Every finding on record at Beth Haven Nursing Home

Based on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment by not maintaining the indoor air temperatures of resident rooms in the facility between 71.0 F. (degrees Fahrenheit) and 81.0 F. for 19 sampled residents on the east wing of the facility (Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #18, #19, #20, #21, #22 and #23) with room temperatures ranging from 82.0 degrees Fahrenheit ( F.) to 90 F. The facility failed to have a comprehensive monitoring system including documentation of resident room temperatures and each resident's condition. The facility census was 69.The Administrator was notified on 6/23/25 at 5:15 P.M., of the Immediate Jeopardy (IJ) which began on 6/23/25. The IJ was removed on 6/24/25, as confirmed by surveyor onsite verification. Review of the facility's undated, Emergency Cooling Plan for the Facility showed the following:-A portable air unit will be installed in each occupied resident room on the East Unit, one portable air unit will be installed in the East Unit dining room, and one portable unit will be installed in the office area at the entrance of the East Unit;-Temperatures will be monitored and recorded by staff hourly in the resident rooms on the East Unit, the resident core area and resident dining room on the East Unit to ensure areas are between 71.0 F. and 81.0 F.;-If temperatures rise to 81.0 F staff will contact the administrator, Director of Nursing (DON), and the maintenance supervisor immediately and residents will be moved to the [NAME] Core and Dining areas temporarily while other emergency cooling measures are implemented.1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/29/25, showed the following:-The resident was cognitively intact;-The resident had diagnoses that included medically complex conditions, diabetes (a condition that occurs when your blood sugar is too high), congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should and can cause shortness of breath with exertion), kidney failure, and coronary artery disease;-The resident required partial to moderate assistance from staff for transfers;-The resident used a wheelchair for ambulation.During an interview on 6/23/25 at 1:59 P.M., the resident said the following:-The air conditioning in the facility did not work;-Staff brought a portable unit to his/her room, but he/she did not remember when it was placed in the room;-As long as he/she sat fairly close to the air conditioning unit he/she was comfortable;-The portable air conditioning unit worked just ok.Observation on 6/23/25 at 1:59 P.M., showed the resident sat in his/her wheelchair in his/her room. The temperature in the resident's room was 88 F., taken with a dial stem thermometer, with a portable air conditioner in the room running and set at 72 F. Observation on 6/23/25 at 3:56 P.M., showed the following:-The resident sat in the common area watching television;-The common area temperature was 84 F., taken with a dial stem thermometer. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included CHF and diabetes;-The resident was dependent on staff for transfers;-The resident used a wheelchair for ambulation.During an interview on 6/23/25 at 1:42 P.M., the resident said the following:-He/She had a portable air conditioner in his/her room, but still got hot later in the day;-If staff left his/her door open it made the temperature rise in his/her room and staff did not always keep the door closed;-He/She was not able to get up on his/her own. Staff used a mechanical lift to get him/her out of bed;-He/She would prefer the temperature to be 72 F;-Staff had not offered to move the resident to another room.Observation on 6/23/25 at 1:42 P.M., showed the following:-The resident was in bed with no blanket or sheet on;-The resident's room had a portable air conditioner running with the temperature set at 73 F.;-The resident's room temperature was 78 F., taken with a dial stem thermometer. 3. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/13/25, showed the following:-The resident was cognitively intact;-The resident had diagnoses that included CHF, kidney failure, diabetes, dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning), and respiratory failure.During an interview on 6/23/25 at 1:24 P.M., Resident #9 said the following:-His/Her portable air conditioner said 61 F but it did not feel 61 F;-It took a lot to cool him/her down, he/she was hot natured;-He/She used a wheelchair and could not always get his/her room door shut when leaving the room and it caused his/her room to get hot;-Staff had not offered to move the resident to another room.Observation on 6/23/25 at 1:24 P.M., showed Resident #9's room was 80 F., taken with a dial stem thermometer. 4. Observation on 6/23/25 at 1:53 P.M., showed the following:-The east hallway for resident rooms 20-29 was 84 F., taken with a dial stem thermometer; -room [ROOM NUMBER] was the only unoccupied room on this hallway;-Two residents propelled their wheelchairs in the hallway; -A 30 (inch) pedestal fan blew air in the hallway.5. Observation on 6/23/25 at 1:57 P.M., showed the East Wing hallway for resident rooms 30-39 was 90 F., taken with a dial stem thermometer (no residents were present). Rooms 30, 31, 34, 35, 38, and 39 were occupied. 6. During an interview on 6/23/25 at 5:40 P.M., Resident #10 said his/her room was hot and uncomfortable.Observation on 6/23/25 at 5:40 P.M., showed the temperature in the resident's was 88 F., taken with a dial stem thermometer.7. Observation on 6/23/25 at 5:47 P.M., showed Resident #14's room temperature was 92 F., taken with a dial stem thermometer. 8. Observation on 6/23/25 at 5:58 P.M., showed Resident #6's room temperature was 80 F. taken with a dial stem thermometer. The resident was in bed asleep with a fan blowing on him/her9. Review of Resident #19's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included cancer, stroke, and medically complex conditions.During an interview on 6/23/25 at 6:08 P.M., Resident #19 said the following: -His/Her room, had been warm;-He/She would like to move to a room that was not as warm;-Staff had not offered to move the resident to another room. Observation on 6/23/25 at 6:08 P.M., showed the resident's room had two fans that blew air, the portable air conditioning unit was running and set at 61 F.; the room temperature was 80 F., taken with a dial stem thermometer.10. Review of Resident #20's admission MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included medically complex conditions, seizure disorder, atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm that can lead to blood clots and increases the risk of stroke, heart failure and other heart-related complications), and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems).Observation of the common area on 6/23/25 at 6:10 P.M., on the East Wing showed the following:-A large portable air conditioning unit vented into the ceiling;-Four residents were in the common area;-The common area temperature was 84 F., taken with a dial stem thermometer.During an interview on 6/23/25 at 6:11 P.M., Resident #20 said the following:-He/She slept in a recliner in the common area;-He/She got sweaty during the night, because it was so hot in the common area. 11. Observation on 6/23/25 at 6:13 P.M., showed the East Wing dining room had a portable air conditioner, that was running and vented into the ceiling. The temperature in the dining room was 88 F. taken with a dial stem thermometer. No residents were in the dining room at the time.12. Review of Resident #21's quarterly MDS, dated [DATE], showed the following:-The resident's cognition was moderately impaired;-The resident had diagnoses that included medically complex conditions and a need for assistance with personal care;-The resident understood others and could make himself/herself understood to others.During an interview on 6/23/25 at 6:17 P.M., Resident #21 said the following:-He/She had bladder cancer and needed to stay hydrated;-If he/she asked for water from most of the certified nurse aides (CNAs), they only brought a small Styrofoam cup of water.Observation on 6/23/25 at 6:17 P.M., showed the resident in his/her room, in bed with no blanket or sheet covering his/her body. A portable air conditioner unit was running and set at 72 F. The room temperature was 80 F., taken with a dial stem thermometer. 