention and separation from peer. The resident was allowed to vent and verbalize. Staff educated the resident to seek staff to assist with concerns and the resident voiced understanding. Staff also discussed the resident's coping skills and the resident voiced understanding. Staff were able to redirect the resident with no invasive measures. The resident was calm and cooperative at this time; -Administer antipsychotic medications as ordered; -Social services to follow up as needed. (The resident's care plan did not include a history of making false allegations or how staff were to respond to the resident's allegations.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder, and borderline personality disorder; -No hallucinations, delusions, behaviors, or rejection of care; -Received antipsychotic and antidepressant medications routinely. Observation on 7/25/24, at 11:00 A.M., showed the following: -The resident was in the 100 hall by the dining area. He/She walked behind the state agency (SA) staff and talked about needing an appointment. The resident did not speak directly to the SA staff, and there were other residents and staff in the area; -The Administrator walked up to the resident with a posture to make himself taller than the resident. In a stern, intimidating voice, the Administrator asked the resident, What are you talking about? Are you just saying stuff because the state is back here? -The resident put his/her head down and stuttering said he/she just needed an appointment and walked away. During an interview on 7/30/24 at 12:00 P.M., the resident said the following: -The Administrator made him/her feel bad when he/she tried to speak with the SA staff; he/she wanted to tell him (the Administrator) off; -The Administrator took away his/her privileges to go out on the main unit all the time. He/She felt like he/she couldn't talk to the SA staff or he/she would be in trouble; -His/Her roommate raped him/her (previously investigated); -He/She told staff the other day he/she wanted to hurt himself/herself; -The staff were rude to him/her and did not treat him/her with respect, more like a dog and they want me to go away. SA staff reported allegations of rape and self-harm to the facility Administrator on 7/30/24, at 1:00 P.M. During an interview on 7/30/24, at 1:40 P.M., the Administrator said the resident made the allegation of rape previously and it was reported and investigated. Observation on 7/30/24 at 1:40 P.M., showed the following: -The Administrator shared the documentation of the previous investigation; -The Administrator then played an audio recording with his voice and the resident's voice; -On the recording, the Administrator asked the resident in a stern, intimidating voice if he/she had been raped, if he/she had a plan to hurt himself/herself, or had any other concerns or issues. The resident responded to each question in a quiet and wavering voice no to each question. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Verbal behaviors. Review of the resident's undated Care Plan showed the following: -The resident had the potential to be verbally aggressive; -Assess the resident's understanding of the situation, allow time for the resident to express himself/herself and feelings towards the situation; -Assess the resident's coping skills. During an interview on 07/24/25 at 12:48 P.M., the resident said the following: -Staff were rude; -Staff do not listen to the resident. Observation on 07/25/24 at 11:56 P.M., showed the following: -The resident's call light was on; -Certified Nurse Assistant (CNA) E opened the resident's door, stood in the doorway, and asked the resident what he/she wanted; -The resident asked CNA E to take his/her roommate to the dining room as it was time for lunch and his/her roommate could not reach his/her call light; -CNA E responded in a loud, rude tone and said the resident could not make his/her roommate go as it was his/her room, too; -The resident attempted to explain that his/her roommate did not have call light in reach to call when he/she was ready to go; -CNA E interrupted the resident and said in a loud, rude tone, that he/she (CNA E) could not make the roommate go, and he/she didn't know what more the resident expected him/her to do; -The resident responded by explaining his/her roommate did not have a call light. The resident asked how his/her roommate was supposed to let staff know when he/she was ready to go to the dining room; -CNA E responded in a loud, rude tone that he/she had been walking the hall and checked on the resident every five minutes; the resident's roommate will tell him/her (CNA E) when he/she was ready to go; -The resident was visibly upset and began to speak. CNA E spoke over the resident in a loud, rude tone, and said he/she (CNA E) could not make the roommate go; -The resident responded that he/she hated this room and his/her new roommate and he/she should have never been moved, but nobody listened to him/her; -CNA E rolled his/her eyes, and said in a loud, rude tone, I'll let the DON know. -CNA E shut the resident's room door; -CNA E never fully entered the room, did not speak to the resident's roommate, and did not check to ensure the roommate had a call light in reach. -The resident's roommate did not respond or speak during the interaction. During an interview on 07/30/24 at 4:03 P.M., CNA E said the following: -Staff should speak to residents in a calm, pleasant tone; -Staff should not argue, be rude or raise their voice when speaking to residents. Staff should not talk over residents or roll their eyes when residents are speaking; -He/She had never been loud, rude or defensive when speaking to residents. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent for toileting hygiene; -Always incontinent. Review of the resident's undated Care Plan showed the following: -He/She has episodes of incontinence and required assistance with toileting and hygiene; -He/She used disposable briefs; -The resident has a potential psychosocial well-being problem related to diagnoses of schizoaffective disorder and bipolar. Observation on 07/24/24 at 10:25 A.M. showed the following: -The resident sat on the edge of the bed and wore only a sweatshirt; -The resident was not wearing an incontinence brief; -The bed sheets under the resident and the two incontinence pads on the resident's bed were soaked in urine. During an interview on 07/24/24 at 10:28 A.M., the resident said the following: -Staff was very busy; -He/She was unable to walk to the bathroom on his/her own; -Staff tell him/her to urinate in the bed and they will clean him/her up later; -Urinating in the bed and not wearing an incontinence brief made him/her feel dirty and embarrassed. Observation on 07/25/24 at 9:19 A.M. showed the resident asleep in bed. He/She was not wearing an incontinence brief. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the resident's undated care plan, showed the following: -Resident has a potential psychosocial well-being problem; -The resident needs assistance, encouragement, and support to identify problems that cannot be controlled; -The resident needs assistance, supervision, and support to identify causative and contributing factors; -The resident has post traumatic stress disorder (PTSD) and may flare up without any trigger; -The resident will be able to identify triggers and utilize positive coping skills. During an interview on 07/25/24 at 10:41 A.M., the resident said the following: -Staff never notify the residents of the alternate entree for the meal. The residents have to go to the kitchen window to ask, but then staff yell at them for bothering the kitchen staff; -The kitchen staff yell in a loud/rude voice to Go away!, You can't be at the window!, We're busy!; -If he/she asked multiple staff about the alternate entree, the staff get annoyed, and tell the resident he/she was not telling the truth about asking other staff; -He/She did not appreciate when staff spoke to him/her in this way, and didn't feel like it was appropriate or polite; -When the staff yelled, raised their voices, or spoke in a rude tone, it made him/her feel very irritated and increased his/her agitation. It made him/her want to raise his/her voice back, but he didn't out of fear of being told he/she was having behaviors and to go back to his/her room. 6. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. Review of the residents undated care plan, showed the following: -The resident has a potential psychosocial well-being problem; -The resident will verbalize feelings related to emotional state; -The resident has a mood problem related to diagnoses of bipolar and depression; -Allow resident time to voice feelings and concerns. During an interview on 07/25/24 at 10:45 A.M., the resident said the following: -Kitchen staff regularly raised their voices and spoke in a rude tone when talking with residents; -He/She was told to tell the kitchen staff prior to meal time if he/she wanted an alternative, but when he/she went to the kitchen window, staff yelled at him/her and told him/her to Go away!; -When the staff yelled, it hurt his/her feelings and made him/her want to cry and yell back. He/She did not do this out of fear of being told he/she was having a behavior, told to go back to his/her room, or threatened to send him/her back to the behavior unit. 7. Review of Resident #6's Care Plan, dated 09/15/23, showed the following: -Communication problem related to hearing impairment; -Use communication techniques which enhance interaction, allow adequate time to respond, do not rush, repeat as necessary, face when speaking and make eye contact; -Diagnosis of depression. Resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Monitor/report signs/symptoms of shame, worthlessness, agitation or anxiety. Review of the resident's quarterly MDS, dated [DATE], showed the resident had no behaviors or rejection of care. Review of the resident's POS, dated 07/2024, showed diagnoses included neurocognitive disorder with Lewy Bodies (progressive brain disease that causes a gradual decline in mental abilities), major depressive disorder and anxiety. During an interview on 07/25/24 at 11:28 A.M., the resident said the following: -Staff could be short and rude with their tone of voice; -One staff was sarcastic and loud when he/she asked for hygiene items; -It made him/her sad and he/she felt like wanting to hit the staff. During an interview on 07/25/24 at 11:31 A.M., a visitor said he/she overheard staff being rude with the resident. One day a staff yelled at the resident (who had requested razors), Well if we aint got it, we can't give it to you! 8. During an interview on 07/30/24 at 5:40 P.M. and 08/02/24 at 9:45 A.M., the Director of Nursing (DON) said the following: -Staff were to ensure female residents did not have facial hair and arm pit hair if the resident did not want facial hair and arm pit hair; -Staff were to assist the residents to keep their fingernails trimmed and clean; -Staff should not tell residents to soil themselves or their bed; -Staff should treat residents with dignity and respect at all times; -Staff should not raise their voice at, yell at, or roll their eyes at residents. During an interview on 08/02/24 at 10:05 A.M., the Administrator said the following: -He expected staff to treat all residents with dignity and respect; -Staff should not raise their voice at, yell at, or roll their eyes at residents. MO237998 MO238302 MO238414 MO239086

Based on interview and record review, the facility failed to ensure the facility transporters, who transported one sampled resident (Resident #3), 13 additional residents (Resident #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20), and five closed record residents (Resident #51, #52, #55, #56, and #57) in the facility van, all of which had elected a full code status, were properly trained and certified in CPR. The facility failed to implement facility policy to have systems in place to ensure there was an adequate number of staff certified in cardiopulmonary resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood) present in the facility, 24 hours a day seven days a week. The facility failed to ensure staff received CPR certification training that included hands on practice and in person skills assessment. This failure had the potential to affect 29 current residents who were identified as full code status (CPR required in the event of cardiac or respiratory arrest). The facility census was 44. The administrator was notified on [DATE] at 8:05 P.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation, reviewed ,d+[DATE], showed the following: Policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest; Policy interpretation and implementation: 1. Cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness); 2. Sudden cardiac arrest (SCA) is a leading cause of death in adults; 3. Victims of cardiac arrest may initially have gasping respirations or may even appear to be having a [CONDITION(S)]. Training in BLS includes recognizing the atypical presentations of SCA; 4. The likelihood of recovering from SCA due to an acute event (such as an arrhythmia) differs substantially from the likelihood of recovering from cardiac arrest that is the end result of multi-system failure and advanced irreversible or terminal conditions; 5. Depending on the underlying cause, the changes of surviving SCA may be increased if CPR is initiated immediately upon collapse; 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness; 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS); 8. If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record; 9. If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR; 10. If the resident is Do Not Resuscitate (DNR), per the medical record, notify the attending provider; Preparation for CPR: 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for clinical staff members who will direct resuscitative efforts, including non-licensed personnel; 2. Facility staff certified for CPR is available for each shift in the case of an actual cardiac arrest. Staff will call 911 when CPR is initiated; 3. The certified staff in this facility have received training and received certification in CPR/BLS. 1. Review of the Facility Assessment, dated [DATE], did not include care requirements for residents who selected Full Code Status. Acuity Efficiency Analysis Summary showed the quality assurance and performance improvement (QAPI) review of overall staffing, staff competencies, and services provided did not identify a deficit or need at this time. The QAPI plan summary did not identify a system breakdown requiring a formal action plan related to staff competency or training. 2. Review of the Maintenance/Transport Driver H's employee file showed no CPR certification. Review of the Maintenance/Transport Driver I's employee file showed no CPR certification. During an interview on [DATE] at 2:51 P.M., Maintenance/Transport Driver I said the following: -He/She was told three years ago that he/she had to have CPR certification so he/she took the class; -He/She did not know if it was BLS for Healthcare providers, but it was in person; -His/Her CPR certification was expired, he/she didn't know he/she had to renew it; -If a resident became unresponsive during transport and did not have pulse or respirations, he/she would have to pull over and call 911, there was not enough room in the van to do CPR. Review of the Social Services Director (SSD)'s employee file showed her CPR certification expired in [DATE]. Review of the facility transportation log for [DATE] through [DATE], showed the following: -Transport Driver transported Resident #8 (full code status), to appointments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; -Transport Driver transported Resident #9 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #10 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #55 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #11 (full code status) to appointments on [DATE], [DATE], [DATE], [DATE], and [DATE]; -Transport Driver transported Resident #12 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #51 (full code status) to an appointment on 10//,d+[DATE]; -Transport Driver transported Resident #52 (full code status) to appointments on [DATE], [DATE], and [DATE]; -Transport Driver transported Resident #13 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #3 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #56 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #14 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #57 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #15 (full code status) to appointments on [DATE], [DATE], [DATE], [DATE], and [DATE]; -Transport Driver transported Resident #16 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #17 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #18 (full code status) to appointments on [DATE] and [DATE]; -Transport Driver transported Resident #19 (full code status) to an appointment on [DATE]; -Transport Driver transported Resident #20 (full code status) to appointments on [DATE] and [DATE]. During an interview on [DATE] at 3:59 P.M. and [DATE] at 11:18 A.M. the SSD said Maintenance/Transport Driver H does most of the transportation. Maintenance/Transport Driver I and he/she (SSD) fills in for the transportation of residents when Maintenance/Transport Driver H was not available to transport. He/She does the transportation schedule. If a resident required physical assistance, sometimes a CNA goes with the drivers for transportation to appointments. He/She did not think Maintenance/Transport drivers H and I were CPR certified. He/She does not keep track of which staff members go to the appointments. He/She does not know which CNAs are CPR certified. He/She did not know his/her CPR certification was expired. He/She obtained CPR certification at his/her previous job and did not know he/she needed to have it to transport. 3. Review of the facility's Daily Staffing Sheets, dated [DATE]-[DATE], showed the facility did not have a staff member who was properly trained in CPR certification for Healthcare Providers, whose training included hands-on practice and in-person skills assessment (online-only certification is not acceptable), on the nursing schedule and did not provide documentation of a properly trained staff member working at the following dates and times: -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 6:00 A.M.-2:00 P.M. Review of the facility's Daily Staffing Sheets, dated [DATE], showed the facility did not have a staff member who was properly trained in CPR certification for Healthcare Providers, whose training included hands-on practice and in-person skills assessment (online-only certification is not acceptable), on the nursing schedule and did not provide documentation of a properly trained staff member working at the following dates and times:-[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 6 :00 A.M.-2:00 P.M.: -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 6:00 A.M.-2:00 P.M.; -[DATE], 10:00 P.M.-6:00 A.M.; -[DATE], 10:00 P.M.-6:00 A.M. During an interview on [DATE] at 3:46 P.M., the Staffing Coordinator said the following: -He/She does the nursing schedule; -He/She does not note who the CPR certified staff are on the schedule; -The facility does not have a list of staff who are CPR certified that he/ knew of; -He/She does not know who was CPR certified and who was not; -He/She does not know if the facility has CPR certified staff 24 hours a day, seven days a week. During an interview on [DATE] at 3:00 P.M., the Director of Nursing (DON) said the following: -She does not know which staff are CPR certified; -She does not know if CPR certified staff were noted on the schedule; -She does not know if the facility had CPR staff scheduled 24 hours a day, seven days a week; -The facility had full code residents; -She was CPR certified, but does not document the hours she was at the facility, so if she worked during the shifts she does not have a record of when she was in the building and when she was not in the building; -She did not know CPR certification was required to be for Healthcare Providers, and training included hands-on practice and in-person skills assessment (online-only certification is not acceptable); -She did not know who verified correct CPR certification, she was hired two months ago and no one asked for her certification. 4. Review of agency staff Licensed Practical Nurse (LPN) Q's American AED/CPR Association card showed the following: -He/She had successfully passed the cognitive and skills assessment of the Healthcare Provider BLS class (Adult, Child, and Infant) given by the American AED/CPR Association. This class was taught in accordance of current AHA/ECC Guidelines. Completion Date: [DATE], Renewal Date [DATE]. Review of www.aedcpr.com, showed American AED/CPR Association was designed for anyone in need of CPR certification online. The American AED/CPR Association had been offering classes for schools, hospitals, state programs, coaches, personal trainers and anyone who was required to have a Healthcare Provider BLS card. The course did not offer hands on skills training. During an interview on [DATE], at 6:44 P.M., LPN Q said the following: -He/She was CPR certified; -His/Her class was online only, there was no hands on part of the class; -He/She did not know he/she needed to have CPR certification with a hands on skills portion. Review of agency staff LPN R's National CPR Foundations card showed the following: -He/She was now certified in the above mentioned course by demonstrating proficiency in the subject by passing the examination in accordance with the terms and conditions of National CPR Foundation. Valid for two years; -Dated [DATE]. Review of www.nationalcprfoundation.com/courses/healthcare-provider-basic-life-support-2/, showed this BLS certification online course teaches medical workers how to perform life-saving techniques on infants, children, and adults. Basic life support essentially aimed to keep individuals suffering from life-threatening medical conditions alive in the interim of being transported to the hospital or during transfers to more advanced treatment centers. The course did not offer hands on skills training. Review of agency staff Certified Nurse Assistant (CNA) T's American Red Cross card showed the following: -He/She completed the requirements for Adult First Aid/CPR; -Date Completed [DATE]; -Valid for two years. Review of www.redcross.org, showed the 2021 Adult, Child and Baby First Aid/CPR/AED Online course equips students to recognize and care for a variety of first aid, breathing, and cardiac emergencies involving adults, children and babies. This course is taught online only (accessed via mobile, desktop or tablet) and does not meet OSHA requirements for workplace certification. To receive a valid two year Red Cross digital certificate that was OSHA compliant and meets other workplace and regulatory requirements, you must enroll in an Instructor-led skill session within 90 days of completing the online course. This course was not BLS for Healthcare providers. 5. During an interview on [DATE] at 5:10 P.M. and [DATE], at 9:12 A.M., the administrator said the following: -He expected CPR certified staff coverage 24 hours a day seven days a week. -He was not aware the online CPR certifications did not meet regulatory guidelines; -The employee that does payroll was in charge of keeping track of staff CPR certifications; -He did not think he/she was doing it appropriately; -He did not know the transportation drivers needed to be certified in CPR, or that it needed to be BLS for Healthcare providers with a hands on skills component. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview, and record review, the facility failed to ensure four residents (Residents #1, #9, #15, and #23), in a review of 24 sampled residents, were free from significant medication errors. The facility failed to ensure Resident #1 received nine out of thirteen doses of an intramuscular (IM) antibiotic to treat an infection to his/her right foot following hospitalization for [CONDITION(S)] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) from the infection. The resident was re-hospitalized on [DATE] for 20 days due to the continued infection in his/her right foot. Facility staff failed to obtain and administer three doses of antibiotic for one resident (Resident #23) on readmission from the hospital for [CONDITION(S)] secondary to a urinary tract infection ([CONDITION(S)]). Staff failed to prime (remove the air) the insulin pen (prefilled pen of insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration) as instructed by the manufacturer prior to administration of the physician prescribed dose, and failed to follow the manufacturer's instructions to keep the needle inserted in the skin for five seconds resulting in administration of less than the ordered dose of insulin. The facility's census was 52. The administrator was notified on [DATE] at 3:15 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 policy, Medication Shortages/Unavailable Medications, last revised [DATE], showed the following: -Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy; -If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action as specified; -If a medication shortage is discovered during normal pharmacy hours: 1. Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2. If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 3. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. -If a medication shortage is discovered after normal pharmacy hours: 1. A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 2. If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: a. Emergency delivery; or, b. Use of an emergency (back-up) Third Party Pharmacy. -If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions; -If the medication is unavailable from pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary; -If the medication is unavailable from pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other clinical reason, facility should collaborate with pharmacy and physician/prescriber to determine a suitable therapeutic alternative; -If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility's medical director for orders/direction, making sure to explain the circumstances of the medication shortage; -When a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Such documentation should include the following information: 1. A description of the circumstances of the medication shortage; 2. A description of pharmacy's response upon notification, and; 3. Action(s) taken. During interview on [DATE] at 11:44 A.M., the DON said there was no facility policy on medication administration. 