13. During an interview on 6/23/25 at 6:25 P.M., Resident #15 said the following:-He/She arrived at the facility today;-The resident asked his/her family member to bring a fan, because his/her room, was hot; -He/She was uncomfortable and sweaty in his/her room.Observation on 6/23/25 at 6:25 P.M., of Resident #15 and his/her room showed the resident sat on the side of his/her bed and the room temperature was 90 F., taken with a dial stem thermometer. 14. Observation on 6/23/25 at 6:31 P.M., showed Resident #16 and Resident #17's room, was 88 F., taken with a dial stem thermometer. 15. During an interview on 6/23/25 at 6:33 P.M., Resident #22 said the following:-He/She was terrible, it was hot in his/her room, -His/Her family member brought in a fan, because it was hot in his/her room;-If he/she just laid on the bed and did not move around, he/she was okay;-He/She would move to another room if it was cooler.Observation on 6/23/25 at 6:33 P.M., of Resident #22 and his/her room showed the following:-The resident was on his/her back in bed watching television;-The resident had a 24 fan blowing on him/her;-The room temperature was 86 degrees F. taken with a dial stem thermometer.Review of the resident's discharge MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included kidney failure, weakness, stroke and hardening of the arteries after a coronary artery bypass graft (CABG- a procedure to treat a blockage or narrowing of one or more of the coronary arteries).16. Observation on 6/23/25 at 6:38 P.M. of unoccupied room [ROOM NUMBER], showed the temperature was 92 F. taken with a dial stem thermometer. A portable air conditioner in the room was running and set on 62 F. Observation on 6/23/25 at 6:40 P.M. of unoccupied room [ROOM NUMBER], showed the temperature was 90 F. taken with a dial stem thermometer. A portable air conditioner in the room was running and set on 65 F. 17. During an interview on 6/23/25 at 6:41 P.M., Resident #11 said the following:-He/She was hot;-He/She kicked the blanket and sheet off to the floor and did not want them on the bed;-He/She would move to cooler room if he/she could.Observation on 6/23/25 at 6:41 P.M., of Resident #11 and his/her room showed the following:-The resident lay on his/her bed with no blankets or sheet and wore only an incontinent brief;-The resident's blanket and sheet were on the floor;-The resident's room was 90 F., taken with a dial stem thermometer.18. Review of Resident #3's admission MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included diabetes and medically complex conditions.During an interview on 6/23/25 at 6:52 P.M., Resident #3 said the following:-The resident only had a sheet covering him/her because he/she just finished eating supper; -It was hot in his/her room and it was going to get hotter;-He/She really suffered from the heat, sometimes it made him/her nauseated;-It was ridiculous it was so hot in his/her room.Observation on 6/23/25 at 6:52 P.M., of Resident #3 and his/her room showed the following:-The resident lay in bed with a sheet covering him/her up to his/her waist;-The temperature in the resident's room was 89 F. taken with a dial stem thermometer;-A portable air conditioning unit was in the room running and set on 61 F. 19. Review of Resident #18's admission MDS, dated [DATE], showed the following:-The resident's cognition was moderately impaired;-The resident had diagnoses that included traumatic brain injury, coronary artery disease, arthritis, hemiparesis (weakness of one entire side of the body), and a need for assistance with personal care. During an interview on 6/23/25 at 7:00 P.M., Resident #18 said the following:-It was hot in his/her room;-He/She was hot and sweaty.Observation on 6/23/25 at 7:00 P.M., of the resident and his/her room showed the following:-The resident lay in bed with a small fan clamped to the bed rail blowing air on the resident's face;-The resident's room temperature was 92 F;-A portable air conditioning unit in the room was running and set on 70 F. 20. Review of weatherunderground.com showed the high temperature for 6/23/25 was 93 F. with a heat index of 98 F.21. During an interview on 6/30/25 at 4:30 P.M. Certified Medication Technician (CMT) E said the following:-On June 21st and June 22nd it was very hot on the east wing in the resident rooms, the dining room, common area, and hallways;-He/She did not use a thermometer to monitor the resident room temperatures, or any other area of the east wing;-Residents were uncomfortable during that weekend. During an interview on 6/23/25 at 12:43 P.M., the Director of Nursing (DON) said the following:-She was not sure when the air conditioning went out on the East wing;-There were portable air conditioning units in each occupied resident room on the East wing;-Staff had not monitored residents more frequently or monitored room temperatures since the air conditioning unit went out on the East wing;-She never saw anything in the emergency preparedness binder that related to a heat plan;-The residents on the East wing continued to use the East wing dining room since the air conditioner went out.During interviews on 6/23/25 at 12:43 P.M., 2:48 P.M., 4:10 P.M., and 6/30/25 at 1:42 P.M., the Administrator said the following:-The facility's air conditioner went down on the East unit the week of 6/3/25;-Portable air conditioners were installed in all occupied resident rooms after the facility air conditioner went out; -Staff had not monitored residents or resident room temperatures since the facility air conditioner on the East wing of the facility went out. The maintenance staff installed portable air conditioning units in their rooms;-Staff usually passed water two times a day. Staff had not been directed to pass water to the residents on the East wing more than twice a day since the facility air conditioner went out; -She had an emergency cooling plan for the facility that was drafted in 2022 specific to the East wing of the facility when the facility had air conditioning problems that was kept in her office;-The staff had not followed the emergency plan to monitor temperatures hourly in resident rooms, core areas, and the dining room;-The staff had not followed the emergency plan to assess residents as appropriate in order to help determine safe room temperatures;-She was responsible for the emergency preparedness policies and keeping the binders up to date;-She did not feel she needed to have a detailed plan in the emergency preparedness binder at the nurse's station because she would expect staff to call her and she would give them instructions;-She did not expect nursing staff to implement a full emergency plan;-It should be general nursing knowledge to monitor residents in the summer for dehydration and excessive heat;-She expected staff to offer fluids throughout the day during the summer and when there was excessive heat.During an interview on 6/30/25 at 2:32 P.M., the Medical Director said the following:-He was aware the air conditioning was broken and there were portable air conditioning units in each resident room;-He would expect staff to monitor residents for excessive heat;-If the facility had a policy but it was not followed, it did not do anyone any good.NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious 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 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 violation(s). MO256298