1. Review of Resident #1's hospital discharge summary, dated [DATE], showed the following: -admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] ([CONDITION(S)]; bacteria) of the right foot; -Discharge medications included [MEDICATION(S)] (antibiotic) 1 gram intramuscularly (IM; injection into the muscle) daily, and [MEDICATION(S)] (antibiotic) 800 milligrams (mg)- 160 mg every 12 hours by mouth; -Patient was discharged back to the nursing home with a course of [MEDICATION(S)] for the isolated proteus mirabilis (bacteria) from the wound culture. He/She was also discharged on [MEDICATION(S)] double strength tablet for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed the resident was readmitted to the facility on [DATE]. Review of the resident's readmission skin assessment, dated [DATE], showed the following: -admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Current infection of [CONDITION(S)] ([CONDITION(S)]). The resident is on antibiotic therapy. Administer medications as ordered. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Solution 1gm inject 1 gram intramuscularly in the evening for infection of his/her foot; -[MEDICATION(S)] Tablet ,d+[DATE] mg give 1 tablet by mouth two times a day for infection for 14 days. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff documented the medication was not available. Review of the pharmacy's delivery manifest, dated [DATE] at 9:52 P.M., showed the pharmacy delivered three doses of [MEDICATION(S)]. Review of the resident's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Staff did not administer [MEDICATION(S)] on [DATE], [DATE], and [DATE]. Staff documented the medication was not available on these days; -Staff did not administer the evening dose of [MEDICATION(S)] on [DATE]; -Staff did not administer [MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], and [DATE]. Staff documented the medication was not available on these days. Review of the resident's nurses notes, dated [DATE], showed the resident had an episode at the wound clinic and he/she was being admitted to the hospital. Review of the resident's medical record showed he/she was hospitalized on [DATE]. Review of the resident's medical record showed he/she was hospitalized on [DATE] with an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required surgical incision and drainage of the right foot wound on [DATE]. The wound was cultured and positive for [CONDITION(S)] on [DATE]. Review of the resident's hospital discharge summary, dated [DATE], showed the following: -The resident has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] -Transferred to the emergency department by emergency medical services; -Met [CONDITION(S)] criteria on admission given [CONDITION(S)], [CONDITION(S)] (rapid heart rate), and infection being diabetic foot; -On [DATE], wound culture showing growing Proteus, [CONDITION(S)], and acinetobacter (bacteria); -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11:10 A.M., the resident said the following: -He/She was admitted to the hospital on [DATE] with [CONDITION(S)]; -He/She was discharged with an oral antibiotic and an injectable antibiotic; -Staff only administered the injectable antibiotic two times and it was supposed to be daily; -He/She does not know what the staff documented, but he/she only received two shots; -On [DATE], he/she had an appointment at the wound clinic, and he/she did not feel right and passed out; -Staff at the wound clinic called the ambulance and he/she went by ambulance to the hospital and was admitted for [CONDITION(S)]; -He/She was admitted to the intensive care unit and was very sick because the staff did not administer the antibiotics that were ordered from his/her first hospital admission. During an interview on [DATE], at 8:10 A.M., licensed practical nurse (LPN) H said the following: -Resident #1 was supposed to receive [MEDICATION(S)] IM in July between his/her hospitalization s; -The medication was not available some of the shifts he/she worked; -He/She passed it on in report for the day shift charge nurse, but does not know if the physician was notified; -Staff should contact the physician if a medication is not available for further orders. During an interview on [DATE], at 8:45 A.M., LPN A said the following: -He/She is an agency nurse and works day shifts; -He/She does not recall receiving in report that the resident's [MEDICATION(S)] was not available; -If a medication was not available, staff would contact the pharmacy to see why and if it could be remedied ; -If they could not obtain the medication then the charge nurse would call the physician for further direction. During an interview on [DATE] at 2:43 P.M., the resident's physician said the following: -He was not aware the resident's IM antibiotic was not available and staff did not administer the medication; -Staff did not contact him/her (regarding the IM antibiotic not being available), but if they had, he/she would have given orders for another appropriate antibiotic; -The resident not receiving the IM antibiotic as ordered could have contributed to the resident's re-hospitalization for [CONDITION(S)]. During interviews on [DATE] at 12:40 P.M., and on [DATE] at 9:50 A.M., the Director of Nursing (DON) said she expected staff to administer medications and treatments as ordered. If there were any issues, staff should let him/her know. Staff should contact the pharmacy after the first dose of a medication was missed. Staff should notify the physician and get orders to hold or change the medication. Staff could also contact the local pharmacy if medications needed to be picked up faster. She was not aware Resident #1's [MEDICATION(S)] was not available. The pharmacy only delivered the three doses of [MEDICATION(S)] on [DATE] at 9:52 P.M. 2. Review of Resident #23's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Short and long-term memory problems; -Independent daily-decision making skills; -Received an antibiotic two of the last seven days; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's hospital discharge note, dated [DATE], showed the resident's discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes, dated [DATE], showed at 5:22 P.M., the resident was readmitted to the facility and medications were ordered. Review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Readmit to the facility on [DATE]; -[MEDICATION(S)] (antibiotic for urinary tract infections) 200 milligrams (mg) twice a day until [DATE]; -[MEDICATION(S)] (broad spectrum antibiotic) 100 mg twice a day until [DATE]. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -On [DATE], no documentation the resident received the evening dose of [MEDICATION(S)] 200 mg or [MEDICATION(S)] 100 mg. (Review of the resident's progress notes showed no documentation as to why the resident did not receive the medications as ordered); -On [DATE], no documentation the resident received the morning or evening dose of [MEDICATION(S)] 200 mg. (Review of the progress notes showed no documentation as to why the resident did not receive the morning dose of the medication as ordered.) Review of the resident's progress notes, [DATE] at 7:19 P.M., showed the [MEDICATION(S)] 200 mg was on order. Review of the resident's progress notes showed no evidence staff notified the pharmacy, the DON or the resident's physician of the medications not being available to administer to the resident. During interviews on [DATE] at 2:45 P.M., and on [DATE] at 12:23 P.M., LPN C said the following: -When a resident is admitted , the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. in order for the medications to be delivered that evening; -If an ordered medication did not come in from the pharmacy, then staff should check the stat kit (emergency medications) to see if the medication was available there; -If the medication was not in the stat kit, then the resident would have to wait to get the dose of medication until the next day when the pharmacy delivered the medications; -If an ordered medication did not come from the pharmacy, staff should call the pharmacy and the DON to receive direction; -He/She did not notify the pharmacy, DON or the resident's physician when Resident #23's medications were not available (after readmission from the hospital on [DATE]); -After the resident missed two doses of a medication, then he/she would call the pharmacy and see what was going on; -If he/she was not able to get a medication from the pharmacy, then he/she would let the DON know and she would handle it. Review on [DATE] of the Stat Safe (emergency drug kit) Inventory sheet showed it contained eight tablets of [MEDICATION(S)] 100 mg. During interview on [DATE] at 3:13 P.M., the DON said the following: -When a resident is admitted to the facility, staff enter the resident's medication orders into the computer and verify the medication orders with the physician; -Once the physician verifies the orders, the orders have to be acknowledged so pharmacy can view them on their end (by reviewing the resident's electronic record); -If staff order the medications after 4:00 P.M., then the pharmacy will not deliver the medications that evening; -If a medication is not available, staff should check to see if the medication is available in the Stat Kit; -If the medication is not in the Stat Kit, then staff should call the pharmacy to check on the delivery status of the medication; -If medications are not available for the staff to administer, then staff should notify the on-call pharmacist and the DON so she can figure out where to get the medications; -Staff should also notify the resident's physician for further direction when a medication is not available; -She did not know until today ([DATE]) that Resident #23 had missed several doses of his/her antibiotic. During interview on [DATE] at 3:45 P.M., Resident #23's physician, Physician X, said it was the facility's responsibilty to have medications available for residents. He/She did not recall the facility staff notifying him/her that the resident's medications were not available. The resident not having his/her antibiotic could have had a negative outcome for the resident. 3. During an interview on [DATE], at 3:00 P.M., the Director of Nursing (DON) said the facility used the manufacturer's guidelines for use of an insulin pen. Review of the manufacturer's instructions for use of the insulin pen, dated [DATE], showed the following: -Pull off the pen cap; -Wipe the rubber stopper with an alcohol swab, screw on the needle, and remove the needle cap; -Turn the dose selector to select two units; -Hold the insulin pen 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. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure. A small air bubble may remain at the needle tip, but it will not be injected; -Select the dose, turn the dose selector to the number of units you need to inject; -Insert the needle into the skin. -Press the push-button all the way in until the dose selector is back to zero; -Insert the needle into your skin, push the dose knob all the way in and keep the needle in the skin for five seconds to ensure the full dose is administered; -Remove the needle from the skin. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the following: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Daily insulin injections; -Diabetic foot ulcer. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Pen (long acting insulin to lower blood sugar) 100 unit/milliliter (ml), inject 27 units subcutaneously (under the skin) every 12 hours for diabetes; -[MEDICATION(S)] Pen (short acting insulin to lower blood sugar) 100 unit/ml, inject as per sliding scale subcutaneously before meals. If 0 - 150 = 0 units; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units; 451 - 500 = 8 units; 502 - 503 = 10 units and call the physician. Observation on [DATE], at 7:35 A.M., showed the following: -Licensed Practical Nurse (LPN) C obtained the resident's blood glucose. The resident's blood glucose was 440; -LPN C removed the cap from the resident's [MEDICATION(S)] pen, cleaned the top of the vial, applied the needle to the pen, and dialed the dose selector to 6 units. LPN C did not prime the pen; -LPN C removed the cap from the resident's [MEDICATION(S)] pen, cleaned the top of the vial, applied the needle to the pen, and dialed the dose selector to 27 units. LPN C did not prime the pen; -LPN C cleaned the administration site on the resident's abdomen with an alcohol wipe; -LPN C inserted the needle of the [MEDICATION(S)] pen into the resident's skin, pushed the dose selector until it reached zero, and immediately removed the needle from the resident's skin. LPN C did not hold the needle in the resident's skin for five seconds; -LPN C inserted the needle of the [MEDICATION(S)] pen into the resident's skin, pushed the dose selector until it reached zero, and immediately removed the needle from the resident's skin. LPN C did not hold the needle in the skin for five seconds. 4. Review of Resident #15's significant change in status MDS, dated [DATE], showed the following: -Moderately impaired cognition; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Daily insulin injections. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Pen 100 unit/ml, inject 36 units subcutaneously at bedtime; -[MEDICATION(S)] Pen 100 unit/ml, inject 10 units subcutaneously before meals; -[MEDICATION(S)] Pen 100 unit/ml, inject per sliding scale subcutaneously before meals. If 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301+ = 8 units. Observation on [DATE], at 7:55 A.M., showed the following: -LPN C obtained the resident's blood glucose. The resident's blood glucose was 171; -LPN C removed the cap from the resident's [MEDICATION(S)] pen, cleaned the top of the vial, applied the needle to the pen, and dialed the dose selector to 12 units. LPN C did not prime the pen; -LPN C cleaned the administration site on the resident's abdomen with an alcohol wipe; -LPN C inserted the needle of the [MEDICATION(S)] pen into the resident's skin, pushed the dose selector until it reached zero, and immediately removed the needle from the resident's skin within two seconds. LPN C did not hold the needle in the skin for five seconds. During an interview on [DATE], at 3:00 P.M., LPN C said the following: -When using an insulin pen, you do not prime the pen; -Staff are to remove the pen cap, clean the rubber stopper, apply the needle, and dial the dose; -When administering the dose, you push the dose selector until it reaches zero, count slowly to three and remove the needle from the skin. 5. During an interview on [DATE] at 12:40 P.M., the DON said he/she was not aware insulin pens needed to be primed before administering insulin to ensure a correct dose was given, or the insulin pen had to remain in the skin for five seconds. During interview on [DATE] at 1:42 P.M., the administrator said the following: -If medications were not available, staff should immediately call the pharmacy to see what was going on and notify the DON. Staff should also notify the resident's physician to let him/her know the medication was not available and get further direction; -He expected staff to check the Stat Kit to see if any needed medications were available. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview, and record review, the facility failed to consistently assess and provide physician ordered treatments for non-pressure related wounds in accordance with current accepted standards of practice for two residents (Resident #1 and #9). Resident #1 developed non-pressure related wounds on both his/her feet. Resident #1 was hospitalized and required surgical intervention and intramuscular (IM) antibiotics to treat a wound and wound infection to his/her right foot. Staff did not follow physician orders to treat and did not consistently provide interventions to promote healing for both wounds. The wound on the resident's right foot deteriorated. Resident #9 has had ongoing infection and is resuming intravenous (through the vein) antibiotics to treat an infection in his/her left heel wound. A sample of 24 residents was selected for review. The facility census was 52. Review of the facility's policy titled Wound Care System Requirements, revised March 2021, showed the following: -The following are the minimum wound care system requirements that are to be maintained in each facility. While some slight differences may exist in each facility's organization, these core requirements should be easily located; -The facility has a designated Wound Care Nurse, who completes weekly assessments and documentation; -Standardized pressure ulcer/pressure injury risk assessment tool in use-Braden Scale, completed on admission, weekly for four weeks, and then quarterly or with any significant change; -Individualized turning and repositioning, toileting, incontinent care, and hydration per individual resident needs; -Skin checks by licensed staff weekly for all residents; -Monthly 100% skin audits of all residents by Director of Nursing (DON) and administrative nurse team completed by the 10th of each month; -Weekly wound assessment is being completed, with individual documentation; -A pressure ulcer, pressure injury worksheet will be completed each time an in house acquired pressure ulcer/pressure injury is identified; -Other ulcers and skin conditions are assessed and documented on weekly; -Weekly Case Management System meetings are being held with appropriate attendance and input; -Collaborate with therapy to initiate therapeutic interventions (adjunct treatments) to prevent occurrence or progression of the pressure ulcer/injury; -Treatments are being completed as ordered and are changed if no progress is noted in two weeks; -Care plans and Minimum Data Set ( MDS, a federally mandated assessment instrument required to be completed by facility staff) reflect the current wound status, risk factors, and individualized approaches/interventions; -Current and ongoing employee education and prevention, treatment, healing, and responsibilities by the wound care nurse. Review of the facility policy Wound Management, Treatment, and Prevention Guidelines, revised January 2019, showed the following: -Wound assessment and documentation checklist includes the type of wound, location, stage, size, exudate (drainage), pain, tissue type, tunneling and undermining, and periwound (wound edges and surrounding tissue); -Steps for pressure ulcer prevention include following a prevention program, maintain nutrition, identifying risk factors and interventions, turning and repositioning immobile or at risk individuals, cleansing and moisturizing, and applying prophylactic foam. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/9/21, showed the following: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -No diabetic ulcers (open wounds or sores usually found on the bottom of feet in individuals with diabetes), venous ulcer (wound on the leg or ankle caused by abnormal or damaged veins), or arterial ulcers (wound caused by poor delivery of nutrient-rich blood to the lower extremities. Review of the resident's skin assessment, dated 5/3/21, showed no skin impairment identified to the resident's feet. Review of the resident's care plan, revised 6/4/21, showed the following: -Potential for skin issues related to diabetes mellitus; -Check all body for breaks in skin and treat promptly as ordered by physician; -Inspect feet daily for open areas, sores, pressure ulcers, blisters, [CONDITION(S)], or redness. Review of the resident's quarterly MDS, dated [DATE], showed no diabetic, venous, or arterial ulcers. Review of the resident's skin assessment, dated 6/9/21, showed the following: -Areas of impairment: scattered scarring (no location or measurements listed); -No new changes this week; -Care plan reviewed. No need for update as the care plan is current. Review of the resident's medical record showed no documentation staff completed weekly skin assessments per facility policy between 6/9/21 and 7/8/21 or inspected the resident's feet daily as directed in the resident's care plan. Review of the resident's Physician Order Sheet (POS) for July 2021 showed an order dated 7/7/21 to cleanse the wound to the bottom of the resident's right foot. Do not scrub. Apply calcium alginate with silver (a highly absorbent, antibacterial wound dressing), then dry gauze and secure with rolled gauze. Change every day. Continue to wear Croc shoe until wound is healed. Every day shift for skin integrity. Review of the resident's skin assessment, dated 7/8/21, showed the following: -No new changes this week; -Areas of impairment were right bottom of foot, 1.5 centimeters (cm) by 1.5 cm by 0.2 cm ulcer cleansed with skin prep, applied nonadherent dressing and wrapped in kerlix (rolled gauze); -No new areas of skin impairment; -Care plan reviewed. No need for update as the care plan is current. Review of the resident's care plan showed no evidence the resident had a wound on the bottom of his/her right foot. Review of the resident's Treatment Administration Record (TAR) for July 2021 showed no documentation staff completed the calcium alginate dressing treatment to the resident's right foot on 7/9/21. Review of the resident's discharge MDS, dated [DATE], showed no diabetic, venous, or arterial ulcers. Review of the resident's medical record showed he/she was hospitalized on [DATE] and was readmitted to the facility on [DATE]. Review of the resident's readmission skin assessment, dated 7/13/21, showed the following: -admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was admitted with the following skin issues: an abscess on the right foot. (Staff did not document measurements or other description of this area); -Current infection of [CONDITION(S)] ([CONDITION(S)]). The resident is on antibiotic therapy. Review of the resident's Physician Order Sheet (POS), dated 7/13/21, showed the following: -Gauze and kerlix dressing, change to right foot daily; -Heel protector boots while in bed or up in recliner to relieve pressure every shift; -Emollient cream (cream applied to the skin to soothe and soften skin), apply to feet topically one time a day for dry feet. Review of the resident's TAR for 7/13/21 through 7/20/21, showed the following: -The physician's order for gauze and Kerlix dressing change to the right foot daily was not listed on the TAR. Review showed no documentation staff completed the ordered dressing to the resident's right foot on 7/13/21 through 7/20/21. -No documentation staff applied heel protector boots while the resident was in bed or up in recliner on the evening shift on 7/15/21, on the day shift on 7/19/21, and on the evening shift on 7/20/21. Review of the resident's skin assessment, dated 7/20/21, showed the following: -New changes this week were a recent illness or acute condition; -Bottom of right foot underneath toes. Ulcer 1.4 cm by 1.5 cm by 0.2 cm. Cleansed with wound cleanser, applied calcium alginate and wrapped with kerlix; -No new areas of skin impairment; -Care plan reviewed. No need for an update as the care plan is current. Review of the resident's POS showed an order, dated 7/21/21, to cleanse the right plantar foot with normal saline, calcium alginate with silver, then dry gauze and kerlix daily. Review of the resident's July 2021 TAR showed the following: -No documentation staff applied heel protector boots on the resident while in bed or up in recliner to relieve pressure on the day shift on 7/21/21, on the evening shift on 7/22/21, and on the evening shift on 7/24/21; -No documentation staff cleansed the resident's right plantar foot with normal saline, calcium alginate with silver, then dry gauze and kerlix on 7/25/21. -No documentation staff applied heel protector boots on the resident while in bed or up in recliner to relieve pressure on the evening shift on 7/27/21. Review of the resident's discharge MDS, dated [DATE], showed no diabetic, venous, or arterial ulcers. Review of the resident's nurses notes, dated 7/27/21, showed the resident had an episode at the wound clinic and he/she was being admitted to the hospital. Review of the resident's medical record showed he/she was hospitalized on [DATE]. Review of the resident's medical record showed he/she was hospitalized on [DATE] with an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required surgical incision and drainage of the right foot wound on 7/27/21. The wound was cultured and positive for [CONDITION(S)] on 7/28/21. Review of the resident's wound management consultation notes from the hospital, dated 7/28/21 and 7/29/21, showed the following: -Wound #1 type: Diabetic foot ulcer of the right foot; -Wound base with black eschar (dead tissue that sheds or fall off from the skin); -Wound measurements: 4.0 cm by 3.3 cm by 0.5 cm. Review of the resident's hospital discharge summary, dated 8/16/21, showed the following: -Resident has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] -Transferred to the emergency department by emergency medical services; -Met [CONDITION(S)] criteria on admission given [CONDITION(S)], [CONDITION(S)] (rapid heart rate), and infection being diabetic foot; -On 7/31/21, wound culture showing growing Proteus, [CONDITION(S)], and acinetobacter (bacteria); -Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurse's note, dated 8/16/21 at 6:29 P.M., showed the resident was readmitted to the facility via ambulance. The resident had necrotic (dead) tissue on the left heel wound, with debridement on the left foot that measured 3.5 cm by 2.2 cm by 1.7 cm. (This is the first documented entry related to a wound on the resident's left foot/heel.) Review of the resident's readmission skin assessment, dated 8/16/21, showed the resident was admitted with skin issues to the right heel and the left heel. (There were no measurements or other descriptions of these wounds on this assessment.) Review of the resident's POS, dated 8/16/21, showed the following: -Wound care to right heel: Cleanse the left heel (this was how it was documented in the resident's orders) with normal saline. Apply [MEDICATION(S)] cream (ointment to prevent and heal skin irritations) to wound edges. Apply 0.125% Dakin's solution (antimicrobial solution used to prevent and treat skin and tissue infections) moistened gauze to wound beds. Secure with [MEDICATION(S)] bordered dressing (self adhering foam dressing). Change the border dressing as needed or if soiled and complete wound care two times a day; -Dakin's solution 0.125%, apply to left heel every three days in the evening. Review of the resident's TAR from 8/16/21 through 8/23/21 showed the following: -No documentation staff completed the resident's wound treatment to the right heel on 8/17/21 and 8/18/21; -The order for Dakin's solution 0.125%, apply to left heel every three days in the evening was not listed on the TAR. Review showed no documentation staff completed the ordered treatment to the resident's left heel on 8/17/21 through 8/23/21. Review of the resident's POS, dated 8/23/21, showed an order to apply skin prep (a liquid used on intact skin to form a protective film) to deep tissue injury (an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer) to left heel. Apply [MEDICATION(S)] border dressing every three to five days. Assess daily and cleanse. Replace if the dressing becomes soiled or edges are rolled. One time a day for wound care (8/23/21). Observation on 8/24/21 from 12:33 P.M. until 6:30 P.M., showed the resident lay in bed. There was a large wound present to the bottom of the resident's right foot and there was no dressing in place. The resident did not have heel protector boots on and both feet lay directly on the mattress. The bottom of the resident's left heel had a large, round, area of dark discoloration. No depth, open areas, or drainage was noted to the left foot wound. Observation on 8/24/21 at 6:30 P.M., showed the following: -Licensed Practical Nurse (LPN) A and LPN M were in the resident's room as the resident lay in bed; -Wound dressing supplies lay in a basin on the floor; -LPN M had just completed the dressing change to the resident's right foot. During an interview on 8/24/21 at 6:50 P.M., the resident said LPN M did not know what his/her dressing orders were, and the resident had to tell LPN M what to do. The resident said LPN M was an agency nurse and it was his/her first day at the facility. The resident said LPN M did not put any Dakin's solution on the wound on his/her right foot. LPN M applied [MEDICATION(S)] to the area and covered it with a dressing. The resident said his/her right foot should have the dressing changed twice a day but there had not been a dressing on his/her right foot since the day before. During an interview on 9/1/21 at 3:02 P.M., LPN M said he/she was an agency nurse and 8/24/21 was his/her first day in the facility. LPN M was not familiar with the resident and his/her dressing changes. LPN M had tried to get someone to help him/her with the dressing changes for the resident but no one was available to assist him/her. There was no dressing in place to the resident's right foot the entire day. LPN M said he/she followed the orders as written for the resident's dressing change, but could not recall what he/she used to dress the wound on the resident's right foot. Review of the resident's wound center visit note, dated 8/25/21, showed the following: -Diabetic ulcer to the right foot that measured 7 cm by 3.5 cm by 0.1 cm. The wound was deteriorating. Treatment orders to cleanse the wound with normal saline, apply calcium alginate to wound bed, cover with gauze and secure with rolled gauze daily; -Diabetic ulcer to left heel that measured 2.5 cm by 5.5 cm by 0.1 cm. Treatment orders to cleanse the wound with normal saline, apply [MEDICATION(S)] and leave open to air daily. Review of the resident's medical record showed no evidence staff notified the resident's physician of the deterioration of the wound on the resident's right foot. During an interview on 8/26/21 at 12:30 P.M., the Assistant Director of Nurses (ADON) said he/she already completed the dressing changes to the resident's feet. The wound to the resident's right heel measured 2.4 cm by 4.2 cm by 0.4 cm. The wound to the resident's left heel measured 1.7 cm by 3.2 cm and had no depth. During an interview on 9/8/21 at 2:43 P.M., the resident's physician said the following: -He/She would expect licensed staff in the facility to monitor the resident's skin closely at regular intervals due to the resident's history of buttock and heel ulcers; -Licensed staff should monitor and assess the wounds, and notify him/her of any deterioration; -Staff should change the wound dressings as ordered. 