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, was free from verbal abuse when Licensed Practical Nurse (LPN) A, after denying to get the resident a cup of coffee when he/she requested one, proceeded to pursue the resident to another wing of the facility, yelled loudly he/she already told the resident the resident could not have a cup of coffee, and LPN A meant it in a demeaning manner at the resident while pointing his/her finger at the resident's face. Witnesses reported the resident had a surprised look on his/her face and asked what he/she had done wrong. The facility investigation showed when interviewed, Resident #1 confirmed LPN A had treated him/her very nasty, pointed his/her finger in the resident's face, and felt like LPN A dismissed him/her like a dog over a cup of coffee. The facility census was 64. The administrator was notified of the past noncompliance on 06/05/25, which occurred on 05/28/25. On 05/28/25, the Director of Nursing (DON) suspended the alleged perpetrator (AP) for the allegation of staff to resident abuse. In-servicing of staff on abuse began and the facility began their investigation into the allegation. In-servicing was completed on 06/01/25. As a result of the facility investigation, the facility determined the AP's actions did constitute staff to resident abuse and the AP was terminated on 06/02/25. This deficiency was corrected on 06/01/25. Review of the facility policy, dated 2001, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, showed the following: -Residents have the right to be free from abuse. This includes but is not limited to freedom from verbal abuse; -Protect residents from abuse by anyone, including, but not necessarily limited to facility staff; -Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems; -The policy did not include a definition of verbal abuse. 1. Review of Resident #1's undated medical diagnosis sheet, showed his/her diagnoses included nonrheumatic aortic valve stenosis (a heart condition, involving the valve between the lower left heart chamber and the body's main artery) , muscle weakness, and falls. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 05/02/25, showed the following: -Hearing: minimal difficulty; -No hearing aids; -Makes self understood; -Understands, clear comprehension; -Adequate vision; -Cognitively intact; -No behaviors or rejection of cares; -It was very important to the resident to make choices regarding snacks/food; -Independent for mobility. Review of the resident's care plan, dated 05/13/25, showed the following: -Assist the resident when he/she asked for help with activities of daily living (ADL's); -Ensure the resident's needs were met such as hunger, thirst, and socialization. During an interview on 06/04/25 at 11:15 A.M., the resident said the following: -He/She enjoyed a cup of coffee throughout the day and in the evenings; -He/She asked LPN A for a cup of coffee, and LPN A said he/she would not make a cup of coffee just for the resident; -He/She went to another area of the facility to get a cup of coffee; -Another nurse came over and asked him/her why he/she was there (on the west wing), and he/she said he/she had friends there who would make him/her some coffee; -LPN A came over and told him/her to not ever do that again; there was a coffee station on the resident's wing; -He/She was a very obedient person and LPN A spoke very loudly. 2. Review of an undated facility investigation, Summary of Investigation, showed the Director of Nurses (DON) documented the following: -On 05/30/25 (DON clarified that this date was typed in error, actual date was 05/28/25) at 07:44 P.M., it was reported by telephone to her by night shift staff that LPN A yelled at Resident #1 in the facility's core area; -She arrived at the facility and suspended LPN A pending an investigation; -She interviewed Resident #1, and the resident confirmed LPN A had treated him/her very nasty, pointed his/her finger in the resident's face, and dismissed the resident like a dog over a cup of coffee; -An investigation was started; -An in-service was started on verbal abuse for all facility staff; -LPN A was terminated on 06/02/25. 3. Review of a facility statement, dated 05/28/25, showed CNA B wrote the following: -He/She stood at the desk on the west side; -LPN A came over from the east side yelling, Where is Resident #1 at?; -LPN A walked over to the resident and was within inches of the resident's face; -LPN A, with his/her finger pointed at the resident's face, yelled at the resident and told the resident he/she could not have coffee and the resident was going to listen to LPN A; -LPN A returned to the east side of the building. During an interview on 06/03/25 at 05:20 P.M., CNA B said the following: -He/She worked on the west wing of the facility on the evening of 05/28/25; -The resident resided on the east wing of the facility but came over to the west wing to get a cup of coffee; -Graduate Practical Nurse (GPN) D gave the resident a cup of coffee and the resident sat down at a table across from the west wing nurses station; -CNA B heard LPN A's voice before he/she saw LPN A; -LPN A said, Where is Resident #1 at? multiple times, in a loud voice, and LNP A sounded angry; -LPN A saw the resident at the table and LPN A put his/her face very close to the resident's face, within 12 inches; -LPN A pointed his/her finger at the resident's face; -LPN A told the resident he/she could not have coffee, and that LPN A meant it; -The resident looked surprised and just sat there; -LPN A left the west wing and went back to the east wing; -The resident said he/she did not know what he/she had done wrong; -CNA B and CNA C went outside of the facility and called the DON; -LPN A should not have spoken to the resident that way; and he/she considered it verbal abuse of the resident. 4. Review of a facility statement, dated 05/28/25, showed CNA C wrote the following: -LPN A stomped over to the west side and screamed, Where is Resident #1 at?; -LPN A marched over to where the resident sat, and got in the resident's face; -LPN A pointed his/her finger at the resident and yelled that the resident was going to listen to LPN A when he/she said no; -LPN A said he/she meant it, and that did not mean the resident could go and ask other people, and he/she was sick of it; -LPN A turned around and marched back to the other side. During an interview on 06/10/25 at 10:54 A.M., CNA C said the following: -He/She worked on the west wing on the evening of 05/28/25; -The resident sat at a table across from the west wing nurses station; -He/She heard LPN A screaming Where is Resident #1, where is Resident #1!? before CNA C saw LPN A; -LPN A marched over to the resident, pointed his/her finger within inches of the resident's face, and yelled at the resident. LPN A said he/she told the resident no, and the resident should not go and ask other people when LPN A told the resident no; -LPN A returned to the east wing; -The resident had a surprised look on his/her face and asked what he/she had done wrong; -CNA C had never heard a staff person yell at a resident like that; that was probably the worst he/she had ever seen; -Yelling at a resident, or refusing a need, was a form of abuse. 5. Review of a facility statement, dated 05/28/25, showed GPN D said the following: -He/She asked LPN A why he/she did not give Resident #1 a cup of coffee when the resident asked for one; -LPN A told GPN D the resident could not have any coffee and he/she had already told the resident no; -GPN D got the resident a cup of coffee. During an interview on 06/10/25 at 03:00 P.M., GPN D said the following: -He/She worked on the west wing of the facility on the evening of 05/28/25; -Resident #1 resided on the east wing of the facility; -The resident came over to the west wing nurses station and begged the staff for a cup of coffee; -The resident said the other nurse would not make him/her a cup of coffee when the resident asked for one; -GPN D went to the east wing to ask the staff why the resident could not have a cup of coffee; -LPN A immediately turned from the medication cart and said, no, the resident was not going to get a fucking cup of coffee, the resident had already asked and been told no, and the resident had already caused a commotion; -GPN D asked again why the resident could not have a cup of coffee, but LPN A did not respond and only said he/she had already told the resident no; -GPN D left the east wing and got a cup of coffee for the resident from another area in the facility; -When GPN D returned to the west wing nurses station, CNA B and CNA C reported LPN A came over from the east wing, found the resident at the table, and yelled at the resident and told him/her that he/she (LPN A) had already told the resident he/she could not have coffee; -Yelling at a resident, or refusing a request or need, would be considered abuse. 6. During an interview on 06/03/25 at 03:55 P.M., the DON said the following: -She received a phone call on 05/28/25 around 07:44 P.M. from CNA C who said that LPN A had yelled at Resident #1 while the resident sat at a table across from the west wing nurses station; -The resident walked to the west wing to get a cup of coffee and told the west wing staff that LPN A had refused to get a cup of coffee when the resident asked for one; -CNA C said LPN A stomped over to the west wing and said, Where is Resident #1 at? multiple times; -CNA C said LPN A saw the resident at the table and laid into him/her (the resident); -CNA C said LPN A had his/her finger in the resident's face and said, LPN A told the resident no!; -CNA C said he/she had never heard a staff person yell at a resident like that; -LPN A went back to the east wing; -GPN D asked LPN A why he/she did not get the resident a cup of coffee when the resident asked for one; -LPN A said he/she had already told the resident no, but did not give any other explanation; -The resident told her that LPN A was very, very nasty to him/her when he/she asked for a cup of coffee; -The resident said LPN A would not make a cup of coffee just for him/her; -The resident walked to the other wing and asked the staff there to make him/her a cup of coffee and they did; -The resident said he/she really got a lashing from LPN A, LPN A did not like it when the resident asked the other staff to get the cup of coffee; -The resident said it hurt his/her feelings when LPN A spoke that way to him/her; -LPN A should have accommodated the resident's request for a cup of coffee and should not have spoken to the resident in that way; -She would consider how LPN A spoke to the resident as verbal abuse. During an interview on 06/04/25 at 2:50 P.M., the administrator said the following: -She was made aware that LPN A yelled at Resident #1 on 05/28/25 and she came into the facility; -LPN A was suspended during the investigation, then terminated on 06/02/25; -Yelling at a resident was a form of abuse. MO00254942

Refer to Y0CV12. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 02/06/25. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7) in a review of 15 sampled residents, had a proper fitting wheelchair that did not cause him/her pain. The census was 65. Review of the facility policy, Accommodation of Needs, last revised March 2021, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being; -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis; -In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include: providing a variety of types (for example, chairs with and without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position; -In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example, arranging personal items so that they are in easy reach of the resident. Review of Resident #7's care plan, last revised 11/18/24, showed the following: -The resident wished to be physically comfortable while maintaining a sense of control; -He/She had a decline in activities of daily living (ADL) performance and mobility status related to diagnosis of multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord); -The resident will maintain highest level of functioning within limits of progressive multiple sclerosis (MS). He/She will remain free of complications or discomfort related to MS. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 01/10/25, showed the following: -Cognitively intact; -Dependent on staff for transfers; -Used a manual wheelchair. Review of the resident's Physician's Orders, dated 03/03/25, showed physical therapy and occupational therapy evaluation for fitting new wheelchair. Review of the resident's Social Services Progress Notes, dated 03/05/25 at 3:44 P.M., showed Social Services spoke with outpatient therapy this afternoon who said a message was left for the Director of Nursing (DON) at some point saying the resident would not be able to receive outpatient therapy for a new wheelchair because one of the occupational therapy requirements for a new wheelchair was the resident could not be in a nursing home. At this time, the resident must wait until this facility was able to offer in house therapy before proceeding with getting a new wheelchair. (There was no documentation to show an alternate plan was made to ensure the resident had a comfortable wheelchair.) Observation on 04/10/25 at 1:40 P.M., showed the resident in bed. The resident's wheelchair sat in front of his/her dresser. During a telephone interview on 04/15/25 at 4:23 P.M., the resident said the following: -The only wheelchair he/she had to use was in his/her room last week; -The wheelchair was too small; he/she had ordered and paid for it with his/her own money when he/she came to the facility; -He/She did not know what he/she was doing when he/she ordered the wheelchair; it was too short and it hurt terrible to sit in the wheelchair; -After 02/06/25, the facility gave him/her a cushion for the wheelchair and he/she tried it; the cushion made it worse because the wheelchair was too small and the cushion made it too high so his/her discomfort was worse, instead of better; -He/She has not been evaluated for a wheelchair, or been given a different wheelchair to see if it would help with his/her discomfort; -He/She would like a wheelchair to sit in that did not cause him/her so much discomfort; -He/She had told the DON and the Social Services Director (SSD) about his/her chair being uncomfortable after the last survey; -The resident said with his/her MS diagnosis, when he/she sat, one hip was higher than the other and that caused pressure/discomfort and when you added the chair that was not the correct size, he/she experienced additional discomfort/pressure. During an interview on 04/10/25 at 4:45 P.M., the SSD said she had not made an appointment for the resident for an occupational therapy evaluation at this time. She made calls on 04/09/25, but did not successfully schedule an appointment. During an interview on 04/10/25 at 11:37 A.M. and 2:15 P.M., the DON said the following: -The resident should have a proper fitting wheelchair that did not cause pain; -The facility was responsible for ensuring residents had proper equipment, including wheelchairs; -The SSD was responsible to ensure the resident had an appointment to be evaluated for a properly fitting or possibly a custom wheel chair; -She gave the resident a Roho (brand of cushion for wheelchairs with air filled pockets for pressure relief) and the resident said it was helping some at first; -She went and asked the resident about the cushion and the resident said after he/she used it for a while it was hurting him/her more so he/she had the staff remove it; -She became aware of the resident's concern of his/her chair being uncomfortable during the last survey.