2. Review of Resident #9's Face Sheet, showed the resident admitted to the facility 10/1/20. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Requires extensive physical assistance of two or more staff members for bed mobility, transfers, toilet use, hygiene, and bathing; -Diabetic foot ulcer. Review of the resident's care plan, dated 3/26/21, showed the following: -The resident has an actual impairment to skin integrity related to Stage III pressure injury to his/her left heel, with a surgical procedure to close the wound with a graft from his/her left thigh; -Administer treatments as ordered and monitor for effectiveness; -Avoid mechanical trauma; -Avoid shearing of left heel while repositioning when in bed; -Ensure appropriate protective device (pressure reducing boot) is applied to affected areas; -Evaluate wound for: Size, depth, margins: peri-wound skin, undermining, exudates, [CONDITION(S)], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated; -Monitor dressing when providing care to ensure it is intact and adhering. Report loose dressing to nurse; -Monitor/document/report to physician as needed for signs and symptoms of infection: Green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, and fever. Review of the resident's wound clinic noted, dated 5/17/21, showed the following: -Evaluation of surgical incision approximated wound on the left heel; -Measures 3.73 cm in length, 2.64 cm in width and no depth. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Requires extensive assist of one staff member for bed mobility, transfers, toilet use, hygiene and bathing; -Dependent on two or more staff members for transfers -Limited range of motion one lower extremity -Diabetic foot ulcer. Review of the resident's census showed the resident discharged to the hospital on 7/29/21. Review of the resident's hospital daily progress note, dated 8/2/21, showed the resident continued on antibiotics for a heel wound infection. Review of the resident's readmission assessment, dated 8/2/21, showed the resident readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Physician's Orders, dated 8/2/21-8/24/21, showed to cleanse left plantar foot with normal saline, apply [MEDICATION(S)] (a medicated moisture barrier cream) to the periwound, fill wound with silver [MEDICATION(S)] (an absorbent moisture retention dressing with an antibacterial agent), cover with dry gauze, secure with roll gauze, change two times daily and as needed if loose or soiled; Review of the resident's MAR, dated 8/2/21-8/20/21, showed the following: -Staff did not document treatment scheduled for 8:00 A.M. for the left plantar foot were completed on 8/3/21, 8/6/21, 8/7/21, 8/16/21, and 8/20/21; -Staff did not document treatment scheduled for 8:00 P.M. for the left plantar foot were completed on 8/5/21, 8/11/21, 8/12/21, 8/16/21, and 8/20/21. Review of the resident's weekly skin check, dated 8/20/21, showed the following: -Left heel wound measures 3.5 cm in length, 5 cm in width, and 0.4 cm ulcer, small breakdown area measuring 1 cm in length, and 1.3 cm in width, no drainage present; -Dressing changed as ordered. During an interview on 8/24/21, at 10:10 A.M., the resident said the following: -He/She admitted to the facility in October of 2020 because he/she had an extensive injury to his/her left heel. He/She lived at home and stepped on a spring that cut his/her left heel to the bone; -He/She had a skin graft to the area and the graft failed and has been infected; -When the wound heals to a point it can be managed at home, he/she plans to go home; -He/She is concerned about the wound healing because the staff do not change his/her dressing as ordered; -The dressing to his/her foot is supposed to be changed twice daily; -Staff sometimes will only change his/her dressing once a day or not at all; -His/Her foot dressing has gone a couple days without being changed; -The dressing he/she has on today was placed on the morning on 8/23/21, no one changed it last night and it has not been changed this morning. During an interview on 8/25/21, at 4:45 P.M., the resident said he/she still has the dressing on his/her left foot from 8/23/21. Observation on 8/25/21, at 4:45 P.M., showed the resident's dressing had a half dollar size dark brown dried drainage area in the center of the dressing covering his/her heel, and a larger, soft ball sized area of dried drainage around the dark area. During an interview on 8/25/21, at 9:57 P.M., the resident said that a nurse finally changed the dressing from 8/23/21, on 8/25/21 at 3:00 A.M. Observation and interview on 8/26/21, at 9:57 A.M., showed the following: -The Assistant Director of Nursing (ADON) removed the resident's soiled dressing; -The soiled dressing contained yellow and green drainage; -The ADON measured the resident's wound and said it measured 5.2 cm in length, 4.5 cm in width and 0.2 cm in depth; -ADON identified a second open area that measured 1.5 cm in length, and 0.5 cm in width, the area did not have any depth; -He/She said the resident's dressing was ordered to be changed twice daily once on day shift and once on night shift; -He/She said the resident is going to have a PICC line (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period) placed for intravenous antibiotic because there is infection in his/her wound, they think it is [CONDITION(S)] (inflammation of bone or bone marrow, usually due to infection). 3. During an interview on 8/26/21 at 12:40 P.M., and on 9/15/21, at 9:50 A.M., the Director of Nursing (DON) said some treatments have a liberal time frame for administration and this liberal time frame would be listed on the TAR. The DON expected staff to administer treatments as ordered and if there were any issues they should let him/her know. TAR's were checked by the DON and the weekend supervisors to ensure treatments were completed. MO 059 MO 030 MO 721 MO 544 MO 151 MO 762

Based on observation, interview, and record review, the facility failed to consistently assess one resident (Resident #1), who the facility identified at risk for developing pressure ulcers, according to facility policy, failed to provide evidence staff notified the resident's physician to obtain treatment when the resident developed two pressure ulcers, failed to update the resident's care plan to include the pressure ulcers and interventions to address healing, failed to adequately and consistently assess the pressure ulcers and provide evidence staff notified the resident's physician of changes to the pressure ulcers, failed to consistently follow treatment orders, failed to reposition the resident as directed in his/her plan of care, failed to follow proper infection control procedures to prevent infection when changing the pressure ulcer dressings and failed to maintain wound dressings to promote healing. Resident #1 developed two Stage III pressure ulcers (full thickness loss of skin). The facility failed to implement a system to ensure consistent assessment and documentation of pressure ulcers. The facility failed to implement a plan of care to include repositioning and checking the resident for incontinence for one resident (Resident #21), who was at risk for developing pressure ulcers and required staff's assistance to perform activities of daily living. A sample of 24 residents was selected for review. The facility census was 52. The administrator was notified on 9/20/21 at 3:15 P.M. of an Immediate Jeopardy (IJ) which began on 7/8/21. The IJ was removed on 9/21/21, as confirmed by surveyor onsite verification. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [CONDITION(S)] (redness). Presence of blanchable [CONDITION(S)] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer). Review of the facility's policy titled Wound Care System Requirements, revised March 2021, showed the following: -The following are the minimum wound care system requirements that are to be maintained in each facility. While some slight differences may exist in each facility's organization, these core requirements should be easily located; -The facility has a designated Wound Care Nurse, who completes weekly assessments and documentation; -Standardized pressure ulcer/pressure injury risk assessment tool in use-Braden Scale, completed on admission, weekly for four weeks, and then quarterly or with any significant change; -Individualized turning and repositioning, toileting, incontinent care, and hydration per individual resident needs; -Skin checks by licensed staff weekly for all residents; -Monthly 100% skin audits of all residents by Director of Nursing (DON) and administrative nurse team completed by the 10th of each month; -Weekly wound assessment is being completed, with individual documentation; -A pressure ulcer, pressure injury worksheet will be completed each time an in house acquired pressure ulcer/pressure injury is identified; -Other ulcers and skin conditions are assessed and documented on weekly; -Weekly Case Management System meetings are being held with appropriate attendance and input; -Collaborate with therapy to initiate therapeutic interventions (adjunct treatments) to prevent occurrence or progression of the pressure ulcer/injury; -Treatments are being completed as ordered and are changed if no progress is noted in two weeks; -Care plans and Minimum Data Set ( MDS, a federally mandated assessment instrument required to be completed by facility staff) reflect the current wound status, risk factors, and individualized approaches/interventions; -Current and ongoing employee education and prevention, treatment, healing, and responsibilities by the wound care nurse. Review of the facility policy Wound Management, Treatment, and Prevention Guidelines, revised January 2019, showed the following: -Wound assessment and documentation checklist includes the type of wound, location, stage, size, exudate (drainage), pain, tissue type, tunneling and undermining, and periwound (wound edges and surrounding tissue); -Steps for pressure ulcer prevention include following a prevention program, maintain nutrition, identifying risk factors and interventions, turning and repositioning immobile or at risk individuals, cleansing and moisturizing, and applying prophylactic foam. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/9/21, showed the following: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Physically dependent on two or more staff for bed mobility, transfers, personal hygiene, and bathing; -Indwelling urinary catheter; -[CONDITION(S)] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); -At risk for pressure ulcers; -No unhealed pressure ulcers; -No pressure reducing device for his/her bed or chair; -No turning or repositioning program. Review of the resident's skin assessment, dated 5/3/21, showed the following: -No new changes this week; -Areas of skin impairment noted at the coccyx (triangular bone at the base of the spinal column), which was reddened and at risk for breakdown; -Care plan reviewed. No need for update as the care plan is current. Review of the resident's care plan, revised 6/4/21, showed the following: -Potential for skin issues related to diabetes mellitus; -Check all body for breaks in skin and treat promptly as ordered by physician; -Consult with wound clinic as needed; -Activities of daily living self-care deficit related to needing extensive assistance with care due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident is totally dependent on staff for repositioning and turning in bed. Needs to be turned every two to three hours to reduce the risk of bed sores. The resident requests to be turned two times per shift: 7:30 A.M., 11:30 A.M., 3:30 P.M., 7:30 P.M., 11:30 P.M., and 3:30 A.M.; -History of pressure wound on right buttock, right foot, and the left and right ischium (part of the hip bone). Review of the resident's quarterly MDS, dated [DATE], showed the following: -At risk for developing pressure ulcers; -No unhealed pressure ulcers; -Pressure reducing device to bed and chair; -Turning/repositioning program; -Application of nonsurgical dressing other than to feet; -Application of ointments/medications other than to feet. Review of the resident's skin assessment, dated 6/9/21, showed the following: -Areas of impairment: scattered scarring (no location or measurements listed); -No new changes this week; -Care plan reviewed. No need for update as the care plan is current. Review of the resident's medical record showed no documentation staff completed weekly skin assessments per facility policy between 6/9/21 and 7/8/21. Review of the resident's skin assessment, dated 7/8/21, showed the following: -No new changes this week; -Coccyx: large unstageable wound has an open area on the left buttock, 9.5 centimeter (cm) by 5.5 cm; -Coccyx: large unstageable wound to the right buttock, 6.5 cm by 4.5 cm; -No new areas of skin impairment; -Care plan reviewed. No need for update as the care plan is current. (Review of the resident's medical record showed no evidence of the unstageable wounds on the resident's left and right buttocks prior to the skin assessment completed on 7/8/21.) Review of the resident's care plan showed no evidence the resident had large unstageable wounds on his/her left and right buttocks, and no evidence of interventions to address these areas. Review of the resident's medical record from 7/8/21 through 7/10/21 showed no documentation staff notified the resident's physician of the wounds to the resident's buttocks. Review of the resident's POS for July 2021 showed no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's discharge assessment, dated 7/10/21, showed the following: -Unhealed pressure ulcers; -Unstageable pressure ulcer. Review of the resident's medical record showed he/she was hospitalized on [DATE]. Review of the resident's admission assessment from the hospital, dated 7/10/21, showed stage III pressure ulcers to the gluteal sulcus (the area just under the buttock and above the upper thigh, also known as the gluteal crease) that were foul smelling. Review of the resident's medical record showed the resident was readmitted to the facility on [DATE]. Review of the resident's readmission skin assessment, dated 7/13/21, showed the resident was admitted with a Stage I (intact skin with non-blanchable redness of a localized area over a bony prominence) pressure ulcer to the right buttock and a Stage I pressure ulcer to the left buttock. (Staff did not document measurements or other description of these areas.) Review of the resident's Physician Order Sheet (POS), dated 7/13/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to buttocks three times a day for skin integrity Review of the resident's Treatment Administration Record (TAR) for 7/13/21 through 7/20/21, showed no documentation staff applied menthol-[MEDICATION(S)] ointment 0.44-20.6% to the resident's buttocks on the evening shift on 7/20/21. Review of the resident's skin assessment, dated 7/20/21, showed the following: -New changes this week were a recent illness or acute condition; -Right buttock- unstageable wound 3 cm by 1 cm. Cleansed with wound cleanser, applied barrier cream around wound, and interdry (moisture wicking fabric) applied (resident requested); -Left buttock- unstageable wound 4.5 cm by 2 cm. Cleansed with wound cleanser, applied barrier cream around wound edges, and interdry applied (resident requested). (Staff did not document any further description of the wounds on the resident's left and right buttocks.) -No new areas of skin impairment; -Care plan reviewed. No need for an update as the care plan is current. Review of the resident's medical record showed no evidence staff notified the resident's physician of the resident's wounds deteriorating from Stage I pressure ulcers to unstageable wounds between 7/10/21 and 7/20/21. Review of the resident's care plan showed no updates addressing the wounds documented on the skin assessment dated [DATE]. Review of the resident's Treatment Administration Record (TAR) from 7/21/21 through 7/27/21 showed the following: -On the day shift on 7/21/21, no documentation staff applied menthol-[MEDICATION(S)] ointment 0.44-20.6% to the resident's buttocks; -On the evening shift on 7/22/21, no documentation staff applied menthol-[MEDICATION(S)] ointment 0.44-20.6% to the resident's buttocks; -On the evening shift on 7/24/21, no documentation staff applied menthol-[MEDICATION(S)] ointment 0.44-20.6% to the resident's buttocks; -On the evening shift on 7/27/21, no documentation staff applied menthol-[MEDICATION(S)] ointment 0.44-20.6% to the resident's buttocks. Review of the resident's discharge MDS, dated [DATE], showed one Stage III pressure ulcer. (Review of the resident's medical record showed no documentation the facility staff identified any of the resident's wounds as a Stage III pressure ulcer.) Review of the resident's medical record showed he/she was hospitalized on [DATE]. Review of the resident's wound management consultation notes from the hospital, dated 7/28/21 and 7/29/21, showed the following: -Wound #2 type: Unstageable pressure ulcer to the right ischial (lower and back portion of the hip bone); -Wound base contains black eschar, slough (consists of dead cells that accumulate in wound drainage), and granulation tissue (new tissue that forms in a wound as part of the healing process); -Wound measurements: 7.0 cm by 5.0 cm ; -Wound #3 type: Unstageable pressure ulcer to the left ischial: -Wound base contains slough and granulation tissue; -Wound measurements: 7.0 cm by 4.5 cm. Review of the resident's medical record showed the resident was readmitted to the facility on [DATE]. Review of the resident's nurse's note, dated 8/16/21 at 6:29 P.M., showed the resident was readmitted to the facility via ambulance. The resident was alert and oriented. The resident had a Stage I pressure ulcer on the left buttock of 4 cm by 2 cm, and a Stage I pressure ulcer on the right buttock of 2 cm by 5 cm. The resident's wounds were redressed. Review of the resident's readmission skin assessment, dated 8/16/21, showed the resident was admitted with skin issues to the right heel, the left heel, and sacrum. (There were no measurements or other descriptions of these wounds on this assessment.) Review of the resident's POS, dated 8/16/21, showed to apply menthol-[MEDICATION(S)] ointment 0.44-20.6% to buttocks three times a day for skin integrity. Review of the resident's TAR from 8/16/21 through 8/23/21 showed the order for menthol-[MEDICATION(S)] ointment 0.44-20.6%. Apply to buttocks three times a day for skin integrity was not listed on the TAR. Review showed no documentation staff completed the ordered treatment to the resident's buttocks. Review of the resident's POS, dated 8/23/21, showed to cleanse ischemia (area with inadequate blood supply) (no location listed in the order) with normal saline. Apply [MEDICATION(S)] to wound edges. Apply 0.125% Dakin's solution (antibacterial solution) moistened gauze to wound beds. Secure with sacral [MEDICATION(S)] border dressing. Dressing can be left in place three to five days unless rolled up or soiled. Pull back dressing daily to assess, cleanse, and replace Dakin's moisturized gauze one time a day for wound care. Observation on 8/24/21 at 6:30 P.M., showed the following: -Licensed Practical Nurse (LPN) A and LPN M were in the resident's room as the resident lay in bed; -Wound dressing supplies lay in a basin on the floor; -LPN A turned the resident to the right side. The bordered gauze dressing on the resident's buttocks was soaked and dripped with liquid. The date on the old dressing was smeared and could not be read. The disposable chux pad under the resident was wet; -LPN M removed the old dressing covering the wounds on the resident's left and right buttocks and sprayed the wound on the resident's left buttock with wound cleanser and wiped with gauze. The skin surrounding both the left buttock wound was lighter in color and wrinkled. The wound appeared as a Stage III pressure ulcer that was deep, with a bright red wound base and minimal drainage; -LPN M changed gloves without washing his/her hands and cleansed the wound to the resident's right buttock with wound cleanser and gauze. The skin surrounding the wound was lighter in color and wrinkled. The wound appeared as a Stage III pressure ulcer that was deep, with a bright red base and minimal drainage; -The resident directed LPN M to apply [MEDICATION(S)] ointment around the wound and not to get the ointment into the wound bed; -LPN M wet gauze with 0.125% Dakin's solution and applied this to the left buttock wound bed and applied [MEDICATION(S)] topically around the wound edge and covered the left buttock wound with bordered foam dressing; -Without washing hands or changing gloves, LPN M wet gauze with 0.125 % Dakin's solution and placed on the right buttock wound bed, applied [MEDICATION(S)] topically around the wound edge, and covered the right buttock wound with a bordered foam dressing. The foam dressing was 4 cm by 4 cm and did not cover the entire right buttock wound. During an interview on 8/24/21 at 6:50 P.M., the resident said LPN M did not know what his/her dressing orders were, and the resident had to tell LPN M what to do. The resident said LPN M was an agency nurse and it was his/her first day at the facility. The resident said he/she had a shower the day before (8/23/21). Staff left the dressing to his/her buttock wounds in place during the shower. Staff did not change the dressing after his/her shower so the dressing was soaking wet during the dressing change today. During an interview on 9/1/21 at 3:02 P.M., LPN M said he/she was an agency nurse and 8/24/21 was his/her first day in the facility. LPN M was not familiar with the resident and his/her dressing changes. LPN M had tried to get someone to help him/her with the dressing changes for the resident, but no one was available to assist him/her; that is why it took so long for LPN M to get the resident's dressings changed. LPN M did remember the dressing to the resident's buttocks was soaked with liquid that was not drainage from the wounds. LPN M said the date written on the buttocks dressing was smeared from being so saturated. LPN M said the buttock dressing must have gotten wet somehow or must have not been changed in a long time to be in such poor condition and the resident's skin under the buttocks dressing was macerated (lighter in color, wrinkly skin that occurs when skin is in contact with moisture for too long. Often associated with improper wound care) from the wet dressing. Observation on 8/25/21 showed the following: -At 7:42 A.M., the resident sat in his/her electric wheelchair in his/her room; -At 8:15 A.M., the resident left the facility in the electric wheelchair for an appointment; -At 11:22 A.M., the resident returned to the facility and sat in the electric wheelchair in his/her room; -At 12:25 P.M., Certified Nurse Assistant (CNA) G fed the resident as the resident sat in the electric wheelchair in his/her room; -At 3:30 P.M., the resident sat in the electric wheelchair in his/her room; -At 4:37 P.M., the resident sat in the electric wheelchair in his/her room; -At 5:10 P.M., the resident sat in the electric wheelchair in his/her room. During an interview on 8/25/21 at 5:10 P.M., the resident said he/she had been sitting in the electric wheelchair since about 6:00 A.M. that morning. Night shift staff transferred him/her into the wheelchair. The resident asked CNA G to transfer him/her to bed after he/she ate lunch. CNA G told the resident he/she would get some help and come back with the Hoyer lift (mechanical lift) but he/she never returned. The resident said staff had not repositioned him/her in the wheelchair that day. The resident said he/she would like to be transferred into bed. During an interview on 8/26/21 at 9:00 A.M., CNA G said the resident preferred to be repositioned every four hours and usually stayed up in his/her wheelchair longer than four hours. The resident had wounds on his/her buttocks. The resident had asked CNA G to transfer him/her to bed yesterday (8/25/21) after CNA G fed him/her lunch. CNA G could not find any other staff available to assist him/her to transfer the resident to bed and CNA G had to leave at the end of the shift. Review of the resident's wound center visit note, dated 8/25/21, showed the following: -Stage III pressure ulcer to the left ischial that measured 1.8 cm by 1.6 cm by 0.6 cm. Treatment orders to cleanse the wound with normal saline, apply [MEDICATION(S)] to surrounding skin for protection, apply 0.125 % Dakin's moistened gauze to wound bed, then cover with gauze pad and secure dressing twice a day; -Stage III pressure ulcer to the right ischial that measured 5.7 cm by 5.0 cm by 0.3 cm. Treatment orders to cleanse the wound with normal saline, apply [MEDICATION(S)] to surrounding skin for protection, apply 0.125 % Dakin's moistened gauze to wound bed, then cover with gauze pad and secure dressing twice a day. Observation on 8/26/21 at 12:06 P.M., showed the following: -The resident lay in bed in his/her room; -The assistant director of nursing (ADON) and CNA F entered the room and washed hands and put on gloves; -The ADON moistened 2 cm by 2 cm gauze with 0.125 % Dakin's solution; -CNA F rolled the resident to his/her right side. There was no dressing in place on the resident's buttocks; -The ADON measured the resident's left buttock wound with a disposable paper ruler; -Without cleansing the wound, the ADON applied the Dakin's moistened gauze to the left buttock wound bed, applied [MEDICATION(S)] ointment around the wound, and covered with a gauze pad; -Without washing his/her hands or changing gloves, the ADON measured the right buttock wound; -Without cleansing the wound, the ADON applied Dakin's moistened gauze to the right buttock wound, applied [MEDICATION(S)] ointment around the wound, and covered with a gauze pad. The ADON secured the dressings with paper tape after he/she removed his/her gloves. During an interview on 8/26/21 at 12:30 P.M., the ADON said he/she did not cleanse the resident's buttock wounds prior to completing the dressing change because the resident had just had a shower. The ADON said he/she threw away the measurements of the resident's right and left buttock wound. The ADON drew the wounds from memory on a piece of paper and measured the drawing of the wounds. The ADON said the right buttock wound measured 2.5 cm by 1.5 cm by 2.5 cm. The left buttock wound measured 2.6 cm by 1.4 cm by 2.5 cm. The wounds to the resident's buttocks were deep and probably deeper than what he/she had measured because they were difficult to measure. The ADON said he/she usually washed or sanitized his/her hands after removing gloves, but had not done so during this observation. During an interview on 9/8/21 at 2:43 P.M., the resident's physician said he/she would expect licensed staff in the facility to be monitoring the resident's skin closely at regular intervals due to the resident's history of buttock and heel ulcers. Licensed staff should be monitoring and assessing the wounds and notifying him/her of any deterioration. Staff should change the wound dressings as ordered. Staff should be turning and repositioning the resident, or attempting to do so at least every four hours. The resident preferred to be turned every four hours. Staff should not leave a wet dressing in place to the resident's wounds after a shower and not replace the dressing as this could cause the wounds to deteriorate. 