Refer to Y0CV12. Based on interview and record review, the facility failed to ensure residents received physical, occupational, and speech therapy services under an arrangement agreed upon by both the facility and the provider of outpatient therapy services. This failure resulted in lack of communication between the facility and the provider, lack of coordination of care with agreed upon goals, lack of communication to ensure residents had their at home programs implemented at the facility, and failed to ensure residents could toilet and have basic assistance while at therapy for two residents (Resident's #400 and #402) in a review of two residents receiving outpatient therapy services. The facility census was 65.

Based on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Residents #43, #66, and #5 and #175), and during medication pass for one resident (Resident #25), in a review of 18 sampled residents. The facility failed to ensure three different staff properly performed infection control procedures when they did not clean the tips of insulin pens prior to applying a needle cap and administering insulin to three residents (Residents #22, #20 and #4). The facility failed to complete, or have documentation of, a two step, or prior two step Tuberculin Skin Tests (TST) as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing), failed to complete annual TB testing as required and failed to document the results of that testing in the appropriate millimeters (mm) for eight of ten sampled employees before compensation. The facility failed to develop specific control parameters for addressing Legionella (a bacterium that can cause a serious type of pneumonia in persons at risk), based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment. The facility did not have an active water management team, detailed water flow map, and did not implement the facility's Legionnaire Disease (severe pneumonia like infection caused by contaminated water) policy that instructed staff how to monitor residents for Legionnaire's disease. The facility census was 71. Review of the facility's policy, Handwashing/Hand Hygiene, dated 2001 and revised August 2019, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before preparing or handling medications; before performing any non-surgical invasive procedures; before and after handling an invasive device (e.g., urinary catheters, IV access sites); before donning sterile gloves; before handling clean or soiled dressing, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution settings; before and after eating or handling food; before and after assisting a resident with meals and after personal use of the toilet or conducting your own personal hygiene; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility policy, Personal Protective Equipment - Using Gloves, dated 2001 and revised July 2009, showed the following: -Gloves must be worn when handling blood body fluids, secretions, excretions, mucous membranes and /or non-intact skin; -Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed; -The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin [NAME] performing the procedure; when the employee has any cuts, wounds or scrapes on his or her hands; when the employee's hands are chapped or have a skin rash or skin condition; when handling soiled linen or items that may be contaminated; during instrumental examination of oropharynx, gastrointestinal tract and genitourinary tract; when examining abraded or non-intact skin or patients with active bleeding; during invasive procedures and during all cleaning of blood, body fluids and decontaminating procedures; -Wash your hands after removing gloves; -Remove gloves before removing the mask and gown and discard them into the designated waste receptacle inside the room. 1. Review of Resident #43's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/6/24, showed the following: -Required moderate assistance of staff for personal hygiene and dressing; -Resident was dependent on staff for toileting; -Occasionally incontinent of bowel and bladder. Review of the resident's undated care plan showed the following: -He/She had impaired activities of daily living (ADL) performance related to dementia; -He/She was incontinent of bowel and bladder; -Help him/her with each incontinence episode. Observation on 2/4/25 at 7:33 A.M. showed the following: -Certified Nurse Assistant (CNA) A entered the resident's room, did not wash his/her hands, put on gloves, retrieved the resident's clothes from the closet and hung them in the bathroom; -CNA A assisted the resident to walk to the bathroom; -CNA A pulled down the resident's pants and soiled incontinence brief and the resident sat on the toilet; -The resident was incontinent of urine and feces; -CNA A removed the resident's pants, socks and slippers and placed them in a plastic bag; -CNA A pulled disposable wipes from the container and wiped feces from the back of the resident's lower left leg; -Without changing his/her gloves, CNA A ran the resident's legs through the leg openings of a clean incontinence brief and pants, changed the resident's shirt, pulled seven disposable wipes from the wipes container, laid them on top of the container, and assisted the resident to stand; -CNA A cleaned the resident's rectal and gluteal crease area with wipes; -Wearing the same gloves, CNA A pulled up the resident's incontinence brief and pants and adjusted the resident's shirt; -CNA A removed his/her gloves, and without washing his/her hands, picked up the resident's hair brush, wet the brush with water and combed the resident's hair, and assisted the resident to the dining room. 2. Review of Resident #46's annual MDS, dated [DATE], showed the following: -Dependent on staff for toileting and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, last reviewed 12/27/24, showed the following: -He/She was at risk for decline in his/her ADLs related to my recent left hip fracture and other comorbid conditions; -He/She needed extensive assistance with toileting; -He/She was occasionally incontinent of bladder. He/She needed assist with toileting. Observation on 2/4/25 at 8:15 A.M., showed the following: -CNA A entered the resident's room, did not wash his/her hands, put on gloves and selected the resident's clothes for the day; -CNA A walked with the resident to the bathroom; -CNA A pulled down the resident's urine-soaked incontinence brief, assisted the resident to sit on the toilet, and removed the soiled incontinence brief; -Wearing the same gloves, CNA A picked up a clean incontinence brief and pants and ran the resident's legs through the leg openings. CNA A changed the resident's shirt, assisted the resident to stand, cleaned the resident's gluteal crease with disposable wipes, pulled up the resident's clean incontinence brief and pants, opened the door to the resident's room and walked with the resident to the dining room. During interview on 2/4/25 at 2:48 P.M., CNA A said staff should change their gloves when going from front to back during peri care. He/She should wash hands between glove changes and when finished with providing care. 3. Review of Resident #5's annual MDS, dated [DATE] showed the following: -Dependent on staff for toileting and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included dementia. Review of the resident's care plan, last revised 1/15/25, showed the following: -Impaired mobility and incontinence; -Change after incontinent episodes. Observation on 2/4/25 at 7:45 A.M. showed the following: -CNA Q entered the resident's room and without washing his/her hands, put on gloves; -CNA Q washed the resident's upper body with a washcloth and then picked up a clean incontinence brief and laid it on the bed; -CNA Q un-taped the resident's urine soiled incontinence brief and pulled it down. He/She washed the resident's front peri-area; -CNA Q wiped feces from the resident's rectum area, pulled the soiled incontinence brief from under the resident, and placed it in the trash; -Without removing his/her gloves, CNA Q touched the resident's hip and back and assisted the resident to roll in bed; -CNA Q removed his/her gloves and exited the room without washing his/her hands. During an interview on 2/4/25 at 1:15 P.M., CNA Q said the following: -He/She should wash his/her hands upon entering the resident's room, when his/her hands were soiled, when changing changes and after providing perineal care; -He/She should change his/her gloves when they were soiled. 4. Review of Resident #175's admission MDS, dated [DATE] showed the following: -Supervision to touch assist with personal hygiene; -Substantial to maximum assist with toileting; -Frequently incontinent of bladder. Review of the resident's care plan, last revised 1/30/25, showed the following: -Incontinent of bladder; -Cleanse skin as needed. Observation on 2/4/25 at 8:06 A.M. showed the following: -CNA R entered the resident's room and without washing his/her hands, put on gloves; -The resident lay in bed on a bed pan; -CNA R removed the urine filled bed pan, emptied it in the bathroom, and then cleaned urine from the resident's buttocks; -Without removing his/her gloves and performing hand hygiene, CNA R applied a gait belt around the resident and assisted the resident to his/her chair; -CNA R removed his/her gloves, and without washing his/her hands, made the resident's bed and exited the room. During an interview on 2/4/25 at 1:25 P.M., CNA R said the following: -He/She should wash before providing care, when he/she changed his/her gloves, after providing care and before exiting the room; -He/She should change gloves when they were soiled. During an interview on 2/6/25 at 11:37 A.M., the Director of Nursing (DON) said the following: -He/She expected staff to wash or sanitize their hands before providing care, when their hands were soiled, and when changing their gloves; -Staff should change their gloves when the gloves were visibly soiled, between tasks, when moving from dirty to clean areas/tasks, and in between residents; -She would not expect staff to touch clean surfaces/items with soiled hands/gloves. 5. Review of the facility's policy, Administering Medications, last revised April 2019, showed staff should follow the facility's established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. 6. Review of Resident #25's Physician Order Sheet (POS), dated February 2025, showed the following: -Amlodipine besylate (a medication used to treat high blood pressure) 10 milligrams (mg) one-half tablet daily; -Coreg (a medication used to treat high blood pressure) 3.125 mg two times daily; -Losartan potassium (a medication used to treat high blood pressure) 50 mg daily; -Meloxicam (a medication used to relieve the symptoms of arthritis) 7.5 mg daily with food; -Myrbetriq (a medication used to treat overactive bladder) 25 mg daily; -Vitamin D (a dietary supplement) 50 micrograms (mcg) daily. Observation on 2/3/25 at 8:10 A.M., showed Licensed Practical Nurse (LPN) B prepared the resident's morning medications for administration. When removing the resident's Myrbetriq from the plastic strip packaging, the tablet fell on to the laptop computer on the medication cart. LPN B put a glove on his/her right hand, picked up the pill and placed the pill in the medication cup with the rest of the resident's morning medications. LPN B administered all the medications to the resident. During interview on 2/4/25 at 2:55 P.M., LPN B said the medication cart should be a clean surface. If a pill dropped on the medication cart, then he/she could pick it up wearing gloves and still administer it to the resident. LPN B said he/she did not clean the laptop computer prior to starting the medication pass. He/She should have destroyed the pill that fell on to the laptop. 7. Review of the facility policy, Insulin Administration, revised September 2014, showed staff was to disinfect the top of the vial with an alcohol wipe. There were no specific instructions for insulin pen use. 8. Review of Resident #4's February 2025 Physician Order Sheets (POS) showed the resident had orders for the following: -Lispro Insulin, six units (U) subcutaneously (subq) (injection to be given in the fatty tissue) three times daily; -Lispro per sliding scale (an amount of medication to be determined based on the blood glucose result), one unit for blood glucose readings of 150 - 199. Review of the manufacturer's instructions for Lispro Insulin (fast-acting insulin to treat diabetes) Pen showed the following: -Step 1: Pull the pen cap straight off; Wipe the rubber seal with an alcohol swab; -Step 3: Select a new needle; Pull off the paper tab from the outer needle shield; -Step 4: Push the capped needle straight onto the pen and twist the needle on until it is tight. Observation on 02/03/25 at 4:38 P.M. showed the following: -Certified Medication Technician (CMT) H removed a Lispro insulin pen and needle cap from the medication cart; -CMT H removed the insulin pen cap, did not clean the tip of the insulin pen with alcohol, and screwed the needle cap on the insulin pen; -CMT H checked the resident's Dexacom Continuous Glucose Monitoring Device (a wearable device that measures blood glucose levels) that showed the resident's blood glucose level was 170; -With bare hands, CMT H cleaned the resident's abdominal injection site with an alcohol pad, placed the insulin pen against the resident's abdomen to begin to administer the resident's ordered insulin; -The Infection Preventionist walked by and stopped CMT H from administering the insulin and instructed him/her to apply gloves. During an interview on 02/03/25 at 4:42 P.M., CMT H said he/she did not know he/she was to clean the tip of the insulin pen prior to applying the needle cap. He/She should always wear gloves when administering insulin. He/She just forgot to apply them. 9. Review of Resident #22's February 2025 POS showed the resident had an order for Humalog 75/25 Insulin, 40 U subq in the evening. Review of the Humalog 75/25 Insulin (mixture of fast-acting and longer-acting insulin to treat diabetes) Pen manufacturer's instructions for use showed the following: -Step 1: Pull the pen cap straight off; Wipe the rubber seal with an alcohol swab; -Step 5: Select a new needle; Pull off the paper tab from the outer needle shield; -Step 6: Push the capped needle straight onto the pen and twist the needle on until it is tight. Observation on 02/03/25 at 4:50 P.M. showed the following: -LPN P removed a Humalog 75/25 insulin pen and needle cap from the medication cart; -LPN P removed the insulin pen cap and without cleaning the tip of the insulin pen with alcohol, screwed the needle cap on the insulin pen; -LPN P then administered the resident his/her ordered insulin. During an interview on 02/03/25 at 5:00 P.M., LPN P said he/she knew to clean the tip of the insulin pen with alcohol before screwing the needle cap on; he/she had just forgotten to do so. 10. Review of Resident #20's February 2025 POS showed the resident had an order for Lispro (fast-acting insulin to treat diabetes) seven U sub three times daily. Observation on 02/03/25 at 5:15 P.M. showed the following: -CMT W removed a Lispro insulin pen and needle cap from the medication cart; -CMT W removed the insulin pen cap and without cleaning the tip of the insulin pen with alcohol, screwed the needle cap on the insulin pen; -CMT W then administered the resident his/her ordered insulin. During an interview on 02/03/25 at 5:20 P.M., CMT W said he/she did not usually clean the tip of the insulin pen prior to applying the needle cap. During an interview on 02/04/25 at 3:05 P.M., the DON said she expected staff to clean the tips of insulin pens with an alcohol pad prior to applying the needle cap and staff should wear gloves when administering injections. 