2. Review of Resident #21's Significant Change in Status MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition intact (BIMS=15); -Required extensive assistance of one staff for bed mobility, transfers, and toilet use; -Always incontinent of bowel and bladder; -At risk for developing pressure ulcers; -No unhealed pressure ulcers. Review of the resident's care plan, last revised 7/6/21, showed the following: -Potential for pressure ulcer development related to immobility; -Pressure redistribution mattress and wheelchair cushion; -Follow facility policies and protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Licensed personnel to conduct weekly skin assessment; -The resident has bladder incontinence. Check the resident every two hours and as required for incontinence; -The resident wears disposable briefs. Change briefs every two hours and as needed; -Apply barrier product to protect skin. Observation on 8/24/21 showed the following: -At 11:00 A.M., the resident sat in his/her room in an electric wheelchair; -At 1:11 P.M., the resident sat in his/her room in an electric wheelchair; -At 3:28 P.M., the resident sat in his/her room in an electric wheelchair. During an interview on 8/24/21 at 3:28 P.M., the resident said he/she had been up in the wheelchair since before 6:00 A.M. Staff had not checked his/her incontinence brief or offered him/her assistance to the bathroom or bed so far that day. Observation on 8/24/21 at 5:22 P.M., showed the resident remained in his/her room in an electric wheelchair. The resident said staff had not been in his/her room to check his/her incontinence brief or reposition him/her or offer any assistance to the bathroom. The resident said he/she had been up too long and would like to lay down. The resident was tearful and turned on his/her call light. Observation on 8/24/21 at 5:40 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident's call light remained on. Observation on 8/24/21 at 5:42 P.M., showed staff entered the resident's room. The resident sat in a wheelchair in his/her room and told staff he/she would like to lay down after he/she finished eating. Observation on 8/24/21 at 5:58 P.M., showed the following: -CNA P entered the resident's room; -The resident told CNA P he/she would like to lay down; -CNA P assisted the resident to stand and lowered the resident's pants; -The resident's incontinence brief was soaked and dripped urine; -CNA P assisted the resident to bed and removed the resident's incontinence brief; -The resident's buttocks were reddened; -CNA P provided hygiene for the resident and put a new incontinence brief on the resident; -CNA P did not apply barrier cream to the resident's buttocks. Observation on 8/25/21 showed the following: -At 7:40 A.M., the resident sat in an electric wheelchair in the dining room; -At 9:00 A.M.,. the resident sat in the electric wheelchair in the hallway; -At 11:42 A.M., the resident sat in an electric wheelchair in the dining room; -At 12:17 P.M., the resident sat in an electric wheelchair in his/her room. CNA F and the MDS Coordinator transferred the resident from the electric wheelchair to a manual wheelchair without checking the resident for incontinence or offering the resident the bathroom; -At 12:32 P.M., the resident left the facility for an appointment in the manual wheelchair; -At 3:15 P.M., the resident sat in his/her room in a manual wheelchair and said he/she wanted to lay in bed. During an interview on 8/25/21 at 3:15 P.M., the resident said he/she returned to the facility from his/her appointment around 2:45 P.M. Staff had not repositioned the resident (other than to move him/her from the electric wheelchair to the manual wheelchair for the appointment) or checked his/her brief for incontinence since he/she got up that morning around 6:00 A.M. Observation on 8/25/21 showed the following: -At 3:20 P.M., CNA Q and CNA P entered the resident's room and transferred him/her from the wheelchair to the bed; -CNA Q and CNA P left the room without checking the resident's incontinence brief; -At 4:35 P.M., the resident lay in bed and said no staff checked his/her incontinence brief since he/she had gotten out of bed that morning before 6:00 A.M.; -At 4:40 P.M., CNA Q entered the resident's room, removed the resident's incontinence brief which was urine soaked, and provided incontinence care; -The resident's buttocks were reddened; -CNA Q did not apply barrier cream and put a clean incontinence brief on the resident. During an interview on 8/26/21 at 9:00 A.M., CNA G said the resident was incontinent and wore disposable briefs. Staff should check the resident for incontinence and reposition him/her every two hours or more often if needed. During an interview on 8/26/21 at 9:15 A.M. CNA F said the resident would let staff know when he/she wanted staff to change his/her incontinence brief or wanted to be repositioned. CNA F would change or reposition the resident at his/her request. 3. During an interview on 8/26/21 at 12:40 P.M., the Director of Nursing (DON) said staff should turn and reposition residents who had or who were at risk of developing pressure ulcers at least every two hours. Resident #1 preferred to be repositioned every four hours. Staff should attempt to reposition residents and check them for incontinence without the resident asking them to do so. The DON was not sure when Resident #1's pressure ulcers were first identified, but thought he/she had been readmitted from the hospital with these areas. Licensed staff should document skin assessments for all residents weekly. The facility did not have a designated wound nurse. It was the charge nurses' responsibility to change wound dressings as ordered and to measure and assess wounds weekly. Licensed nurses should document this in the electronic record. It had been a challenge to get agency staff to document wound assessments and measurements, and a challenge to maintain consistency with these assessments with different staff members assessing and measuring the wounds. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s). MO 4 MO 1

Based on interview and record review, the facility failed to provide appropriate assistance for one resident (Resident #5) who was dependent on two or more staff for transfers and bed mobility. One staff member transferred and positioned the resident in bed and the resident rolled out of bed onto the floor sustaining a fractured left shoulder. Facility staff also failed to ensure the resident's mattress was the appropriate size for the resident's bed frame and was safe to use. A sample of 24 residents was selected for review. The facility census was 52. Review of the facility's Fall Prevention Policy, revised February 2021, showed the following: -Resident room or bed or assistive devices are identified with a symbol that indicated high fall risk; -Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care; -All Occurrence Reports are reviewed at the daily Quality Assessment (QA) meeting to ensure that an intervention was immediately implemented, added to the plan of care, and that the current intervention is appropriate; -Occurrences will also be reviewed weekly at the Care Management Meeting to ensure the occurrence report is completely finished and closed, that interventions were implemented timely, and to evaluate the outcomes of the interventions; -Revisions to the plan of care will be done if indicated. Patterns and trends will also be reviewed at that time to enhance the success of the program. Review of the Nurse Assistant in a Long Term Care Facility Manual, 2001 revision, showed the following: -A mechanical lift is a device used to lift and transfer residents who are unable to do so on their own; -If the resident is non weight bearing, the nurse aide should transfer him/her with a mechanical lift; -Two people are needed to use this device safely. 1. Review of Resident #5's care plan, initiated on 9/20/16, showed the following: I am a -Transfer with assistance of two; -Turn and reposition with assistance of two; -Use a hoyer lift (mechanical lift used to transfer residents who cannot bear weight) for transfers. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, required to be completed by facility staff, dated 5/12/21, showed the following: -Diagnoses included stroke, dementia, anxiety, and depression; -Height of 69 inches; -Weight of 235 pounds; -Long term and short term memory problems; -Dependent on two or more staff for bed mobility, transfers, dressing, and toilet use; -No falls since the previous assessment; -Impaired range of motion of the upper and lower extremities on both sides. Review of the resident's nurse's notes showed the following: -On 6/27/21 at 9:10 P.M., the Certified Nurse Aide (CNA) alerted the nurse the resident was on the floor. Upon entering the room, the resident was on the floor between the door and the bed laying on the left side. The CNA said he/she was changing the resident and the resident fell to the floor. The resident was assessed and no injury was found at the time; -On 6/28/21 at 5:49 A.M., the resident fell on second shift, however, assessment was not done during the night shift. The resident grimaced all night and it was observed the thumb on the left hand was swollen and bruised; -On 6/28/21 at 8:32 A.M., this nurse was notified of the resident rolling off the bed over the weekend. Staff reported there were no injuries at the time, but bruising/swelling to the left thumb/hand is now present and the resident showed discomfort around the trunk when being moved. Bruising and swelling noted to the left hand. The resident responded in pain when the left hand was touched and discomfort to the trunk/rib area upon movement. The physician's office was contacted for X-ray orders. Stronger pain medication was requested by the resident's family member; -On 6/28/21 at 8:51 A.M., orders were received for an X-ray of the left hand and chest, including ribs; -On 6/28/21 at 1:41 P.M., X-ray results received. No fracture noted in the left hand or ribs. Documentation in the nurse's notes did not show the resident complained of left shoulder pain. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Diagnosis of [CONDITION(S)] (paralysis of the upper and lower body); -Cognition intact (BIMS=15); -Dependent on two or more staff for bed mobility and transfers. Review of a facility acquired written statement, dated 6/28/21, showed Resident #1 wrote the following: -On Sunday, 6/27/21 between 8:00 P.M. and 8:30 P.M., a CNA told the resident that he/she was going to move Resident #5 before his/her family member called; -Resident #1 told the CNA that Resident #5 was a two person assist and the CNA said he/she does it himself/herself all the time; -That night, another CNA told Resident #1 that Resident #5 had rolled off the bed; -Resident #5's family member had a camera in the room and Resident #1 was not sure if the family member saw what occurred, but Resident #1 wanted to be sure it got reported. During an interview on 8/24/21 at 6:50 P.M., Resident #1 said CNA R had tried to transfer and reposition Resident #1 by himself/herself on several occasions. Resident #1 said he/she required two staff and the hoyer lift for transfers and two staff to reposition in bed, so Resident #1 refused to let CNA R work with him/her by himself/herself. Resident #1 said he/she wrote a report about what he/she knew regarding Resident #5's fall in June because Resident #1 was in the hallway when the incident occurred. Review of Resident #5's nurse's notes showed the following: -On 6/29/21 at 3:04 A.M., the resident grimaced with turning during incontinence care which resolved with rest; -On 6/29/21 at 10:15 P.M., a new order for [MEDICATION(S)] (opioid pain medication) every six hours as needed; -On 7/1/21 at 3:59 A.M., the resident showed mild signs and symptoms of pain while turning and repositioning, but quickly resolved with rest; -On 7/9/21 at 12:30 A.M., black, purple, and slight green bruising continues to the left upper arm and hand. Bruising consistent with the healing process. The resident said his/her arm still hurts in the upper area of the arm/shoulder. Staff have the arm supported in bed at this time. Will report to the current nurse the resident voicing pain. Review of the resident's medical record showed he/she was transferred to another facility on 7/15/21. Review of the resident's admission assessment note at the new facility, dated 7/15/21 at 6:50 P.M., showed the resident had bruising to the left arm from a fall at the previous facility. Review of the resident's X-ray result of the left arm, dated 7/21/21, showed a left humeral neck (part of the upper arm/shoulder) fracture. During an interview on 8/24/21 at 4:15 P.M., the resident's family member said he/she had a camera in the resident's room for some time and staff were aware. On 6/27/21, the family member saw on the camera, CNA R transfer the resident with the hoyer lift by himself/herself. CNA R then rolled the resident in bed causing the resident to roll onto the floor. The family member said he/she spoke to staff at the facility about what he/she saw regarding the incident and also spoke to CNA R. CNA R told the family member he/she didn't know the resident had to be transferred and cared for in bed by two staff. The family told the Director of Nursing (DON) he/she did not want CNA R to care for the resident and the DON told the family member that was not possible because CNA R would still be working in the facility. The family member moved the resident to another facility on 7/15/21. The new facility found bruising to the resident's left arm and obtained an X-ray of the left arm and shoulder which showed a fracture. During an interview on 8/24/21 at 4:33 P.M., the DON said he/she was notified back in June Resident #5 had rolled his/her leg over and rolled himself/herself out of bed. The DON was not sure of the name of the staff member involved, if he/she had spoken to the staff member about the incident, or if the staff member still worked in the facility. Resident #5's family member never told the DON anything about a staff member transferring the resident alone. During an interview on 8/24/21 at 4:50 P.M., the administrator said the staff member involved with the incident on 6/27/21 when Resident #5 rolled out of bed was CNA R. CNA R did receive re-education on transfers and care. During an interview on 8/24/21 at 5:00 P.M., CNA B/Staffing Coordinator said he/she provided verbal education to CNA R on transfers and resident care requirements. CNA R still worked in the facility. CNA B had not heard anything about CNA R transferring Resident #5 by himself/herself. Staff were aware the resident had a camera in his/her room. During an interview on 8/25/21 at 10:45 A.M., CNA R said Resident #5 had a sign on his/her wall that showed two assist with the hoyer. CNA R said he/she did not realize that meant two person assist for care while the resident was in bed. CNA R said he/she transferred Resident #5 to bed with the hoyer lift with CNA G. Once the resident was in bed, CNA R, by himself/herself, rolled the resident to his/her side to complete incontinence care and the resident rolled off the bed onto the floor. CNA R went and got the charge nurse who assessed the resident. CNA R and other staff placed a hoyer sling under the resident and transferred him/her back into bed with the lift. CNA R said the resident's mattress was too wide for the bed frame, making the bed appear larger than it actually was. After the incident the resident received a new bed frame that fit the mattress. CNA R did not work with Resident #5 after this incident per a family member's request. CNA R did receive education from CNA B about where to find resident care information in the computer. CNA R said he/she could do things by himself/herself that other CNA's couldn't do, because he/she was larger and stronger than most staff. CNA R said he/she was aware Resident #5 had a camera in his/her room. CNA R denied ever attempting to transfer or provide care for Resident #1 alone. During an interview on 8/25/21 at 12:25 P.M., CNA G said he/she did not work the night Resident #5 fell from the bed and therefore could not have transferred the resident with CNA R. CNA G was told by several other staff that CNA R transferred Resident #5 by himself/herself. CNA G said Resident #5's mattress was too large for the bed frame prior to the accident on 6/27/21 and when staff would roll the resident in bed, the opposite side of the mattress would flip up. CNA G said he/she reported this to several nurses, but nothing was done about it until after the resident fell . During an interview on 8/25/21 at 2:45 P.M., the Social Service Director (SSD) said he/she had heard one staff member assisted Resident #5 while in bed and the resident rolled out of bed onto the floor. Resident #5 did have a bariatric bed for a long time. The SSD had not heard anything about the resident's bed being too large for the bed frame. The SSD did obtain a statement from Resident #1 about the fall because Resident #1 was in the hallway at the time the fall occurred. During an interview on 8/25/21 at 12:35 P.M. and on 8/26/21 at 12:40 P.M., the DON said Resident #5 was on a bariatric mattress. The DON was not aware and had never heard anything about the mattress being too large for the bed frame. The resident was ordered a bariatric mattress which did arrive before the bed frame, but the bed frame arrived the following day. The expectation was for two staff to transfer and provide care for Resident #5 while he/she was in bed as stated in his/her care plan. Staff should refer to the resident's care plan to determine their care needs. During an interview on 9/8/21 at 2:43 P.M. the resident's physician said he/she was not aware of the resident having any other falls or incidents after 6/27/21 when he/she fell on to the floor from the bed. The left humeral neck fracture identified on X-ray on 7/21/21 was most likely a result of the resident's fall from bed on 6/27/21. The physician was not notified about the resident's complaint of pain and bruising to the upper left arm that was documented in the nurse's note on 7/9/21. If the physician had been made aware he/she would have ordered an X-ray of the left shoulder at that time. MO 4 MO 7 MO 4 MO 4

Based on observation, interview, and record review, the facility failed to appropriately assess pain, administer scheduled narcotic pain medication as ordered, and offer non-pharmacological interventions such as repositioning to relieve pain for one resident (Resident #3), who was distressed, tearful, and rated his/her pain a ten on a zero to ten scale with ten being the worst pain possible. The resident was fatigued from the uncontrolled pain and remained in bed the following day. A sample of 24 residents was selected for review. The facility census was 52. Review of an email from the Director of Nurse's (DON) on 9/8/21 at 2:49 P.M., showed the facility did not have a written policy on pain. 1. Review of Resident #3's Admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/25/21, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -BIMS (brief interview for mental status), score of 14, indicating the resident's cognition was intact; -Dependent on two or more staff for transfers and toileting; -Impaired range of motion of the lower extremities on both sides; -Pain was present occasionally. Review of the resident's care plan, revised on 6/9/21, showed the following: -The resident had times of pain and need for scheduled and as needed pain medication; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Evaluate the effectiveness of pain interventions; -Healing hip and pelvic fracture from a fall at home. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Pain scale: Record each shift, 0-1=no pain, 2-3=mild pain, 4-5=moderate pain, 6-7=severe pain, 8-9=very severe pain, 10=worst possible pain; -Non weight bearing to lower left extremity; -Acetaminophen (non steroidal anti [CONDITION(S)] medication), 500 milligrams, give two tabs by mouth every eight hours; -[MEDICATION(S)] patch (opioid pain medication absorbed through the skin) 25 micrograms (mcg)/hour (hr) related to pain from fractured left hip joint. Apply one patch topically and change every 72 hours; -[MEDICATION(S)] (opioid pain medication) tablet 5 mg by mouth four times day for pain related fractured left hip joint. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident's pain scale was not documented on day shift for 8/17/21 or 8/20/21; -The resident rated his/her pain at 8:00 A.M. on 8/24/21 as 0 out of 10, (resident was not present in the facility on that date and time and was out to an appointment); -Staff documented administering all morning medications on 8/24/21 including [MEDICATION(S)] 5 mg by mouth four times a day; -Staff documented not administering the resident's 12:00 P.M. dose of [MEDICATION(S)] 5 mg as the resident was away from the facility without medications; -Staff documented administering acetaminophen 1000 mg at 2:00 P.M. Observation on 8/24/21 at 5:38 P.M., showed the resident sat in a wheelchair in his/her room. The resident was tearful and appeared distressed. During an interview on 8/24/21 at 5:38 P.M., the resident said he/she had been at an orthopedic appointment and had been out of the facility all day. The resident complained of severe pain in his/her hip that he/she rated 10 out of 10. The resident said he/she did not receive any medications that morning before leaving for his/her appointment and no medications were sent with him/her. The resident was very uncomfortable and had been sitting in the wheelchair all day long and wanted to be transferred to bed. The resident had not received any pain medication so far that day and asked the surveyor to let the nurse know he/she was in distress. Review of the resident's MAR for 8/24/21 showed staff held the 5:00 P.M. dose of [MEDICATION(S)] 5 mg; see progress note. Review of the resident's progress notes showed the following: -On 8/24/21 at 5:46 P.M., staff held the [MEDICATION(S)] 5 mg because the resident was not in the building; -On 8/24/21 at 9:07 P.M., staff administered [MEDICATION(S)] 5 mg for pain related to a fracture of the left hip joint. During an interview on 8/24/21 at 5:40 P.M., Licensed Practical Nurse (LPN) M said no one had informed him/her the resident was back in the facility or experiencing pain. LPN M would take care of the resident. Review of the resident's narcotic sign out sheet for [MEDICATION(S)] 5 mg on 8/25/21 showed the following: -On 8/24/21 at 9:00 A.M., staff signed out one tablet of [MEDICATION(S)] 5 mg for the resident; -On 8/24/21 at 9:00 P.M., staff signed out one tablet of [MEDICATION(S)] 5 mg for the resident. During an interview on 8/25/21 Certified Nurse Aide (CNA) F said he/she accompanied the resident to his/her appointment the day before. It was a long day. They left the facility around 7:00 A.M. and returned at approximately 5:00 P.M. There were no medications sent with the resident. During an interview on 8/25/21 at 4:52 P.M., the resident said a nurse came to his/her room the evening before and asked about his/her pain, but did not give the resident any pain medication. The resident said he/she did not get transferred to bed until 7:20 P.M. and did not get any pain medication until 9:00 P.M. The resident said he/she was more comfortable after staff transferred him/her to bed and the oncoming staff were upset that staff had not already laid him/her down because he/she was so uncomfortable. The pain medication [MEDICATION(S)] was effective when taken. The resident was still worn out from the ordeal the day prior and preferred to remain in bed that day. During a telephone interview on 9/1/21 at 3:02 P.M., LPN M said the resident was out at an appointment all day on 8/24/21. LPN M had popped out all the resident's 8:00 A.M. medications on 8/24/21, but the resident had already left for his/her appointment. LPN M kept the medications in a medication cup labeled with the resident's name on the medication cart. No one told LPN M that the resident had returned to the facility prior to the surveyor telling him/her the resident was back and in pain at 5:40 P.M. LPN M went to the resident's room and the resident expressed to LPN M that he/she was in pain. LPN M administered the resident's 8:00 A.M. medications to the resident which included [MEDICATION(S)] 5 mg. LPN M said he/she administered the medications he/she had already popped out so they wouldn't be wasted. 8/24/21 was LPN M's first day working in the facility. He/She did not get any orientation or training before starting work in the facility. LPN M said the communication in the facility was very poor and staff needed to be better about informing the nurses when residents were leaving and returning to the facility. During an interview on 8/26/21 at 12:40 P.M. the DON said typically the facility did not send medications with residents to take to appointments. Resident #3 should have received his/her scheduled medications prior to leaving for the appointment. Staff should have immediately completed a pain assessment when he/she returned to the facility, administered ordered medications and laid the resident down so he/she could be comfortable. MO 8

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #10), in a review of 24 sampled residents, remained free from abuse when Certified Nurse Assistant (CNA) J grabbed the resident's arm and forcefully removed his/her arm from the resident's bed rail causing four bruises to the resident's forearm and wrist. The facility census was 52. Review of the facility's policy Abuse, Prevention, and Prohibition policy, last revised November 2018, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents; -Each resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse, corporal punishment and involuntary seclusion; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; that includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being; -Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -The owner, licensee, administrator, employee or agent of the facility shall not abuse or neglect a resident. 1. Review of Resident #10's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Care Plan, last revised 5/4/21, showed the following: -The resident has potential impairment to skin integrity related to requiring assistance with bed mobility and toilet use; -At times, the resident is difficult to understand; -Encourage the resident to continue stating thoughts even if resident is having difficulty; -Focus on a word or phrase that makes sense; -Allow the resident adequate time to respond, repeat as necessary, do not rush, request feedback, clarification from the resident, validate resident's message by repeating aloud; -The resident requires physical assistance of one or two staff for incontinence care; -When incontinent, wash, rinse, and dry perineum, and apply barrier cream. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment instrument, dated 7/6/21, showed the following: -Cognitively intact; -Unclear speech; -No behaviors or rejection of care; -Requires extensive assistance of two or more staff with bed mobility, toilet use, and hygiene; -Dependent of two or more staff for transfers. Review of the facility's investigation, dated 8/2/21, showed the following: -The resident reported to staff that on 7/31/21, CNA J answered his/her call light; -The resident asked to be cleaned and for some cream for his/her bottom; -The CNA did not help him/her and said he/she could not deal with him/her anymore; -CNA J then grabbed the draw sheet on the left and moved the resident to his/her right side and walked out saying, I'm going to get the [OBSCENITY] out of here; -CNA J was an agency CNA and it was the last day of his/her contract. Review of the resident's statement taken by Registered Nurse (RN) L, dated 8/2/21, and attached to the facility investigation showed the following: -Resident said on 7/31/21 he/she was wet, and CNA J came in to answer his/her call light; -He/She rolled over on his/her left side and asked to be cleaned up; -CNA J said there was no medicine for his/her bottom; -He/She asked for the medicine several times; -He/She also asked that his/her bottom be cleaned; -CNA J never cleaned him/her up, and said he/she couldn't deal with the resident anymore; -CNA J grabbed the draw sheet on the left and threw him/her back to the right side; -CNA J said, I'm going to get the [OBSCENITY] out of here; -CNA J walked out. During an interview on 8/24/21, at 10:52 A.M., the resident said the following: -On the night of 7/31/21, CNA J hurt him/her; -The CNA was providing care to the resident; -The resident was in bed on his/her left side holding the bed rail with his/her left arm; -He/She asked CNA J to put the cream to his/her back side and CNA J would not put it on the resident; -CNA J told the resident to roll over, and the resident told CNA J he/she still needed the cream on his/her back side; -CNA J grabbed the resident's left forearm and wrist, and forcefully removed it from the bed; -CNA J then, threw his/her arms in the air, and said, 'I'm going to get the [OBSCENITY] out of here'; -It made the resident frustrated, like what he/she needed didn't matter, and made him/her feel like he/she was a nuisance; -The resident reported it to the charge nurse LPN T that night and was told it was his/her fault for scratching the CNA; -The resident told the charge nurse he/she did not scratch anyone and his/her fingernails were short; -He/She was angry and upset and worried it would happen to someone else; -The next day the resident's wrist was sore, and he/she had four round bruises, two bruises along the bone of the outer left wrist and two bruises going up the forearm; -He/She reported the same incident again Monday morning (8/2/21) to the nurse so he/she could speak to someone in administration. Registered Nurse (RN) L came to talk to him/her. (The resident was tearful and sobbing while he/she explained what happened.) Observation on 8/24/21, at 10:52 A.M., showed the following: -The resident lay in his/her bed; -His/Her left outer wrist had two round bright purple discolored bruised areas with fading around the edges; -There were also two round discolored areas brown to green in color above the purple areas on the resident's forearm (consistent in distance with bruises caused by fingertips). During an interview on 8/26/21, at 4:00 P.M., CNA O said the following: -He/She often takes care of the resident on the night shift; -The resident has had the bruises on his/her left wrist and forearm for a couple of weeks; -The resident said the bruises were from CNA J. During an interview on 8/24/21, at 4:40 P.M., Licensed Practical Nurse (LPN) A said the following: -He/She has worked in the facility since January; -Resident #10 was easy going and never complains about staff; -The resident has trouble with his/her speech, but is alert and oriented and sharp as a tack. During an interview on 9/2/21, at 9:00 A.M., CNA J said the following: -He/She worked a contract agency position at the facility; -The first day they paired him/her with another staff member, but he/she was doing most of the work independently; -Staff gave report at the beginning of the shift and that was about it; -The last day of his/her contract with the facility was 7/31/21; -On 7/31/21, the facility called him/her in. He/She had just worked a 16-hour shift, and had only got two hours of sleep; -He/She went in for the assignment because the facility was so short (short staffed); he/she was assigned two halls by himself/herself; -He/She was tired and frustrated because there wasn't enough help; -The resident was on his/her assigned hall; -The resident got upset during incontinence care because he/she wanted cream applied; -He/She applied the cream to the resident, but couldn't understand what else the resident wanted with the cream; -He/She couldn't understand what the resident was saying; -The resident was yelling at him/her; -He/She had to help the resident roll over and get someone else because he/she couldn't understand what the resident wanted; -He/She was frustrated during the resident's care; -He/She does not know if he/she grabbed the resident's wrist to turn him/her over; -He/She does not remember what he/she said to the resident, but he/she went to find someone else who could understand the resident better. During an interview on 9/2/21, at 10:39 A.M., CNA N said the following: -CNA J came up to the desk and was very frustrated because he/she couldn't understand the resident and thought CNA N should take care of the resident for the rest of the shift; -When he/she went to the resident's room, the resident said CNA J grabbed his/her arm; -The resident's left forearm just above his/her wrist was red, and the resident said it was sore; -He/She reported the resident's arm was red, and what the resident said to the charge nurse. During an interview on 9/8/21, at 4:20 P.M., LPN T said the following: -She was the charge nurse on 7/31/21; -CNA J told him/her the resident cursed at him/her; -She asked the full time CNA's to take over care of the resident for the night; -She said no one reported to him/her that the resident said CNA J cursed at the resident, or that the CNA grabbed the resident's arm. During an interview on 8/25/21, at 11:40 A.M., RN L said the following: -On 8/2/21, the administrator asked him/her to get a statement from the resident about 7/31/21; -The resident has some problems with his/her speech and can be hard to understand; -He/She put what he/she understood from the resident in the resident's statement; -The resident may have told him/her that CNA J grabbed his/her wrist and forearm, but he/she did not understand that; -He/She did not know the resident had bruises on his/her wrist and forearm; -The resident is truthful and tries to see the good in everyone. During an interview on 9/2/21, at 10:15 A.M., the administrator said the following: -He had RN L interview the resident and then he went to speak to the resident; -The resident did not say anything to him about CNA J removing the resident's arm from the bed rail; -The resident said CNA J turned him/her over using the draw sheet, and cursed at him/her; -He did not understand him/her to say anything about the CNA grabbing the resident's body; -He does not know if the agencies educate their staff on abuse and neglect; -The facility does not do any abuse and neglect training with the agency staff, some are only there for one shift. MO 341

Based on observation, interview, and record review, facility staff failed to ensure acceptable parameters of nutritional status for one resident (Resident #1), with a [MEDEQUIP] tube in a review of five sampled residents when the facility failed to consistently monitor weights and meal intakes or notify the physician of the resident's refusals for adequate daily nutritional intake resulting in weakness and severe malnutrition. The facility census was 59. 1. Review of the facility policy Nutrition (impaired)/Unplanned Weight Loss Clinical Protocol, revised on September 2012, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time; -The physician, with the help of the multidisciplinary team, will identify conditions and medications that may be the causing anorexia, weight loss or increasing the risk of weight loss. Review of the undated facility policy Significant Change and Notification showed the following: -Purpose: To ensure the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: -Refusal or inability to consume food for two meals; -Other abnormal assessment findings; -A need to significantly alter treatment; -All significant changes will be recorded on communication board and in the resident record; -Charting will be done each shift for seventy two hours with a change in condition; -Change of condition is reviewed by director of nursing or designee for the continued need for additional documentation 2. Review of the Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 8/31/19, showed the following: -Cognitively intact; -Did not reject care; -Did not display any symptoms of [MEDICAL CONDITION]. Review of resident's registered dietician note, dated 9/30/19, showed the following: -Follow-up on tube feeding, skin status and evaluation for weight gain. Weight 94.2 pounds; -Unable to identify if weight gain fully related to intakes. Diet remains regular with intakes 50-100% as documented as present; -[MEDICATION NAME] (nutritional supplement that helps support needs of wounds) twice daily and multivitamin remain in place for skin integrity. Calorie support interventions include Magic Cup (nutritional snack) all meals, will not take med pass (fortified nutrition shake), total feeding order (nutritional feeding administered through a small flexible tube) in place every eight hours. Registered Dietician talked to nurse and he/she reports resident will not allow feeding or flushes to be given per tube, want it (tube) out; -Based on reports from staff, review of chart review and review of Medication Administration Record [REDACTED] -Discontinue [MEDICATION NAME]; -Discontinue order for feeding; -Discontinue Magic Cup as resident will not take. Plan at this time is to encourage by mouth and offer alternatives as accepted due to past attempts for interventions not accepted by resident. Monitor and follow-up monthly/as needed while peg tube (or gastrostromy tube, a tube inserted through the abdomen that delivers nutrition and/or medications directly to the stomach) in place. Review of the resident's Treatment Administration Record (TAR) dated October 2019 showed the following: -Weekly weight in the morning every Wednesday for weight loss: -On 10/2, no documentation staff obtained the weekly weight (left blank); -On 10/9, staff documented the resident refused weekly weight; -On 10/15, staff documented the resident refused the weekly weight. Review of the resident's physician assessment and plan (completed on visit at the facility), dated 10/15/19, showed the following: -Subjective: The resident said he/she just has not felt well since last Thursday, and has been having breathing difficulty. He/She has been having rattling in his/her chest and coughed up some sputum. He/She has chilling episodes at night through the last 24 hours and prior to that he/she did not. Swallow study had very bad results. He/She had silent aspiration (breathing a foreign substance into you airways) with every consistency but he/she still wants to feed himself/herself orally despite the risk involved of aspiration. Based on what we found today, told the resident he/she may very well have pneumonia so a portable chest x-ray was ordered. Also ordered a sputum specimen collection and nebulizer treatments (a drug in the form of a mist inhaled into the lungs) to try to induce the sputum if he/she has trouble coughing up a sputum specimen. Also will cover him/her with a broad spectrum antibiotic (effective against a large variety of organisms) until the sputum returns, potentially directing the therapy; -Objective: The resident is taking in liquids by mouth but not solid food due to the nausea because of his/her breathing distress; -Assessment/Plan: -Silent aspiration (food or stomach contents enter the lungs), despite our wishes to keep him/her nothing by mouth (NPO) and use his feeding tube, we will leave the tube in place, but he/she refuses to allow us to feed him/her through that device, he/she will take on the risk involved with potential aspiration. Review of the resident's TAR, dated October 2019, showed no evidence staff obtained a weekly weight on 10/23/19 (the box was left blank). Review of resident's documentation survey report for nutrition/amount eaten, dated October 2019, showed on 10/27/19 at 8:00 A.M., staff documented the resident ate 76-100% of breakfast; at 12:00 P.M.; staff documented the resident ate 26-50% of lunch; staff did not document the meal percentage for supper. Review of the resident's Medication Administration Record [REDACTED] -Enteral feeding order every eight hours related to anorexia 120 milliliters (ml) of [MEDICATION NAME]; -On 10/27/19 at 6:00 A.M., 2:00 P.M., and 10:00 P.M., staff documented the resident refused the tube feeding. Review of resident's documentation survey report for nutrition/amount eaten for 10/28/19 showed no documentation of the resident's meal intake for the entire day. Review of the resident's MAR, dated October 2019, showed on 10/28/19 at 6:00 A.M., staff documented the resident refused his/her tube feeding. At 2:00 P.M., staff documented the resident received his/her tube feeding. At 10:00 P.M., staff documented the resident refused the tube feeding. Review of resident's documentation survey report for nutrition/amount eaten, dated 10/29/19, showed no documentation of the resident's meal intake for the entire day; Review of the resident's MAR, dated October 2019, showed on 10/29/19 at 6:00 A.M., 2:00 P.M., and at the 10:00 P.M., staff documented the resident refused the tube feeding. Review of the registered dietician note, date 10/29/19 at 10:22 A.M., showed the following: -Follow-up on tube feeding, skin status and evaluation for weight loss/gain. Weight 89.4 pounds (4.8 pound loss since 9/30/19); -Weight variances per history. Resident refuses interventions for nutritional support. Registered dietician talked to unit nurse and is reported to the physician will not discontinue interventions despite consistent refusals; -Diet remains regular with varied intakes as documented. Kitchen reports resident often asks for alternates for meals: -The following interventions remain in place: -[MEDICATION NAME] twice daily and multivitamin for skin integrity; -Calorie support interventions include Magic cup all meals 290 calories and 9 grams protein each, tube feeding order in place that states every eight hours 120 ml (no product listed); -Flushes 100 ml four times per day after bolus. Have attempted to change orders without success, no changes planned. Plan remains to encourage by mouth and offer alternatives as accepted; -Monitor and follow-up monthly/PRN while peg tube in place. Review of resident's documentation survey report for nutrition/amount eaten, dated 10/30/19 showed at 8:00 A.M., staff documented the resident ate 0-25% of breakfast. Staff did not document intake for lunch or supper. Review of the resident's MAR, dated October 2019, showed on 10/30/19 at 6:00 A.M., 2:00 P.M., and at 10:00 P.M., staff documented the resident refused the tube feeding. Review of resident's documentation survey report for nutrition/amount eaten, dated 10/31/19, showed no documentation of the resident's meal intake for the entire day. Review of the resident's MAR, dated October 2019, showed on 10/31/19 at 6:00 A.M., 2:00 P.M., and at 10:00 P.M., staff documented the resident refused the tube feeding. Review of the registered dietician note, dated [DATE], showed he/she talked to kitchen staff who reported the resident will eat regular ice cream. Will instruct kitchen to serve regular ice cream, two bowls for lunch and supper in place of Magic Cup. Resident will not take and physician will not discontinue. Monitor and follow-up as indicated. Review of the resident's care plan, last revised [DATE], showed the following: -Provide tube feeding as ordered; -Flush 100 ml four times per day after bolus feedings; -Every eight hour feedings 120 ml [MEDICATION NAME] (nutritional supplement); -On 10/29/19, will not discontinue tube feeding related orders despite continued refusals; -Serve diet as ordered, weight as ordered, record meal intake, encourage appropriate intake of food and fluids, and offer substitutes for dislikes; -Regular diet; -Skin/calorie/protein support interventions; -Will not take house supplement; -New orders for multivitamin with minerals daily and [MEDICATION NAME] (nutritional supplement that helps support needs of wounds) one packet twice daily; -Magic cup increased to all meals; -On 10/29/19, the physician will not discontinue house supplement support orders despite continued refusals; -On [DATE], registered dietician directed kitchen to serve two ice creams with lunch and supper instead of magic cup; -Registered dietician to evaluate quarterly and as needed, monitor caloric intake estimate needs, and make recommendations to tube feedings as needed; -The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders; - He/She preferred snacks between meals. He/She would like anything soft for a snack, and favorite foods are meat and potatoes. Review of the resident's MAR, dated November 2019, showed the following: -Enteral feeding order every eight hours related to anorexia 120 milliliters (ml) of [MEDICATION NAME]; -On [DATE] at 6:00 A.M., staff documented the resident refused; -On [DATE] at 2:00 P.M., staff documented administering the feeding; -On [DATE] at 10:00 P.M. no documentation staff administered the resident's tube feeding. Review of the resident's documentation survey report for nutrition/amount eaten, dated November 2019, showed on [DATE] at 8:00 A.M., the resident refused breakfast. Staff did not document the resident's meal intake for lunch and supper. Review of the resident's MAR, dated [DATE], showed staff documented the resident refused all his/her ordered enteral feedings for the day. Review of the resident's documentation survey report for nutrition/amount eaten, dated November 2019, showed on [DATE], staff did not document meal intake for all three meals. Review of the resident's MAR, dated 11/3/19, showed staff documented the resident refused all his/her ordered enteral feedings for the day Review of the resident's documentation survey report for nutrition/amount eaten, dated November 2019, showed on 11/3/19, staff did not document meal intake for all three meals. Review of resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with transfers and locomotion on the unit; -Required limited assistance from one staff with toileting; -Rejection of care occurred four to six days out of the past two weeks; -Feeling down or depressed occurred one day over the 14-day look back period; -Feeling tired or no energy occurred seven to 11 days, nearly half or more of the last two weeks; -Appetite was poor 12 to 14 days, nearly every day over the past two weeks. Review of the resident's MAR, dated 11/4/19, showed staff documented the resident refused the A.M. feeding. (The resident was admitted to the hospital on [DATE]). Review of the resident's documentation survey report for nutrition/amount eaten, dated November 2019, showed on 11/4/19 at 8:00 A.M., staff documented the resident refused breakfast. Staff did not document the resident's intake at lunch. Review of the continuity of care document provided to the facility, dated 11/4/19, showed [MEDICATION NAME] (main protein in the human blood, a lower level often indicates malnutrition), plasma was 2.1 grams/deciliter (g/dL) (low) range 3.4-4.8 g/dL. Review of the physician's hospital note/problems present on admission status, dated 11/5/19, showed the following: -Severe malnutrition: Onset date 11/5/19, unspecified severe protein-calorie malnutrition; -Plan and assessment: Pneumonia. Will continue intravenous antibiotics; -Chronic malnutrition. Apparently the resident refused the tube feeding the last three days. Resident can have by mouth as well. During interview on 11/9/19 at 2:05 P.M., the resident said he/she was eating and going to the dining room a week or so before he/she went to the hospital. He/She then became so weak he/she couldn't even get up to use the bathroom. He/She had no appetite. He/She was using his/her scooter but didn't have the energy to even transfer to the scooter. He/She wasn't able to eat, as he/she felt so bad. During interview on 11/9/19 at 1:45 P.M. and 11/13/19 at 11:35 A.M., Certified Nurse Assistant (CNA) B said the resident was going to the dining room routinely up to a week before he/she went to the hospital. The resident started refusing meals prior to his/her hospitalization . He/She reported to the charge nurse each time the resident refused to eat. He/She thought the nurses either got busy or forgot to follow up on issues the aides reported to them. The resident did not really eat the weekend before he/she went to the hospital, and he/she could no longer get out of bed. The aides worked with the residents on a daily basis and knew when something was not right with them. During interview on 11/14/19 at 11:30 A.M., Nurse Assistant (NA) F said the resident was very independent and went to meals with the other residents and had coffee. About a week before the resident went to the hospital, he/she was refusing to go to the dining room, he/she was very different, unlike himself/herself. He/She just thought the resident was sick or something. He/She had never seen the resident that depressed. He/She charted the resident was not eating, and notified the charge nurse (he/she did not recall which nurse). During interview on 11/9/19 at 3:28 P.M., Licensed Practical Nurse (LPN) E said the resident was coming out for meals prior to hospitalization and all of the sudden he/she stopped going to meals. The physician was aware the resident refused the tube feedings, but he/she was not sure about the resident refusing meals. During interview on 11/14/19 at 3:10 P.M., LPN A said he/she was not aware the resident had stopped eating prior to his/her recent hospitalization . The resident had being doing well and going to meals in the dining room in his/her scooter. He/She found out the resident was refusing meals a day or two before the resident was sent to the hospital. The aides or other nursing staff had not passed this information on to him/her, or it would have been followed up on. During interview on 11/12/19 at 7:05 A.M., the Director of Nursing (DON) said the resident was eating well prior to his/her hospitalization . The resident refused medications off and on and refused his/her tube feedings. The physician should be updated on the resident's status if the resident refused medications and meals consistently. During interview on 11/9/19 at 3:50 P.M., the resident's family member said the resident was refusing his/her tube feedings, but was eating on his/her own. He/She had concerns and thought the facility should have monitored the resident more closely. He/She was told the resident had not eaten for a few days prior to going to the hospital. During interview on 11/12/19 at 2:45 P.M., the resident's physician said he would have expected the facility to notify him if the resident refused to eat by mouth. The resident could not go multiple days without anything to eat by mouth and/or feedings through his/her [MEDEQUIP] tube. He saw the resident on 10/15/19 and at that time, the resident decided he/she would take the risks of eating by mouth instead of [MEDEQUIP] feedings. He would have made a point to see the resident at the facility if he was aware the resident was not eating by mouth or had a change in his/her condition. The resident was in starvation mode and he was not notified. The [MEDEQUIP] feedings should have resumed if the resident could not take in oral nutrients either. He would have discussed that with the resident and the risks of eating nothing. He should have been notified repeatedly on the resident's status if there was changes in his/her condition. MO 5