11. Review of the Department of Health and Senior Services Tuberculosis Screening for Long-Term Care Facility Employees Flowchart (based on the requirements identified in the state regulation for administering TB testing), updated 03/11/14, showed the following: -Administer TST first step prior to employment. (Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date); -Read results of first step TST within 48-72 hours of administration (results must be read and documented in millimeters (mm) induration prior to or on the employee start date); -If first TST is negative, administer second step within 1-3 weeks; -Read results within 48-72 hours of administration; -The employee cannot start work for compensation until the first step TST is administered and read. Review of the Missouri Department of Health Infection Control Guidelines for Long Term Care Facilities, dated January 2020, showed the following: -The following occupationally-exposed persons should be tested at least annually include, all employees, attending physicians and dentist, volunteers who spend more than 10 hours a week in the facility, and nursing and allied health personnel; -Provide a tuberculin skin test (PPD) to all employees during pre-employment procedures; -The Department of Health rule states employees will be skin tested on an annual basis as a means of surveillance within a facility. 12. Review of LPN I's employee file showed the following: -His/Her date of hire was 09/18/24 (compensation began on this date); -First step TST administered on 09/18/24 and read on 09/20/24. Staff documented the results as negative (-) and did not document in mm of induration; -Second step TST administered on 10/02/24 and read on 10/04/24. Staff documented the results as negative (-) and did not document the results in mm of induration; (The employee received compensation before the first step TST was administered and read and the results were not documented appropriately.) 13. Review of the Social Service Director's employee file showed the following: -His/Her date of hire was 01/24/24; -No documentation of a previous two step TST; -An annual TST was administered on 02/12/24 and read on 02/14/24. Staff documented the results as 0 and did not not document in mm of induration; -No documentation of an annual TST in January of 2025; (The employee received compensation without proof of a prior two step TST. Staff did not document the results of his/her 2024 annual TST properly, and did not ensure he/she received an annual TST in January 2025.) 14. Review of CNA Y's employee file showed the following: -His/Her date of hire was 05/25/23; -No documentation of a previous two step TST; -An annual TST was administered on 02/19/24 and read on 02/22/24. Staff documented the results as 0 and did not document in mm of induration; -No documentation of an annual TST in January of 2025; (The employee received compensation without proof of a prior two step TST. Staff did not document the results of his/her annual 2024 TST properly, and did not ensure he/she received an annual TST in January 2025.) 15. Review of Dietary Aide AA's employee file showed the following: -His/Her date of hire was 08/23/24; -First step TST administered on 08/23/24 and read on 08/26/24. Staff documented the results as negative (-) and did not document in mm of induration; -Second step TST administered on 09/10/24 and read on 09/12/24. Staff documented the results as negative (-) and did not document in mm of induration; (The employee received compensation before the first step TST was administered and read, and staff did not properly document the results in mm of induration.) 16. Review of the Housekeeping/Beautician Staff's employee file showed the following: -His/Her date of hire was 11/24/23; -No documentation of a first step or second step TST; -No documentation of an annual TST, previous or current; -The employee received compensation before TB testing. 17. Review of the Receptionist's employee file showed the following: -His/Her date of hire was 04/10/24; -First step TST administered on 04/10/24 and read on 04/12/24. Staff documented the results as negative (-) and did not document the results in mm of induration; -Second step TST administered on 04/18/24 and read on 04/20/24. Staff documented the results as negative (-) and did not document the results in mm of induration. (The employee received compensation before the first step TST was administered and read, and staff did not properly read the results in mm of induration.) 18. Review of the CMT W's employee file showed the following: -His/Her date of hire was 03/08/24; -No documentation of a first step or second step TST; -Annual TST administered on 03/05/24 and read on 03/07/24. Staff documented the results as 0 and did not document the results in mm of induration. (The employee received compensation without proof of a prior two step TST. Staff did not properly document the results on his/her 2024 annual TST and did not ensure he/she received an annual TST in January 2025.) 19. Review of the CMT BB's employee file showed the following: -His/Her date of hire was 01/26/24; -No documentation of a previous two step TST; -An annual TST was administered on 01/20/24 and read on 01/22/24. Staff documented the results as 0 and did not document in mm of induration; -No documentation of an annual TST in January 2025; (The employee received compensation without proof of a prior two step TST. Staff did not properly document the results on his/her 2024 annual TST, and did not ensure he/she received an annual TST in January 2025.) 20. During an interview on 02/04/25 at 3:05 P.M., the Administrator said the following: -The Infection Preventionist (IP) was responsible for administering, reading and reporting the TB test results and was also responsible for tracking the annual TB tests. Annual TB tests were normally given in January and July. There had been recent staff turnover for the IP position and things might be getting missed or not done; -She expected the facility to follow the regulation for TB screenings, administration and documentation; -She was aware the first-step TST should be administered and read prior to the first date of contact with residents. She did not know that this had to be done by the first time of compensation. Staff do not have contact with residents immediately, but they are paid for their orientation, which would be their date of hire. Staff are given their first step TST during orientation. 