Based on interview and record review, the facility failed to administer medications as ordered for one resident (Resident #1), which resulted in the the resident requiring hospitalization for treatment of [REDACTED].#2), in a review of five sampled residents. The facility census was 59. 1. During an interview on 11/14/19 at 2:00 P.M., the administrator said the facility did not have a policy on following physician's orders [REDACTED]. 2. Review of Resident #1's physician assessment and plan (completed on visit at the facility), dated 10/15/19, showed the following: -Subjective: The resident said he/she just has not felt well since last Thursday, and has been having breathing difficulty. He/She has been having rattling in his/her chest and coughed up some sputum. He/She has chilling episodes at night through the last 24 hours and prior to that he/she did not. Swallow study had very bad results. He/She had silent aspiration (breathing a foreign substance into you airways) with every consistency but he/she still wants to feed himself/herself orally despite the risk involved of aspiration. Based on what we found today, told the resident he/she may very well have pneumonia so a portable chest x-ray was ordered. Also ordered a sputum specimen collection and nebulizer treatments (a drug in the form of a mist inhaled into the lungs) to try to induce the sputum if he/she has trouble coughing up a sputum specimen. Also will cover him/her with a broad spectrum antibiotic (effective against a large variety of organisms) until the sputum returns, potentially directing the therapy; -Objective: The resident is taking in liquids by mouth but not solid food due to the nausea because of his/her breathing distress; -Lungs: rattling in both sides of his/her chest anteriorly. The base of his/her lungs had hypo aeration (reduced or deficient ventilation of the lungs); -Assessment plan: Silent aspiration; -Potential aspiration pneumonia: Portable chest x-ray to evaluate. Collect the sputum, culture and sensitivity, and will give him/her nebulizers three times a day for 10 tens regularly. [ENTITY]t him/her on Levoflaxcin (antibiotic used to treat infection) 500 milligrams (mg) one daily for ten days; -[MEDICAL CONDITION] (a group of lung diseases that block airflow and make it hard to breath): This is probably exacerbating (worsening) but will use the nebulizer treatment. Review of new physician orders [REDACTED]. -[MEDICATION NAME] 500 mg daily for ten days; -Send sputum to lab for culture (test to find the germ causing an infection) and sensitivity (a test that checks to see what kind of medicine will treat the infection). Obtain specimen before starting antibiotic; -Nebulizer treatment with [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] a drug that causes widening of the bronchi and increase air flow to the lungs) three times a day for ten days (underlined); -Portable chest x-ray; -The order was signed off on 10/20/19 by nursing staff five days after it was written. Review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] 500 mg, give one tablet one time a day every ten days for ten days for upper respiratory infection (start date 10/20/19); -[MEDICATION NAME] three times a day every ten days for shortness of breath (start date was 10/20/19); -No evidence staff administered [MEDICATION NAME] 500 mg or completed [MEDICATION NAME] treatments on 10/15/19 through 10/19/19 (as ordered by the resident's physician); -On 10/20/19, staff documented they administered [MEDICATION NAME] and administered [MEDICATION NAME] three times. (The resident did not receive [MEDICATION NAME] and complete [MEDICATION NAME] treatments as ordered from 10/15/19 until 10/20/19, a five day delay in the ordered treatments.) Review of the resident's mobile diagnostics portable chest x-ray, dated 10/21/19, showed the following: -Impression: There is marked diffuse [MEDICAL CONDITION] (a chronic irreversible disease of the lungs) with complete to near complete resolution of the left lung airspace opacities (x-ray findings of pneumonia are often airspace opacities) and interval development of bilateral perihilar thickening (occurs when excess fluid or mucous builds up in the small airway passages) with associated right parahilar airspace opacities extending into the upper and lower lung suggestive of atypical infectious process (infection caused by uncommon pathogen or atypical pneumonia); -A hand written note by the physician at the bottom of the report showed put on [MEDICATION NAME] 500 mg one daily for ten days. Review of the resident's MAR, dated [DATE] to 10/31/19, showed the following: -[MEDICATION NAME] 500 mg one tablet by mouth one time a day every 10 day(s) for upper respiratory infection (URI) start date was 10/20/19 and discontinue date was 10/28/19; -On 10/20/19, staff administered one dose. Review showed no evidence the resident received the medication after 10/20/19. Review of the resident's sputum collection, dated 10/24/19 (nine days after the sputum lab was ordered), showed the following: -Report results received 10/28/19 (13 days after the sputum lab was ordered); -Moderate white blood cells (may indicate infection) seen, moderate mixed bacterial flora (multiple organisms are growing) indicates the specimen is representative of the lower respiratory tract ; -Moderate growth of yeast (fungus) isolated; -A note at the bottom of the report indicated the report was reviewed by the physician and order to start the resident on fluconazole (antifungal used to treat fungal infections) 100 mg daily for 14 days and to stop all antibiotic use; -The report was noted by nursing staff on 10/28/19. Review of the resident's MAR, dated October 2019, showed the following: -Fluconazole 100 mg, give one tablet by mouth one time a day for infection for 14 days (start date 10/29/19 at 8:00 A.M.); -On 10/29/19, staff documented the resident refused the medication; -On 10/30/19, staff administered the medication; -On 10/31/19, staff documented the resident refused the medication. Review of the resident's nurse's note, dated 10/31/19 at 8:37 P.M., showed the assistant director of nursing (ADON) documented the resident refused his/her medications and gastric feedings (a tube inserted in the stomach for long term nutrition). Physician and family aware of ongoing situation. Review of the resident's MAR, dated November 2019, showed the following: -Fluconazole 100 mg one tablet by mouth one time daily for infection for 14 days (start date 10/29/19 at 8:00 A.M.); -On [DATE], staff administered the medication to the resident. Review of the resident's nurse's note, dated [DATE] at 4:06 P.M., showed the ADON documented the resident continued to refuse medications. (Review showed no evidence the resident's physician was notified the resident was refusing his/her medications.) Review of the resident's MAR, dated November 2019, showed the following: -On [DATE], staff documented the resident refused Fluconazole; -On 11/3/19, staff documented the resident refused Fluconazole. Review of the resident's medical record showed no evidence the resident's physician was notified of the resident's medication refusal on [DATE] and 11/3/19. Review of the resident's MAR, dated November 2019, showed staff administered Fluconazole on 11/4/19. Review of the resident's nurse's note, dated 11/4/19 at 2:38 P.M., showed staff spoke with the resident's physician office concerning the resident's cough and respiratory issues. The physician wanted the resident sent to the emergency department for evaluation. Review of the resident's nurse's note, dated 11/4/19 at 9:31 A.M., showed the resident was admitted to the hospital with [REDACTED]. Review of the resident's discharge orders from the hospitalization , dated 11/4/19 to [DATE], showed the following: -Chief complaint: shortness of breath, productive cough; -History of histoplasmosis (a type of lung infection). Presented to emergency department with worsening shortness of breath, productive cough with yellow colored sputum. In emergency department found to have [MEDICAL CONDITION] (relating the the lungs) opacity (unclear) suggestive of pneumonia; -Assessment showed pneumonia, -Home medications at discharge included [MEDICATION NAME]-[MED] (antibiotic used to treat infections) 8[AGE] mg-125 mg oral tablet, one tablet orally every 12 hours [DATE] to 11/12/19. Review of the resident's nurse's note, dated [DATE] at 8:00 P.M., showed the resident was readmitted to the facility and medications ordered. Review of the resident's MAR, dated [DATE] through 11/10/19, showed the following: -[MEDICATION NAME] 8[AGE] mg-125 mg, give one tablet orally every 12 hours for five days; -[ENTITY]t date was 11/10/19 at 8:00 A.M.; -No documentation staff administered the medication on [DATE] or 11/9/19 as ordered on the resident's hospital discharge orders; -Documentation showed staff administered the medication twice a day starting 11/10/19. During interview on 11/14/19 at 3:10 P.M., Licensed Practical Nurse (LPN) A said when the resident came back from the hospital on [DATE], staff was busy and short staffed; it was a disaster. Staff had multiple admissions/readmissions. LPN A started putting Resident #1's orders in for readmission on [DATE] and did not get all the medications put in. It kept getting passed on from shift to shift; it was just late getting put in. Staff could have started the [MEDICATION NAME] on 11/9/19 since it is kept in the emergency drug kit, but the orders were not taken off or put in the computer until 11/10/19. During interview on 11/14/19 at 3:30 P.M., the Assistant Director of Nurses (ADON) said the resident had refused medications. She thought the physician was aware. She could not find any documentation of that but felt he was aware. During interviews on 11/12/19 at 7:30 A.M. and 11/14/19 at 2:15 P.M., the Director of Nursing (DON) said the following: -The ADON was late taking Resident #1's orders written on 11/15/19 off and putting them in the computer. The ADON also put the orders in incorrectly. The [MEDICATION NAME] and breathing treatments were to be daily for ten days but were put in the computer as one dose every ten days; -The nursing staff did not follow through with the orders as directed on 10/15/19. What could have started out as a upper respiratory infection, could have progressed to pneumonia and hospitalization due to delay in treatment and medication errors. She expected better quality of care from the nursing staff; -When the resident was readmitted from the hospital, she expected staff to administer the resident's [MEDICATION NAME] on 11/9/19 as ordered, if it was available in the emergency drug kit. -She expected staff to take all resident orders off and put them in the computer prior to end of the shift the resident was readmitted on ; -She worked the night shift of 11/9/19 and it was not reported to her the resident's readmission orders [REDACTED]. During interview on 11/12/19 at 2:45 P.M., the resident's physician said the following: -He expected the facility to follow his orders as written; -He ordered for the resident to have a chest x-ray, sputum culture, increased breathing treatments, and [MEDICATION NAME] on 11/15/19, as he felt the resident had pneumonia; -The facility's delay in treatment as he ordered, led to the resident's hospitalization ; -He should have been notified if the resident had refused his/her medications. 3. Review of Resident #2's care plan, last revised on 10/28/19, showed the following: -The resident had a pacemaker related to heart failure (a chronic condition where the heart doesn't pump blood like it should); -Daily weight. Record review of the resident's physician post hospital check, dated 10/31/19, showed the following: -Post hospital follow up check: -History of present illness: The resident was recently admitted to the hospital with [REDACTED]. -Current medications included [MEDICATION NAME] (a diuretic used to treat fluid retention and swelling caused by heart failure) 40 mg by mouth once tablet daily and [MEDICATION NAME] (used to treat high blood pressure and used for the treatment of [REDACTED]. -Assessment: Dilated [DIAGNOSES REDACTED] (hearts ability to pump blood is decreased) with ejection fraction (amount of blood leaving your heart each time it contracts) around 25% (normal is 55% to 70%) with recent decompensation (failure of an organ) and clinically appeared to be close to euvolemic (having a normal amount of body fluids) and [MEDICAL CONDITION] with cardiorenal syndrome (a disorder affecting both the heart and kidneys); -Plan cardiac wise resident seems stable, clinically appeared to be euvolemic. Resident was requested to monitor body weight and trying to target current body weight as dry weight and trying to minimize within 1 to 2 pound variation. Current maintenance dose of [MEDICATION NAME] to be continued and [MEDICATION NAME] can be upper titrated down the road as tolerated; -Resident's weight is to be monitored on daily basis along with blood pressure change with supine and standing. Review of the resident's physician orders, dated 10/31/19, showed an order for [REDACTED].>Review of the resident's POS for November 2019 showed daily weight every day shift related to heart failure. Review of the resident's weight summary on 11/14/19 for November 2019 showed no documentation staff obtained daily weights for 11/3/19 through 11/7/19, and 11/9/19 through 11/13/19 (ten days without a daily weight). During interview on 11/14/19 at 11:35 A.M., Certified Nurse Assistant (CNA) B said he/she was not sure how often staff was to obtain the resident's weight. The nurses weighed the residents. During interview on 11/14/19 at 2:38 P.M., CNA C said the following: -The nurse who was responsible for obtaining the residents' weights recently quit; -He/She felt resident weights were not getting done as ordered because the nurse responsible was no longer at the facility; -The resident's weight (on 11/14/19) was 182.4 pounds (a gain of 7.6 pounds from the last weight obtained, which was 174.8 pounds on [DATE]). During interview on 11/14/19 at 2:00 P.M., Registered Nurse (RN) D said he/she was not sure if staff was to weigh the resident daily. He/She would have to check; the aides typically obtained the weights. During interview on 11/14/19 at 2:15 P.M., the DON said she expected staff to weigh Resident #2 daily as ordered. If the resident gained two pounds, she expected staff to notify the physician as the resident had been in the hospital recently. During an interview on 11/14/19 at 3:30 P.M., the resident's physician said he expected staff to follow physician orders.

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, intervene when the resident exhibited crying out and facial grimacing and failed to notify the physician of the pain and ineffectiveness of the current pain medication regimen for one resident (Resident #17) in a review of 15 sampled residents. The facility census was 61. 1. During interview on 2/16/18 at 2:30 P.M. the Director of Nursing (DON) said the facility did not have a policy that addressed pain. 2. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/17 showed the following: -[DIAGNOSES REDACTED]. -Cognition severely impaired; -Sometimes makes self-understood and understands others; -Extensive assistance of one staff member with personal hygiene; -Extensive assistance of two staff members with bathing; -Always incontinent of urine and stool; -Received scheduled and as needed (PRN) medication; -No non-medication interventions; -Pain indicators: expression and body; -Pain frequency: one to two days over the last seven days. Review of the resident's care plan last revised 12/4/17 showed the following: -The resident is on pain medication therapy related to [MEDICAL CONDITION] (weakness numbness and pain related to nerve damage usually in hands and feet); -He/she will be free of any discomfort or any adverse side effects from pain medication through the next review date of 3/6/18; -Reposition for pain relief, let the resident roll around the facility in wheelchair or offer snack for distraction, if not effective administer pain medication as ordered and reassess effectiveness; -Review every shift for pain medication efficiency, assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; -Controlled adequately by therapeutic regimen, no treatment regimen or change in regimen required but continue to monitor closely; -Therapeutic regimen followed, but pain control not adequate, changes required; -Resident has a communication problem related to stroke; -Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed; -Activities of daily living (ADL) self-care performance deficit related to dementia, immobility and incontinence; -Transfer assist of two with Hoyer (mechanical lift), turn reposition assist times two; -Toilet use: total dependence, assist of two; - There was no evidence in the care plan the resident's normal behavior was to holler out. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Pain scale: record every shift: 0-1 no pain, 2-3 mild pain, 4-5 moderate pain,; 6-7 severe pain; 8-9 very severe pain; 10 worst pain possible pain every shift for pain; -[MEDICATION NAME] (used for pain and fever) 325 milligrams (mg) give two tablets orally three times a day for pain-mild; -[MEDICATION NAME] 500mg tablet give two tablets orally every six hours as needed (PRN), for elevated temperature/pain-mild level pain 0-3 not to exceed 3grams (gm)/24hours; -[MEDICATION NAME] HCL (can treat moderate to severe pain) tablet 50mg give 50mg by mouth every 12 hours as needed for pain. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Observation on 2/14/18 at 4:30 P.M. in the resident's room showed the following: -The resident lay in bed on his/her right side; -Certified Nurse Assistant (CNA) J said he/she was getting the resident up for supper; -CNA J grasped hold of the resident's right hip area and attempted to turn the resident onto his/her back; -The resident immediately yelled out loudly, Oh, Oh, my leg hurts! -The resident exhibited intense facial grimacing; -CNA J said he/she will have to leave the resident in bed but needed to try and reposition the resident; -CNA J grasped hold of the resident's right hip area a second time and attempted to turn the resident; -The resident immediately yelled out, Oh, Oh! and the resident exhibited intense facial grimacing; -CNA J stopped and said he/she would let the charge nurse know about the resident's pain. Review of the resident's Medication Administration Record [REDACTED] -Day shift 5, moderate pain; -Evening shift 0, none; -Night shift 8, very severe pain. Review of the Medication Administration log for PRN [MEDICATION NAME] showed the following: -Date: 2/14/18; -Pain 5; -[MEDICATION NAME] administered at 8:03 A.M., effective. Review of the resident's nurse's note on 2/14/18 showed no documentation of the resident's pain or an assessment of the resident. During interview on 2/15/18 at 2:25 P.M. CNA J said the following: -The resident yelling out in pain like he/she did yesterday was not normal for the resident; -The resident had never stayed in bed for supper because of pain; -He/she tried to get the resident up for supper but the resident's right leg hurt so bad, he/she left the resident in bed; -He/she reported the resident's pain to the charge nurse. During interview on 2/15/18 at 2:30 P.M. Licensed Practical Nurse (LPN) I said the following: -He/she worked on 2/14/18 evening shift; -The resident had never stayed in bed for supper because of pain; -He/she was told in report that the resident was having pain in the right leg; -If the pain would continue he/she would let the physician know; -The resident had pain last night but LPN H had already given the resident [MEDICATION NAME] PRN on his/her shift and it wasn't time for another dose; -The resident had Tylenol which was routinely scheduled; -The resident did finally fall asleep; -He/she had notified the physician in the past about pain for a resident and not much was really done about it. During interview on 2/15/18 at 5:50 A.M. LPN G said the following: -He/she had worked the floor as an aide on the night shift; -He/she got the resident up for an hour last night and the resident ate a sandwich; -The resident remained in bed yesterday because of so much pain in his/her leg. Observation on 2/15/18 at 8:12 A.M. in the resident's room showed the following: -The resident lay in bed on his/her right side facing the wall; -CNA C and CNA D said they were going to get the resident up for the day; -CNA C grasped the resident's right leg area and attempted to assist the resident on to his/her back to provide incontinence care; -The resident immediately yelled out loudly, Oh God that hurts!; -The resident exhibited facial grimacing; -CNA C said the resident never complained about anything; -CNA C attempted to turn the resident a second time and grasped the resident on the right thigh/ hip area and the resident hollered out, That hurts!; -The resident clinched hold of the hand of CNA C; -CNA C had to pull the resident's clinched hand loose from his/her own; -CNA D and CNA C continued with dressing the resident for the day while the resident continued to holler out loudly in pain any time the staff touched his/her right hip area. Review of the resident's Medication Administration Record [REDACTED] -Day shift 5, moderate pain; -Evening shift 5, moderate pain; -Night shift 0, none. Review of the resident's medication administration log for [MEDICATION NAME] 500 mg PRN dated 2/15/18 showed the following: -Date 2/15/18: -Pain level 3; -At 12:31 A.M. medication administered, ineffective. Review of the medication administration log for [MEDICATION NAME] PRN dated 2/15/18 at 3:46 A.M. showed pain level 8 (very severe pain) administered, ineffective. Review of the nurse's notes showed no documentation the physician was notified of the ineffectiveness of the [MEDICATION NAME] or [MEDICATION NAME]. During interview on 2/15/18 at 8:30 A.M. CNA C said the following: -The resident normally did not complain about anything; -He/she had let the nurse know yesterday about the pain; -The resident was hurting yesterday but nothing like today; -He/she let the nurse know about how bad the pain was again today. During interview on 2/15/18 at 1:30 P.M. LPN F said the following: -The resident had an increase in pain today; -Night shift told him/her that the resident was hurting more in the night and they had given the resident a [MEDICATION NAME]; -It wasn't time for the resident to get another [MEDICATION NAME], so the resident received his/her routine Tylenol, it helped a little but not a lot. Observation on 2/16/18 at 12:30 P.M. showed the following: -The resident lay in bed; -CNA C and CNA E said they were going to try and get the resident up for the day but because of so much pain it may not be possible; -CNA C and CNA E attempted to turn the resident and the resident screamed out loudly, Ouch, Ouch!; -The resident grabbed hold of his/her right leg and pulled it towards him/her; -CNA E lifted the resident's right leg up to put the resident's sock on and the resident cried out, Oh, oh God that hurts!; -The resident exhibited intense facial grimacing; -CNA C said the resident was in so much pain that he/she would have to let the nurse know, the pain was just not normal for the resident. Review of the nurse's notes from 2/14/18 to 2/16/18 showed no documentation of an assessment of the resident or documentation of the pain in the right hip or the ineffectiveness of pain control. Review of the x-ray report dated 2/19/18 showed the following: Procedure: -Hip two views; History: -Right hip pain and bruising; Impression: -[MEDICAL CONDITION] third diaphysis (the shaft or central part of a long bone) of the right femur (the proximal bone of the hind or lower limb that extends from the hip to the knee) and suggestion of fractures of the right superior/inferior rami (pubic bones); -Recommend orthopedic surgeon consult and correlation with computed tomography scan (CT) to better evaluate. Review of the physician's progress note dated 3/1/18 showed the following: -The resident really has not been eating or drinking since he/she had his/her injury; -On review of his/her note from the hospital indicates a fracture distal to the prosthesis and I suspect underlying pathologic fracture due to his/her [MEDICAL CONDITION] and previous [MEDICAL CONDITION] on that right side; -It is really uncomfortable for him/her to be up in the chair much; Plan: -We are going to go ahead, due to his/her lack of eating and unwillingness and no further intervention being desired, seek a hospice referral. During interview on 2/16/18 at 3:55 P.M. and 3/2/18 at 9:10 A.M. the DON said the following: -He/she would expect staff to follow interventions put in place for pain; -If the staff was changing an incontinent resident in pain he/she would expect staff to finish changing the resident and report the pain to the nurse; -Staff should address the pain and realistically give it a day and then let the physician know; -He/she would expect some type of an assessment of the resident, if it was a new pain issue and it should be documented in the progress notes; -Staff should assess and address any new pain; -If pain medication was not effective staff should follow-up with the physician; -The resident was diagnosed with [REDACTED]. -The resident is going to be put on hospice care. During interview on 3/2/18 at 9:50 A.M. the resident's attending physician said the following: -The resident had a right [MEDICAL CONDITION]; -He/she felt it was a pathological fracture; -If the resident was lucid enough to specify pain to a specific area he/she would want to know that because he/she was not normally lucid.

Based on record review and interview, the facility failed to identify a resident's preference of code status as full code (all possible measures are to be taken to revive a person and sustain life) or do not resuscitate (DNR) and obtain physician orders [REDACTED].#1). Staff found the resident unresponsive and without pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired in the facility. Two cognitively intact residents (Residents #2 and #3), in a review of six sampled residents, said no one in the facility had discussed with them their preference regarding code status. One resident (Resident #3) said he/she wished to be a DNR and was listed as full code status in his/her medical record. The facility failed to ensure staff were trained, certified, and available to provide CPR when transporting residents in the facility van who requested to be a full code. Five additional residents (Residents #15, #16, #17, #18, and #19), who were identified as being full code status, were transported by two facility transport staff who were not certified to perform CPR. The facility census was 62. 1. Review of the facility's CPR Code Blue Policy and Procedure, revised [DATE], showed the following: -Policy: It is the policy of the facility to initiate CPR when there is no pulse, no respiration, and resident is unresponsive and there is no order for a DNR. Any staff member trained/certified in CPR may initiate the CPR and necessary process; -Procedure: The person finding the resident without signs of life; heartbeat or respiration, will initiate CPR if certified, if the resident is designated as a Code; -If the person is not certified, they will immediately notify the nurse who will initiate the emergency response. Code Blue will be paged to the location. As the charge nurse arrives at the bedside, she will assume responsibility and continue the CPR process, direct response of other staff, delegating staff to complete the following tasks, as quickly as possible, not necessarily in this order: -Secure resident's chart and verify code status; -Initiate or delegate the initiation of CPR; -Initiate or delegate 911 notification; -Delegate a staff member to retrieve the crash cart and oxygen; -Delegate a staff member to take notes and a timeline; -Delegate staff nurse to notify physician and family; -Delegate a staff member to watch for emergency team and direct them to the resident; -CPR Process will be delivered via the policy and procedure. When the Emergency Medical Response Team arrives, the facility staff will transfer the responsibility of the Code to them in preparation of transport. Nurse will be designated to provide documentation of the event to response team. 2. Review of Resident #1's hospital history and physical, dated [DATE], showed the resident's [DIAGNOSES REDACTED]. apnea (pauses in breathing during sleep due to a narrowed or partially blocked airway). Review of the resident's discharge orders from the hospital to long term care, dated [DATE], showed the resident's code status was full code. Review of the resident's face sheet showed the resident's original admission to the facility was on [DATE]. The resident was listed as his/her own responsible party. Review of the resident's Health Care Directive and Durable Power of Attorney for Health Care, signed by the resident on [DATE], showed the directive did not address the resident's code status. Review of the resident's admission orders [REDACTED] -These orders supersede any others sent from the hospital; -Physical therapy (PT) and Occupational therapy (OT) evaluations and institute plan of care. -Help the patient improve endurance, strength and mobility. Review of the resident's physician orders, dated [DATE], showed no documentation of the resident's code status. Review of the resident's medical record showed no documentation of a full code or DNR code status sheet. Review of the resident's nurse's notes showed the following: -On [DATE] at 12:56 P.M., a getting-to-know-you meeting was held with the resident and his/her niece. The physical therapy assistant (PTA), the resident assessment coordinator (RAC), dietary services manager (DSM), and the social service director (SSD) were in attendance; -On [DATE] at 6:23 P.M., the resident worked with PT and OT during the day. The resident remained in bed this shift. Leg dressings were changed and the resident rested comfortably afterwards. The resident was incontinent of bowel and bladder and required frequent repositioning. The resident was able to make his/her needs known; -On [DATE] at 5:08 A.M., staff documented at 4:03 A.M., staff alerted the nurse the resident was found deceased . At 4:05 A.M., the resident was noted to have no breath sounds, pulse, or heartbeat by two nurses. The resident's son was contacted by two different numbers at 4:10 A.M. and a message was left. The physician was notified at 4:17 A.M. The funeral home was not notified due to unknown preference. The coroner was notified at 4:46 A.M.; -On [DATE] at 7:11 A.M., staff documented staff was up and down the hall and made eye contact with the resident who appeared to be sleeping at approximately 3:20 A.M. Review of a written statement from Certified Nurse Assistant (CNA) E, obtained by the facility, dated [DATE], showed the following: -CNA E entered the resident's room at approximately 4:00 A.M. and found the resident had expired; -CNA E ran and found Registered Nurse (RN) C and Graduate Nurse (GN) D and informed them of the situation; -CNA E, RN C, and GN D ran to the resident's room and verified the resident had expired. During an interview on [DATE] at 2:05 P.M., CNA E said the following: -On [DATE], Resident #1 had no complaints throughout the shift; -At approximately 2:00 A.M., the resident was breathing and nothing appeared unusual; -At approximately 4:00 A.M., CNA E entered the resident's room and found him/her not breathing. The resident's color was normal; -CNA E alerted GN D and RN C. The three staff returned to the resident's room; -RN C left the room and returned with a stethoscope; -RN C and GN D verified the resident did not have a heartbeat and wasn't breathing; -CNA E left the room to care for other residents. Review of a written statement from RN C, obtained by the facility, dated [DATE], showed the following: -The resident's condition did not appear any different from the previous shift; -The resident rested in bed with his/her head on a pillow with legs elevated; -The resident did not complain of pain or show any signs or symptoms of pain; -RN C saw GN D and CNA E walking fast in the hallway; -CNA E said he/she thought the resident had expired; -RN C went to the resident's room and the resident appeared unresponsive; -RN C left the resident's room and went to the nurse's station to find a stethoscope and look for the resident's code status; -RN C was unable to find the resident's code status; -RN C went back to the resident's room and verified the resident had no heartbeat, pulse, or breath sounds; -At 4:05 A.M., RN C and GN D determined the resident was expired and notified the resident's physician. During an interview on [DATE] at 10:50 A.M., RN C said the following: -On [DATE] at approximately 3:20 A.M., RN C looked in on the resident, who appeared to be sleeping; -The resident was alert and oriented and able to use the call light; -The resident had no complaints throughout the shift; -At approximately 4:00 A.M., CNA E and GN D ran towards the resident's room; -RN C followed CNA E and GN D into the resident's room; -RN C called the resident's name and GN D shook the resident's shoulders. The resident did not respond; -RN C checked the resident for a pulse and did not find one; -The resident was not stiff or cold. The resident's feet were cool but not cold; -RN C left the room and went to the nurse's station to find the resident's code status; -RN C did not find a code status listed in the resident's chart or electronic medical record; -RN C returned to the resident's room with a stethoscope and verified with GN D the resident did not have a heartbeat; -RN C and GN D went to the nurse's station; -RN C called the resident's physician and notified him/her the resident had expired; -GN D called the resident's family member and left a message; -RN C and GN D did not discuss starting CPR on the resident at any point; -RN C had been employed with the facility since the end of [DATE]. RN C did not receive any in-servicing during orientation or since hire regarding how to respond to a code. During a telephone interview on [DATE] at 10:43 A.M., GN D said the following: -CNA E said he/she thought the resident was dead; -CNA E, GN D, and RN C ran to the resident's room and found him/her not breathing and without a heartbeat; -The resident's hands were warm and his/her feet were slightly cold; -RN C and GN D went to the nurse's station and could not find the resident's code status listed in the hard chart or in the electronic medical record; -RN C and GN D verified the resident was not alive; -RN C called the resident's physician and the coroner; -GN D was not sure when staff had last been in the resident's room but thought the resident was checked every two hours; -RN C and GN D never discussed starting CPR on the resident. Review of a fax to the resident's physician, dated [DATE] at 10:11 A.M., showed the following: -Message: Facility reports the resident was listed as a Full Code but no CPR was done on the resident. The nurse stated the resident was found dead and cold at the time so no CPR was started; -Physician response: The resident had not reached a decision to forego resuscitation but from medical status he/she was considered a poor candidate for CPR. With an unwitnessed arrest and being found cold, CPR was not indicated. Common sense in such a situation dictates to not do CPR. During an interview on [DATE] at 8:50 A.M., the Director of Nursing (DON) said the following: -The nurse handling a resident on admission identified the resident's code status if it was included in their orders; -The Social Service Director (SSD) followed up to verify a resident's code status if it was not included in their orders; -Resident's code status was listed on the front page of their chart; -Resident #1 was identified as full code status on the discharge orders from the hospital; -Resident #1's admission orders [REDACTED] -The SSD spoke with residents upon admission and quarterly when care plans were due about their wishes regarding code status; -Resident #1 had an advanced directive in his/her chart, but it did not indicate whether the resident was to be a full code or DNR. During an interview on [DATE] at 11:32 A.M., the SSD said the following: -Upon admission, he/she reviewed residents' orders to see if a code status was listed; -The SSD then spoke with the resident to determine their wishes for code status; -If the resident wanted to be a full code and had an order to be a full code, the SSD placed a green sheet in the front of the chart which said full code; -If a resident wanted to be a DNR, the SSD had the resident sign the DNR form and then mailed the form to the physician for signature. A white copy of the DNR form, signed by the resident, remained in the front of the chart until the signed copy from the physician was received in the facility; -The SSD said he/she did not review Resident #1's orders or speak with the resident about code status prior to his/her death; -The SSD attended the resident's getting-to-know-you meeting 72 hours after his/her admission on [DATE]. The SSD did not speak with the resident or his/her family about code status at that time; -The SSD usually made a copy of residents' physician orders [REDACTED].#1. During an interview on [DATE] at 9:16 A.M., Medical Records Staff A said the following: -He/she put together charts for newly admitted residents; -72 hours after a resident was admitted , he/she checked the charts to ensure assessments had been completed; -If the resident had an order to be a full code, he/she placed a full code sheet in the front of the resident's chart, if the SSD had not already done so; -When the facility received the signed DNR form from the physician, he/she gave the signed form to the SSD; -He/she usually looked to ensure a code status was in place when checking the resident's chart 72 hours after admission; -He/she did not check Resident #1's chart 72 hours after admission or at any point prior to his/her death. During an interview on [DATE] at 12:12 P.M., the DON said the facility required all licensed staff to be CPR certified. The DON verified that all licensed staff were CPR certified on a regular basis. Code status was not gone over with new employees during general orientation but it was included in the clinical orientation packet, which new employees read (600 pages or more). RN C and GN D had started sometime around June or July of 2015. The DON did not think RN C or GN D had received any in-service training on how to respond to a code since they were hired. Review of RN C's CPR certification showed it expired in [DATE]. Review of GN D's CPR certification showed it is valid until [DATE]. Review of the facility's Clinical Orientation packet showed the following information regarding code status: -Resident code status is reviewed upon admission/readmission, quarterly, and with significant changes, -Code status will be verified with the resident and physician and order received along with signature and any state form secured as applicable; -The definitive method of verifying a resident's code status is by review of the chart; -If the resident is found to be without pulse or respiration and wished CPR to be performed, CPR should be initiated by CPR certified staff and continued until emergency personnel take over. During a follow up telephone interview on [DATE] at 12:20 P.M., RN C said if she/she had located a full code sheet in the resident's chart, or an order for [REDACTED]. During a follow up telephone interview on [DATE] at 12:25 P.M., GN D said he/she was hired on [DATE]. GN D had not received any training in the facility on how to respond to a code. If a full code sheet had been located in Resident #1's chart, GN D would have initiated CPR and called 911. During a follow up interview on [DATE] at 12:33 P.M., the DON said he/she would expect staff to initiate CPR for a resident in a code situation if code status could not be identified for the resident. He she expected staff to initiate CPR for Resident #1. During a follow up telephone interview on [DATE] at 4:48 P.M., RN C said the resident had an advanced directive in the chart. RN C referred to the advanced directive on [DATE] when the resident was found unresponsive. The resident's advance directive did not direct RN C whether or not to start CPR. During an interview on [DATE] at 6:03 P.M., the Administrator said an in-service was done on [DATE] with some staff members regarding CPR, full code and DNR status. A problem was identified at that time that code status pages were missing from residents' charts. The Administrator verbally instructed the SSD at that time to correct the problem. Review of the in-service sheet, dated [DATE], showed the following: -CPR, Full Code and DNR Status: How and When to Respond; -Problem identified: Audit Charts for missing code status pages; -Eight staff signed the in-service form, including the SSD; -RN C, GN D and CNA E's signatures were not on the in-service form. 3. Review of Resident #3's face sheet showed the resident's original admission to the facility was on [DATE]. The resident was listed as his/her own responsible party. Review of the resident's electronic physician order [REDACTED]. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Able to make himself/herself understood; -Understood others; -Cognition was intact; -No [MEDICAL CONDITION]; -No delusions or hallucinations; -No behavioral symptoms. Review of the resident's social service progress notes showed documentation by the Social Service Director (SSD), dated [DATE], the resident wanted full code status to remain in place. The resident was full code per his/her request. During an interview on [DATE] at 9:55 A.M., the resident and his/her spouse said no one in the facility had spoken with them about the resident's wishes regarding his/her code status. The resident had lived in the facility since [DATE]. The resident adamantly said he/she did not wish to be resuscitated and did not want staff to initiate CPR if his/her heart stopped and he/she stopped breathing. The resident said he/she wanted to be a DNR and had always felt that way. Review of the resident's medical record on [DATE] at 10:17 A.M. showed a full code sheet located in the front of the record. During an interview on [DATE] at 3:00 P.M. the SSD said he/she had spoken with Resident #3 about his/her wishes for code status at admission and quarterly. The SSD said Resident #3 wanted to be full code status since admission and his/her wishes had not changed. 4. Review of Resident #2's face sheet showed the resident's original admission to the facility was on [DATE]. The resident was listed as his/her own responsible party. Review of the resident's electronic physician order [REDACTED]. Review of the resident's care plan, dated [DATE], showed the resident was full code status. Ensure his/her wishes are honored. Review quarterly and with significant changes. Review of the resident's MDS, dated [DATE], showed the following: -admission date of [DATE]; -Able to make himself/herself understood; -Understood others; -Cognition was intact; -No [MEDICAL CONDITION]; -No delusions or hallucinations; -No behavioral symptoms. Review of the resident's social service progress notes showed documentation by the SSD dated [DATE] the resident was full code status per his/her request. During an interview on [DATE] at 9:45 A.M., the resident said he/she had been a resident in the facility for a couple of weeks. No one in the facility had spoken to him/her regarding his/her wishes about code status or CPR. The resident was his/her own person and made his/her own decisions. The resident was not sure what his/her wishes for code status were at this time. Review of the resident's chart on [DATE] at 10:15 A.M. showed a full code sheet located in the front of the chart. During an interview on [DATE] at 11:32 A.M., the SSD said he/she discussed a resident's wishes regarding code status with residents and families upon admission and quarterly with their care plans. The SSD said he/she discussed the CPR process including chest compressions and rescue breathing with residents and their families in detail and felt comfortable with these discussions because of his/her nursing background. 5. During an interview on [DATE] at 10:00 A.M., Transport Staff G said he/she occasionally transported residents in the facility van. Transport Staff G said he/she was not CPR certified. During an interview on [DATE] at 10:20 A.M., Transport Staff F said he/she handled most of the transports for residents in the facility van. Transport Staff F said his/her CPR certification had expired in 2013. During an interview on [DATE] at 11:00 A.M. the Administrator said Transport Staff F and Transport Staff G transported residents in the facility van who were full code status. Transport Staff F and Transport Staff G were not CPR certified. The Administrator said he/she was not aware transport staff were required to be CPR certified. 6. Review of Resident #15's electronic medical record showed an admission date of [DATE]. Review of the resident's notes by the Social Service Director (SSD) showed on [DATE], the resident was a full code per his/her request. Review of the facility's transport logs for the last three weeks showed the following: -On [DATE], Transport Staff G transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present. 7. Review of Resident #16's physician order [REDACTED].>Review of the facility's transport logs for the last three weeks showed the following: -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present. 8. Review of Resident #17's physician order [REDACTED].>Review of the facility's transport logs for the last three weeks showed the following: -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present. 9. Review of Resident #18's physician order [REDACTED].>Review of the facility's transport logs for the last three weeks showed the following: -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present; -On [DATE], Transport Staff F transported the resident to an appointment. No other staff were present. 10. Review of Resident #19's physician order [REDACTED].>Review of the facility's transport logs for the last three weeks showed on [DATE], Transport Staff F transported the resident to an appointment. No other staff were present. Complaint MO 187 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began inservicing nursing staff immediately regarding procedures to follow if a resident was found without respirations, including initiating CPR for a resident if their code status could not be determined. The remainder of nursing staff were to be inserviced prior to contact with residents until all nursing staff had received this inservice. The facility will inservice any newly hired staff on the facility's CPR policy. The facility will implement a new check sheet for staff to use to ensure code status is identified and orders obtained for code status for admissions and readmissions. Administrator and DON to monitor. The facility immediately reviewed current residents' medical records for code status and discussed the current orders with residents and families to ensure the wishes of the resident were followed regarding code status. The Director of Nursing will review CPR certification for all licensed nursing staff. The administrator will monitor. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address class I violations.

Based on observation, interview, and record review, facility staff failed to hold [MEDICATION NAME] for one resident (Resident #6) for one day as ordered by the physician. Staff also failed to reduce the dose over the next three days and instead staff administered the discontinued (2 milligrams (mg)) dose plus the reduced dose (1.5 mg) for four days, which resulted in a critically high PT/INR, for which the physician ordered vitamin K to treat. The facility also failed to appropriately manage pain for two residents (Residents #9 and #10), with [DIAGNOSES REDACTED]. The facility census was 72. 1. Review of the Nursing 2011 Drug Handbook showed the following information related to [MEDICATION NAME] therapy: -Black Box Warning: [MEDICATION NAME] can cause major or fatal bleeding which is more likely to occur during the starting period: -Pro-time (PT)/International Normalized Ratio (INR) determinations are essential for proper control: -Elderly patients and patients with [MEDICAL CONDITION] are especially sensitive to the drug's effect. 2. Review of Mosby's Manual of Diagnostic and Laboratory Tests second edition showed the following lab values PT/INR: -Normal Findings for the PT is 11.0-12.5 seconds; -Critical Values for the PT are greater than 20 seconds; -Therapeutic INR is usually considered to be 2.0-3.5 in most institutions. 3. Record review of Resident #6's admission Minimum Data Set (MSD), a federally mandated assessment instrument completed by the facility staff dated 1/2/15, showed: -The resident was able to make self- understood; -The resident was able to understand others; -The resident required limited assist of one staff for locomotion, dressing, toilet use and personal hygiene. Record review of the resident's care plan, dated 1/30/15, showed the following: -Laboratories (labs) ordered and report abnormal lab results to the physician; -Monitor, document, and report to the nurse/physician signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs; -Review medication list for adverse interactions and avoid use of aspirin or non-steroidal anti-[MEDICAL CONDITION] drugs (NSAIDS). Record review of the resident's physician's order sheet for February 2015, showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (medication used to thin the blood) 2 milligrams (mg), one tablet, by mouth, in the evening. Record review of the resident's lab results, on 2/27/15 showed an INR of 3.71 (normal range 2.0 - 3.5). Record review of the electronic physician's order, dated 2/27/15 showed the following: -Omit [MEDICATION NAME] (generic for [MEDICATION NAME]) dose today; -Change the dose at this time, to [MEDICATION NAME] 1.5 mg daily; -Repeat PT with INR on 3/2/15. Record review of the resident's medication administration record (MAR) for February 2015, showed the following: -On 2/27/15 and 2/28/15 at 5:00 P.M., staff administered [MEDICATION NAME] 1.5 mg; -On 2/27/15 and 2/28/15 at 5:00 P.M., staff administered [MEDICATION NAME] 2 mg; -The facility staff did not hold the dose on 2/27/15 and gave a total of 3.5 mg on 2/27/15 and 2/28/15. Record review of the resident's MAR for March 2015, showed the following: -On 3/1/15 and 3/2/15 at 5:00 P.M., staff administered [MEDICATION NAME] 1.5 mg; -On 3/1/15 and 3/2/15 at 5:00 P.M., staff administered [MEDICATION NAME] 2 mg; -The facility staff gave a total of 3.5 mg on 3/1/15 and 3/2/15. (the physician ordered staff to hold the [MEDICATION NAME] on 2/27/15 and then administer 1.5 mg daily) Record review of the nurse's note on 3/2/15 at 9:10 A.M., showed the resident was experiencing a change in condition and a situation background assessment request was completed for further information and family/physician notification. Review of the resident's laboratory results on 3/2/15 showed the resident's INR was 9.24 (normal range 2.0 - 3.5) and the PT was 105.4 (normal range 9.1 - 11.2). Record review of the electronic physician's order, dated 3/2/15 at 6:16 P.M., showed the following: -The director of nurses (DON) contacted the physician's office; -A nurse did not hold the [MEDICATION NAME] on 2/27/15 as ordered and gave the [MEDICATION NAME] 3.5 mg on 2/27/15, 2/28/15, 3/1/15, and 3/2/15 prior to receiving the call from laboratory, on the critical high INR; -An order to give vitamin K (used to reverse the effects of [MEDICATION NAME]) 5 mg now, by mouth and inform the resident what has occurred. Record review of the resident's MAR, dated 3/2/15 at 6:29 P.M., showed vitamin K tablet, 5 mg, given by mouth. During interview on 5/21/15 at 3:23 P.M., Licensed Practical Nurse (LPN) J said the following: -When a new order is received, the charge nurses are to place the order in the computer, on the MAR and initial the order sheet; -The charge nurse was to document in the progress notes (nurse's notes) showing the order had been received, who the physician was and what changes were made; -The charge nurse was then to place the order on a clip board and the night nurse was to double check. During an interview on 5/21/15 at 2:04 P.M., the DON said the following: -It was determined the order for 2 mg of [MEDICATION NAME] was not discontinued; -The [MEDICATION NAME] 2 mg was placed on hold in the computer; -When an order is placed on hold, in the computer, the computer will come back on and remove the hold, allowing that specific order to remain active; -The new order for [MEDICATION NAME] 1.5 mg was entered in the computer; -The staff gave both doses per the MAR. Review of the fax received from the resident's physician on 6/4/14 at 9:25 A.M., showed according to research the risk of bleeding approximately doubles for each single point of increase in the INR above 3.0. The physician felt this placed the resident at risk for complications related to the critically high INR (9.24). 4. Review of the facility's Pain Clinical Protocol, dated 4/2013 showed: -The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes a review of each person's known [DIAGNOSES REDACTED]. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary treatments; -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain; -The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning; -The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbances, social isolation, and falls; -With input from the resident and/or advocate, the physician and staff will establish goals of pain treatment; -The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain; -The staff will evaluate and report how much and how often the individual asks for PRN pain medication; -Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain; -The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. For example, review frequency and intensity of pain, ability to perform ADLs, sleep pattern, mood, behavior, and participation in activities; The staff will discuss significant changes in levels of comfort with the attending physician who will consider adjusting interventions accordingly. 5. Record review of Resident #9's care plan, dated 3/16/15 showed: -[DIAGNOSES REDACTED]. -Staff failed to address potential or actual pain/discomfort. Record review of the resident's April 2015 MAR showed: -Pain scale every shift for pain management (0-1 no pain, 2-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-9 very severe pain, 10 worst possible pain); -On 4/11/15, the resident complained of pain at a 2 on the day and evening shift; -On 4/12/15, the resident complained of pain at a 5 on the evening shift; -Staff failed to document level of pain from 4/15/15 through 4/27/15; -On 4/29/15, the resident complained of pain at an 8 on the evening shift and a 3 on the night shift; -No physician's order for pain medication. Record review of the resident's nurse's notes, dated 5/2/15 at 11:07 P.M. showed the resident was unable to answer appropriately when asked about pain. The resident said, "It hurts." when the Certified Nurse Assistant (CNA) attempted to put the resident's shoes and socks on and when the nurse applied lotion to the resident's feet. Record review of the resident's May 2015 MAR showed: -Pain scale every shift for pain management (scale of 0-10); -On 5/7/15 the resident complained of pain at a 4 on the day shift and a 5 on the night shift. Record review of the resident's nurse's notes dated 5/8/15 at 2:31 A.M. showed the resident complained of pain in his/her feet, especially in the left foot near the great toe. The area had a large callous and was red and tender. Record review of the resident's May 2015 MAR showed: -Pain scale every shift for pain management (scale of 0-10); -On 5/14/15 the resident complained of pain at a 5 on the night shift; -On 5/15/15 the resident complained of pain at an 8 on the day shift and a 7 on the evening shift; -On 5/16/15 the resident complained of pain at a 4 on the day shift; -No physician's order for pain medication. Record review of the resident's electronic physician orders on 5/18/15 showed no active pain medication orders. Observation on 5/19/15 at 7:10 A.M. showed: -The resident lay in bed rubbing his/her left leg and moaning. The resident said, "Oh that leg" ; -Two CNAs entered the room to assist the resident up in the wheelchair; -The resident said, "Oh I hurt so bad" and complained of his/her left side hurting; -The resident complained of pain with movement and said, "Oh Lord baby. You do not know how much that hurts", as the CNAs assisted the resident with perineal care and up to the side of the bed; -CNA D repositioned the resident's left leg; -The resident screamed out, patted his/her left leg and began rubbing his/her thighs; -The CNAs provided extensive assist three times to stand the resident, pull up incontinent brief and adjust clothing. The resident's knees buckled and he/she said, "I cannot do this baby"; -The CNAs provided extensive assist to pivot transfer the resident into the wheelchair. Observation on 5/19/15 at 9:20 A.M. showed the resident leaving in the facility van for a [MEDICAL CONDITION] appointment. During an interview on 5/19/15 at 1:00 P.M. LPN E said: -All the resident had for pain was Tylenol (pain medication); -He/she gave the resident Tylenol 325 mg before the resident left for his/her appointment that morning; -LPN E looked at the MAR; -The resident did not have anything for pain. He/she evidently did not give the Tylenol if the resident did not have an order. The resident's pain needed to be addressed. Record review of the resident's May 2015 MAR showed on 5/19/15 the resident complained of pain at a 5 on a scale of 0-10 on the day shift. Record review of the resident's nurse's notes dated 5/19/15 at 1:29 P.M. showed: -The resident was out of the facility for [MEDICAL CONDITION] treatment; -The resident complained of leg pain prior to leaving, but had no pain medication ordered; -The resident's physician was faxed for pain medication. Record review of the resident's physician orders showed a new order, dated 5/19/15 for Tylenol 650 mg every four hours as needed (PRN) for pain. Observation on 5/20/15 at 8:05 A.M. showed the resident sitting at the dining room table in his/her wheelchair rubbing his/her left calf. Observation on 5/20/15 at 8:50 A.M. showed: -The resident was in his/her room in a wheelchair with his/her left leg straight out. The resident was holding and rubbing his/her left leg and said, "Oh Lord, it just sets me on fire," and it had hurt for about two weeks; -LPN E and social service designee/LPN moved the resident closer to the bed for a transfer; -The resident said, "Ooowee", and grabbed his/her left leg; -The DON and wound nurse were present in the room; -LPN E and social service designee/LPN transferred the resident to bed; -The resident said, "Mercy, mercy" and moaned in pain during the transfer. Record review on 5/20/15 at 11:10 A.M. of the resident's May 2015 MAR showed staff failed to administer the resident's pain medication on 5/20/15 prior to leaving for [MEDICAL CONDITION] treatment and no evidence the resident had refused pain medication. During an interview on 5/21/15 at 3:25 P.M. the DON said: -She would expect a resident who rated pain from a 2-8 on a scale of 0-10 to have a PRN pain medication order; -She did not recall Resident #9 complaining of left leg pain other than on 5/20/15; -Any nurse who identifies a pain issue is responsible for obtaining a pain medication order; -She would expect staff to call and ask for a pain medication order if the resident was not admitted with an order or if the resident's current orders were not controlling their pain. 6. Review of Resident #10 nursing admission data collection, dated 5/13/15, showed the following: -Does the resident have pain? "Yes"; -Location of the pain. "upper back, left side"; -Is the pain acute? "Yes"; -Does the pain inhibit activities of daily living? "No"; -What is the resident's verbal description of the pain? "ache, sharp"; -Intensity of the resident's pain using verbal descriptor scale: "moderate"; -What alleviates the pain? "Tylenol (nonopioid [MEDICATION NAME] to treat mild to moderate pain) on occasion"; -What makes the pain worse? "nothing"; -List non-medication interventions the resident uses to control pain: "nothing". Review of the resident's care plan, dated 5/14/15 showed: -[DIAGNOSES REDACTED]. -Nothing in the care plan to address potential or actual pain/discomfort. Review of the resident's MDS, dated [DATE], showed the following: -Usually makes self-understood; -Understands others; -Brief Interview for Mental Status (BIMS) Score of 15, indicating cognitive intact; -[DIAGNOSES REDACTED]. -No pain management regimen. Review of the MAR for May 13, 2015 through May 21, 2015 showed the following: -On 5/13/15, the resident rated his/her pain a 2 during the night shift; -On 5/14/15, the resident rated his/her pain a 3 during the day shift. Record review of the progress notes showed the following: -On 5/14/15 at 12:01 P.M., the resident requested something for pain, fax was sent to the physician requesting something for pain due to not having anything ordered; -On 5/14/15 at 1:01 P.M., pain scale (0-10) every shift for pain management, the resident has nothing ordered for pain, fax has been sent to physician to get something ordered; -On 5/14/15 at 1:11 P.M., physician faxed at 9:30 A.M. in regard to resident complaining of pain. The physician replied back that he did not know the resident and would not prescribe pain medication without seeing him/her. Appointment was scheduled at the earliest on Monday the 18th at 1:30 P.M. Yesterday the 13th, the physician was also called at 12:00 P.M. and was out at lunch. Will follow up with physician in regards to pain; -On 5/14/15 at 2:05 P.M., faxed the physician regarding the resident's pain, he/she responded back with, he/she does not know the resident and cannot order anything at this time, until he/she sees the resident. The nurse tried calling the physician back for a Tylenol (brand name for [MEDICATION NAME]) order, and could not get a hold of him/her. Record review of the progress notes showed on 5/15/15 at 10:14 A.M., staff called the physician at 10:00 A.M. to inform of the resident's complaint of pain. The physician gave a new order. See the MAR. Record review of the resident's electronic physician orders, dated May 13, 2015 through May 30, 2015, showed [DIAGNOSES REDACTED]. -Order dated 5/15/15 for [MEDICATION NAME] (nonopioid [MEDICATION NAME] to treat mild to moderate pain) tablets 1000 mg by mouth every six hours as needed for pain. Review of the resident's MAR for May 13, 2015 through May 21, 2015 showed the following: -Order for [MEDICATION NAME] tablet, give 1000 mg by mouth every six hours as needed for pain, start date of 5/15/15 at 10:15 A.M.; -On 5/15/15, the resident rated his/her pain a 6 during the evening shift; -No evidence staff administered the [MEDICATION NAME] as ordered for the resident's pain, which he/she rated as a 6. During interview on 5/21/15 at 10:58 A.M., Graduate Nurse (GN) G said the following: -The resident's pain was documented in the nurse's notes on 5/14/15, when he/she was admitted and a fax was sent to the physician requesting something for pain; -The physician would not order anything for the resident's pain until he/she saw the resident on May 18; -There was no documentation to show what was done for the resident's pain of 6 on May 15th; -The physician did give a Tylenol order on the 15th; -The normal process for alternatives is to reposition the resident or ask the physician for ice or heat to the area of pain; -The resident said that if he/she moves around and repositions it feels better, but would still like something for pain; -The physician was faxed and phone calls were made to follow up with the faxes three different times. During interview on 5/21/15 at 11:28 A.M., GN G said he/she did not know why Tylenol was not given on May 15 when the resident had a pain rating of 6. He/she added that he/she was the charge nurse and Certified Medication Technician (CMT) I was passing the medications. During interview on 5/21/15 at 11:45 A.M., CMT I said the following: -He/she told GN G the resident had pain on May 15; -GN G was aware of the pain and he/she had requested and received an order for [REDACTED]. -He/she said that he/she and GN G got Tylenol out and gave it to the resident; -CMT I did not chart the effectiveness because it did not flag, because it was never charted as being given; -He/she should have gone back and charted the Tylenol had previously been given after it hit the MAR. Record review of the resident's daily skilled nurse's notes showed on 5/18/15 at 11:33 P.M., 5/19/15 at 9:23 P.M., and 5/20/15 at 9:26 P.M., staff documented the resident was alert, had no memory problems, alert and orientated to person, place and time, no impairments with decision making, no indication of [MEDICAL CONDITION] and no concerns with cognition. During interview on 5/20/15 at 11:25 A.M., the resident said the following: -He/she was currently not in any pain; -He/she has had pain before, but not today. Hasn't had any pain since seeing the physician yesterday; -He/she had pain when he/she was first admitted to the facility. Nothing was given for pain because the staff couldn't get a hold of the physician; -He/she rated the pain a 6 or 7 on pain scale of 1-10 during his/her first days at the facility; -He/she added "Of course it was on a weekend and that made it worse". During interview on 5/21/15 at 8:30 A.M., the resident said he/she did not have any pain currently, but he/she had pain on his/her right side area earlier. Record review of the order-administration note on 5/21/15 at 11:15 A.M., showed the following: -On 5/21/15 at 7:42 A.M., the nurse documented he/she gave [MEDICATION NAME] tablet, 1000 mg by mouth every six hours PRN for pain, complaint of pain in right side of the resident's ribs, rated at a 7 of 10 on the pain scale; -No documentation of follow up to evaluate for the effectiveness of the pain medication. Review of the resident's MAR for May 13, 2015 through May 21, 2015 showed the following: -On 5/21/15, the resident rated his/her pain a seven during the day shift; -LPN H documented he/she gave the resident [MEDICATION NAME] tablets, 1000 mg at 7:42 A.M. for pain; -LPN H did not document effectiveness of the pain medication on the MAR. During interview on 5/21/15 at 11:15 A.M., LPN H said staff should follow up on pain medication within an hour of administration to evaluate the effectiveness. He/she gave the resident's pain medication at 7:42 A.M. and had not followed up to know if it was effective or not. During an interview on 5/21/15 at 3:25 P.M. the DON said: -Any nurse who identifies a pain issue is responsible for obtaining a pain medication order; -She would expect staff to call and ask for a pain medication order if the resident was not admitted with an order or if the resident's current orders were not controlling their pain. During a telephone interview on 5/26/15 at 10:33 A.M., the DON said the following: -If a resident is in pain, the nurse should check to see if the resident had pain medications and address the pain issues; -Staff should offer alternative ways to relieve pain other than medications, like turning and repositioning; -She would expect staff to do something if a resident rated their pain at a 6 or 7 on a scale of 10; -She would expect staff to assess the pain, contact the physician, offer alternatives and administer medications as ordered.

Based on observation, record review, and interview, the facility failed to reposition two residents (Residents #2 and #4) who were at risk for developing pressure ulcers (any [MEDICAL CONDITION] caused by unrelieved pressure that results in damage to underlying tissue. Pressure ulcers usually occur over a bony prominence), failed to notify one resident's (Resident #4) physician of wounds on the resident's heels following the resident's return to the facility from a hospitalization , failed to notify the physician of wounds on the resident's heels in February, 2011, failed to complete adequate skin assessments to identify two unstageable areas with eschar on the resident's heels, and failed to provide a nutritional supplement as ordered to promote wound healing. The resident sample was 13 residents. The facility census was 78. 1. Review of the facility policy, Pressure Ulcer Prevention, revised November, 2010, provided by the administrator on 3/17/11, showed the following: -Assessment: A standardized pressure ulcer risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcers. This assessment will be completed upon admission, weekly x 4, quarterly, and when a significant change in the resident's condition is noted; -Planning: An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition, and overall clinical condition of the resident as well as the risk factors as they apply to each individual. The goal is for the resident to be free of preventable pressure ulcers; -Minimize Pressure: Turning and repositioning - every two hours when in bed, or more frequent depending on the need of the resident, relieve pressure to heels by using pillows or other devices. Do not depend on heel protectors, they do not provide pressure reduction/relief, pressure reductions/relief devices should serve as adjuncts and not replacements for repositioning protocols; 2. Review of the facility's undated policy for S.T.A.R. (Set Time Action Rounds) showed the following: -Is a team effort of turning, toileting, hydration, positioning and releasing restraints every two hours for all triggered residents; -Takes place at the following times: 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 5:00 P.M., 7:00 P.M., 9:00 P.M., 11:00 P.M., 1:00 A.M., 3:00 A.M., 5:00 A.M.. -All nursing assistants and licensed nurses are to participate in STAR each time it is called; -At least one licensed nurse must participate in STAR each time it is called and should check that this is being done; -It is important that you start with the same resident each time and work your way up the hall, so each resident is turned or released approximately the same time each two hours, and does not go over their two hour limit. 3. Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, lesson titled Preventing and Caring for Pressure Ulcers, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to lack of blood flow and oxygen supply to an area of the body; -The lack of circulation usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; -Pressure is the main cause; -Prevent pressure: Change the resident's position at least every two hours or more frequently if indicated in the care plan, use anti-pressure devices and mattress overlays; -A pressure ulcer (decubitus or bedsore) can be as stressful to the human body as major surgery. It is worth every effort to prevent one. For every minute it takes to cause a pressure ulcer, it takes weeks to heal. 4. Record review Resident #4's nurses notes dated 12/16/10 showed the following: -Resident returned to the facility (following hospitalization ); -Left lateral foot with suspected deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue), measured 1 centimeter (cm) x 0.5 cm; -Left inner toe (fifth), open area measured 0.5 cm, red warm to touch; -Left foot second toe with scab, 0.3 cm in diameter; -Right heel with suspected deep tissue injury .05 cm in diameter; -Right lateral foot 1 cm x 1.8 cm; -Right outer heel, Stage I (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: Skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues) 3.5 cm in diameter; -Sacrum 8.5 cm x 6 cm x 3.5 cm, undermining 9:00 to 4:00 with 2.7 cm tunneling and at 3:00 with 6 cm of tunneling. -No documentation the resident's physician was notified of the areas on the resident's left and right heels. Review of Physician Order Sheet dated, 12/16/10 through 1/15/11, showed no orders to treat areas on the resident's heels. Record review or the weekly pressure ulcer assessment, completed by the wound care nurse, showed the following: -On 12/16/10, the resident had a Stage I on his/her right outer heel that measured 3.5 cm x 3.5 cm; -On 12/16/10, the resident had a suspected deep tissue injury to his/her left lateral foot that measured 1 cm x 0.5 cm; -On 12/16/10, the resident had a suspected deep tissue injury area to his/her right heel that measured 1.5 cm x 1.5 cm; -On 12/16/10, the resident had an unstageable pressure ulcer related to slough and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) to his/her left inner heal that measured 5 cm x 2.2 cm; -On 12/16/10, the resident had a suspected deep tissue injury to his/her right lateral foot which measured 1 cm x 1.8 cm; Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/23/10, showed the following: -Resident at risk for developing pressure ulcers; -One stage I pressure ulcer; -One stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle, often includes undermining and tunneling), measured 8.5 cm X 6.0 cm x 3.5 cm; -Four unstageable pressure ulcers with suspected deep tissue injury; -One unstageable pressure ulcer due to coverage of wound bed by slough and /or eschar; -The most severe tissue type for any pressure ulcer was necrotic tissue; -Turning/repositioning program. Record review or the weekly pressure ulcer assessment, completed by the wound care nurse, showed the following: -On 1/03/11, the area of the left lateral foot was resolved; -On 1/06/11, the resident's right lateral foot had unstageable area with eschar that measured 1 cm x 1.8 cm. On 1/10/11, the would care nurse signed and dated the weekly pressure ulcer assessment but did not document on the wound (no further documentation on the wound); -On 1/10/11, the area to the right heal was resolved; -On 1/26/11, the area to the left inner heal was resolved; -On 2/14/11, the area of the right outer heel was resolved; Review of the weekly skin assessments, completed by Licensed Practical Nurse (LPN) S, showed the following: -On 1/16/11, no documentation of a skin assessment; -On 1/23/11, open area on coccyx and scabbed areas on bilateral heels, wears boots; -On 1/30/11, open area on coccyx, scabbed areas on bilateral heels; -On 2/06/11, open area on coccyx wound, scabbed areas on bilateral heels; -On 2/13/11, no documentation of a skin assessment; -On 2/20/11, open area on coccyx, wound vac (is used to facilitate wound healing by converting an open wound to a closed wound); -On 2/27/11, no documentation of a skin assessment; -On 3/06/11, open area to coccyx; -On 3/13/11, no documentation of skin assessment. Review of the nurse's notes, dated 2/12/11, showed the following: -Registered Nurse (RN) C documented boots on bilateral and has dark area on heels. -No further documentation regarding areas on the resident's heels until 3/15/11. -No documentation staff notified the resident's physician of the dark areas on the resident's heels. During telephone interview on 3/17/11 at 1:05 P.M., RN C said he/she had documented on 2/12/11 the resident had a black purple area on his/her heels which were not open. He/she had reported this to the wound care nurse and was not sure if the physician was notified of the areas on the resident's heels. Review of nutrition progress record showed the following: -On 01/24/11, wounds per wound log dated 1/14/11 through 1/20/11 showed the sacrum wound stage IV, right inner heel unstageable, right outer heel unstageable. Nursing documentation reflects resident accepts the diabetic supplement; suggest clarifying and increasing the diabetic supplement to one carton by mouth three times a day with med pass; -On 2/18/11, noted order for diabetic house supplement one carton three times a day, Director of Nursing to follow up. Sacral wound is decreasing in size per wound nurse progress note dated 2/14/11. Director of Nursing to follow with order for diabetic supplement; one carton three times a day; -On 2/25/11, skin per wound report 2/18/11 through 2/24/11, stage IV sacral wound, improving per verbal report from the wound registered nurse. Diabetic supplement three times a day, increased 1/25/11, the resident eats well and accepts supplement. Review of the resident's physician order sheet, dated 1/16/11 through 2/15/11 showed the resident was to receive a diabetic supplement twice daily. Review of physician order sheet received by fax, dated 01/25/11, showed diabetic supplement one carton three times daily was ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility failed to provide the resident the diabetic supplement three times daily as ordered by the resident's physician. Review of Resident #4's physician order sheet, dated 2/16/11 through 3/15/11, showed the [DIAGNOSES REDACTED]. The resident was to receive diabetic supplement twice daily. Review of physician order sheet received by fax, dated 2/26/11, showed to increase boost (diabetic supplement) to one carton three times a day. Review of the MAR, dated 2/16/11 through 3/15/11, showed diabetic supplement twice daily on all days, including 2/26/11 through 3/15/11. The facility failed to provide the resident the diabetic supplement three times daily as ordered by the resident's physician. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/05/11, showed the following: -Sometimes understands; -Severely impaired cognitive skills for daily decision making; -Other behavioral symptoms not directed toward others occurred daily; -Total assist of two plus person ' s physical assist with bed mobility, dressing and toilet use; -Resident at risk for developing pressure ulcers; -Has one stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue with shiny, moist, granular appearance) and eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) may be present on some parts of the wound bed. Often includes undermining and tunneling), measured 5.0 cm X 1.5 cm x 2.0 cm. -One unstageable pressure ulcer due to coverage of wound bed by slough and /or eschar; -The most severe tissue type for any pressure ulcer was necrotic tissue; -Pressure ulcers were present on the prior assessment; -Turning/repositioning program. Review of the resident's care plan, dated 3/12/11, showed the following: -Nutritional compromise, potentially related to increased nutritional needs associated with healing process and potentially related to pressure ulcer, low back; -Improve dietary intake to meet his/her nutritional needs and enhance his/her well-being; -Adjust nutritional plan as needed; -Hollers out and resistive to care; -Leave alone and try again later; -Increased risk for impaired skin integrity related to diabetes; -The resident will maintain or improve skin condition; -Inspect feet daily; -Stage IV actual pressure ulcer. At increased risk for pressure areas, potentially related to his/her limited mobility; -Star rounds; -Assess for registered dietitian referral; -Head to toe skin assessment, checking pressure areas with hygiene care; -Provide positioning devices to prevent skin to skin contact and offload bony prominences; -Provide proper repositioning to avoid prolonged time to points of pressure. Review of the Braden scale (tool used for predicting pressure sore risk), dated 3/05/11, showed the following: -Score 14, which indicated moderate risk for skin breakdown; -Bedfast; -Requires moderate to maximum assist in moving; -Frequently slides down in bed or chair; -Requires frequent repositioning with maximum assist; -Mobility is very limited and makes occasionally slight changes in body or extremities position but unable to make frequent or significant changes independently. Observation on 3/14/11 showed the following: -At 3:40 P.M., the resident was positioned on his/her right side in bed, with heel protectors on and nothing positioned in between thighs/knees; -At 6:45 P.M., the resident's family member had elevated the resident's head of bed and fed the resident, the resident was still positioned on his/her right side, nothing positioned between resident's knees and thighs; -At 7:00 P.M., the resident lowered the resident's bed, the resident's position remained unchanged, the resident's family member said the staff usually reposition the resident after he/she eats but staff had not been in to reposition the resident since he/she had been there; -At 7:30 P.M., the resident remained positioned on his/her right side, position remained unchanged, thighs and knees remained skin to skin. Staff failed to reposition the resident for at least three hours and fifty minutes. Observation on 3/15/11 showed the following: -At 9:30 A.M., the resident was positioned on his/her right side in bed; -From 9:30 A.M. until 11:15 A.M., the resident remained positioned on his/her right side. The resident's position remained unchanged; -At 11:15 A.M., the wound care nurse changed the dressing on the stage IV pressure area on the resident ' s coccyx, the area measured 4 cm x 2 cm x 2 cm. Staff did not reposition the resident; -At 12:10 P.M., the resident remained on his/her right side, his/her position remained unchanged. Staff failed to reposition the resident for at least two hours and forty minutes. During interview on 3/15/11 at 11:30 A.M., the wound care nurse said his/her job duties were to complete the Braden scale (one of the tools recommended to assess the risk of developing a pressure ulcer), measure and document on all wounds once a week, recommend treatment for [REDACTED]. He/she educated all staff on repositioning the resident every two hours. During interview on 3/15/11 at 2:15 P.M., the wound care nurse said he/she considers the resident at high risk for developing pressure ulcers. He/she codes all wounds on the MDS. He/she said on 12/16/10, the resident had four unstageable areas on his/her heels and the areas had healed by 1/26/11. He/she said the resident also had one Stage I pressure area on his/her right outer foot that healed on 1/10/11. He/she said the physician was not notified of the wounds on the resident's heels. Observation and interview on 3/15/11 at 2:40 P.M. showed the wound care nurse removed the resident's heel protectors and assessed the resident's heels. The resident was found to have an unstageable area with eschar on the resident's left heel that measured .8 cm x .8 cm and an unstageable area with eschar on his/her right heel that measured 2.5 cm x 2 cm. The wound care nurse did not have knowledge of these areas on the resident's heels. He/she said the resident had wounds in December, 2010, which had healed and no one had reported any new wounds on the resident ' s heels. During interview on 3/15/11 at 4:10 P.M., the wound care nurse said charge nurses complete whole body skin assessments weekly and the nurse is to follow through by contacting the doctor, family and receiving orders for treatment. During telephone interview on 3/17/11 at 8:20 A.M., LPN S said when completing a skin assessment he/she does a head to toe assessment of the skin if the resident will allow him/her to do this. Resident #4 is sometimes difficult to do. He/she was unable to remove the resident's boots and complete a skin assessment of the resident's feet on 3/06/11 due to the resident not cooperating. He/she was unable to complete a skin assessment on 3/13/11 due to the resident "throwing a fit." He/she usually lets the oncoming nurse know if a skin assessment was not done. He/she should document when the resident refused the skin assessment but he/she had been side tracked and did not document the resident refused. LPN S was not aware of any areas on the resident's heels. Review of nurse's note date 3/15/11 at 5:00 P.M., showed the following: -An area of eschar noted to left heel, measuring 0.8 cm X 0.8 cm; -An area of eschar noted to right heel, measuring 2.5 cm X 2 cm; -Physician notified by fax and orders requested; -Family member aware. Review of Physician Order Sheet, dated 3/16/11 through 4/15/11, showed an order dated 3/15/11 for Sureprep (protective barrier wipe) to bilateral heels daily until resolved. Review of nurse's note dated 3/17/11 at 3:45 A.M., showed the resident's heels floated and turned and repositioned every two hours. During interview on 3/17/11 at 7:30 A.M., LPN P said the nurse aides put the resident heel protectors on. Staff are to take the heel protectors off twice a shift and check the resident's skin. He/she said there is not always an order for [REDACTED]. During interview on 3/17/11 at 7:45 A.M., Certified Nurse Assistant (CNA) Q said the heel protectors were on the resident at all times and they were only taken off during whirlpools which were scheduled twice a week. During telephone interview on 3/17/11 at 8:05 A.M., CNA R said the resident received a whirlpool sometime in the morning on 3/14/11. He/she had seen some spots on the resident's heels that had been on the resident's heels off and on for a long time. The areas looked like they were trying to heal. The areas were brown in color with rough dry skin. This is why the resident had heel protectors on and they were only to be removed during whirlpools. He/she had remembered reporting the areas on the resident's heels to the wound care nurse in the past but doesn't remember when. He/she does not remember if he/she filled out shower sheet. During interview on 3/17/11 at 9:10 A.M., CNA K said he/she had reported to the wound care nurse in February, 2011, a big black scab had come off of the resident's left heel during whirlpool. CNA K said the right heel had a black scab that appeared to be flaking off. He/she said the wound care nurse did look at the resident's heels and said they looked fine. He/she said only new areas on the resident's skin are documented on the shower sheets and these areas on the resident's heels were not new. During a telephone interview on 3/31/11 at 12:25 P.M., the wound care nurse said he/she was unable to locate documentation of the unstageable pressure ulcer identified on the 3/05/11 MDS. He/she was unsure if the resident had an unstageable pressure ulcer at the time of the assessment and may have made an error on the MDS. During interview on 3/17/11 at 11:00 A.M., the director of nursing (DON) said the following: -She would not consider areas with scabs to be healed; -Nurses need to complete full body assessments weekly and nurse assistants are to look at the resident's body during showers and document findings on the shower sheets; -When residents come back from the hospital with wounds, the nurse that finds the wounds calls the physician; -The nurses are to keep the resident's heels floated at all times and they do not have order for boots because they will no longer be used on the resident. During a telephone interview on 3/31/11 at 12:30 P.M., the DON said he/she would expect staff to notify the physician of unstageable pressure areas. 6. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/19/11, showed the following staff assessment of the resident: -Totally dependent on two plus staff members for bed mobility, transfer, and toilet use; -Always incontinent of bowel and bladder; -Resident had a Stage I or greater, a scar over a bony prominence, or a non-removable dressing/device; -At risk of developing pressure ulcers; -Turning/repositioning program. Review of the resident's care plan, dated 1/19/11, showed the following problems and approaches: -Total care with activities of daily living (ADL); -Provide total care for turning; -Turn and reposition during incontinence care; -Turn and reposition every two hours; -At risk for skin integrity; -Incontinent, STAR (Set Time Action Rounds) Review of the resident's most recent Braden scale (assesses the patient's level of risk for development of pressure ulcers), dated 1/19/11, showed the resident's score was nine, indicating he/she was at high risk for developing pressure ulcers. Observation on 3/14/11 showed the following: -Resident #2 lay on his/her bed; -At 3:25 P.M., CNA G and NA F provide peri-care (perineal) for the resident; -When staff completed the peri-care they positioned the resident on his/her left side; -At 4:00 P.M., the resident remained in bed on his/her left side; -From 4:00 P.M. to 5:00 P.M., the resident remained in the same position; -From 5:00 P.M. to 6:30 P.M., the resident remained in bed positioned on his/her left side; -At 6:30 P.M., CNA G and CNA I provided peri-care for the resident; -The resident remained positioned on his/her left side for a total of three hours and five minutes. During telephone interview on 3/22/11 at 8:25 P.M., CNA I said the following: -Resident #2 should be repositioned every one and one half to two hours; -The resident is on STAR rounds at 2:00 P.M., 4:00 P.M., 6:00 P.M. and 8:00 P.M.; -Staff provided peri-care and reposition the resident during STAR rounds. During telephone interview on 3/23/11 at 11:30 A.M., CNA G said staff reposition residents every 30 minutes to one hour.