21. Review of the facility's policy, Legionella Water Management Program, dated 2001 and last revised September 2022, showed the following: -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team; -The water management team consists of at least the following personnel: the infection preventionist, the administrator, the medical director (or designee), the director of maintenance and the director of environmental services; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; -The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program; -The water management program includes the following elements: -a. An interdisciplinary water management team (see above); -b. A detailed description and diagram of the water system in the facility, including the following: receiving, cold water distribution, heating, hot water distribution, and waste; -c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks; water heaters; filters; aerators; showerheads and hoses; misters, atomizers, air washers and humidifiers; hot tubs; fountains; and medical devices such as CPAP machines, hydrotherapy equipment, etc; -d. The identification of situations that can lead to Legionella growth, such as: construction; water main breaks; changes in municipal water quality; the presence of biofilm, scale or sediment; water temperature fluctuations; water pressure changes; water stagnation; and inadequate disinfection; -e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); -f. The control limits or parameters that are acceptable and that are monitored; -g. A diagram of where control measures are applied; -h. A system to monitor control limits and the effectiveness of control measures; - i. A plan for when control limits are not met and/or control measures are not effective and -j. Documentation of the program; -The water management program is reviewed at least once a year, or sooner if any of the following occur: -a. The control limits are consistently not met; -b. There is a major maintenance or water service change; -c. There are any disease cases associated with the water system or -d. There are changes in laws, regulations, standards or guidelines. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. 22. Record review of the facility's water temperature log for November 2024 through February 2025 showed staff only checked the temperature of the hot water in areas of the facility. During an interview on 2/4/25 at 11:31 A.M., the Maintenance Director (MD) said the following: -He started as Maintenance Director at the facility in July 2024; -He checked water temperatures daily; -He only checked hot water temperatures; he did not check cold water temperatures; -He ensured water temperatures were between 105 degrees F and 120 degrees F; -He did not know anything about Legionella or other water-borne pathogens, or what to monitor to prevent water-borne pathogens; -The facility did not have a water flow map; -He was not aware of a water management team. During an interview on 2/4/25, at 12:17 P.M., the DON/Infection Preventionist (IP) said the following: -She was not aware of a water management team, but the team should consist of the IP and Maintenance Director; -She took over as DON in July 2024 as DON and was the interim IP since January 2025; -There used to be a water management flow map, but she was not sure where it was; -She has not talked to the Maintenance Director about water testing or the Legionella program; -She would have to review for the signs/symptoms to look for related to Legionella since the facility policy changed recently; -The facility had test kits at one time but she did not know where they were now. During an interview on 2/5/25, at 1:59 P.M., the Administrator said the following: -The facility did not officially have a water management team, but the team would include the Maintenance Director, IP, DON and Administrator; -The facility had test kits but was she was unsure where they were located or if the Maintenance Director was aware of them; -The Maintenance Director should test the cold water temperatures as well as the hot water temperatures; -She was not sure the Maintenance Director knew what he should do for the water management program. 32899

Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from 07/01/24 through 09/30/24. The facility census was 71. 1. Review of the CMS PBJ Staffing Data Report, dated 1/28/25, showed the facility did not report staffing data for the period of 07/01/24 through 09/30/24. During an interview on 2/5/25 at 2:50 P.M., the Administrator said the following: -The facility had not been submitting their PBJ information; -The last person responsible for submission was the payroll clerk who had since left employment; -Their payroll service was responsible for submitting the PBJ for them once the contract began.

44665 Based on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, date, store per manufacturer's instructions, or properly thaw food items in order to prevent potential contamination. Staff did not practice proper hand and glove hygiene, hair restraint usage, and consumption of personal food and beverage items. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris or demonstrate proper surface sanitization procedures and knowledge of chemical sanitizer levels. Staff did not ensure dishes and utensils were stored and handled in a sanitary manner. Staff failed to ensure an air gap was present at the facility's ice machine drains to prevent possible backflow from the drain back into the ice machines. The facility census was 71. 1. Observation on 2/3/25 at 10:38 A.M., in the kitchen reach-in freezer, showed a box of catfish nuggets did not have the inner plastic securely sealed around the nuggets. Observation on 2/4/25 at 8:29 A.M., on the kitchen spice shelf, showed the following: -An open, unrefrigerated bottle of lemon juice, with a label that read 'Refrigerate after opening'; -An open, unrefrigerated bottle of chocolate syrup, with a label that read 'Refrigerate after opening'. Observation on 2/3/25 at 1:34 P.M., near the kitchen, showed the following: -Four pork loins thawed in a tray in the walk-in cooler. The pork loins hung over the sides of the tray by 2 inches on one side and were not completely contained in the tray; -A box of chocolate chips in the walk-in freezer had the inner bag not securely sealed. Observation on 2/4/25 at 8:35 A.M., in a reach-in cooler in the kitchen, showed a box of sausage patties did not have the inner plastic sealed and the box flaps were open. Observation on 2/3/25 at 1:56 P.M., in the Gardens Special Care Unit (SCU) kitchenette refrigerator, showed the following: -An undated pan of mixed fruit; -An undated stack of approximately 30 cheese slices; -An unlabeled and undated unknown food item wrapped in foil; -An undated grease stained fast food bag of unknown food items with the first name of a person written on the bag. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said food items should be stored in a safe and sanitary manner. Food should be sealed, labeled, dated, and stored per label instructions. Raw meats should thaw in a large enough container so as not to overhang over the edge of the container. During an interview on 2/4/25 at 4:49 P.M., the Administrator said she expected food to be stored, served, and prepared in a safe and sanitary manner. 2. Observation on 2/3/25 at 10:42 A.M., showed Dietary Aide K finished using the food processor to prepare resident food items for the lunch meal service. When he/she moved the food processor machine, an approximate 6-inch by 6-inch area of black oily substance remained on the preparation counter. Dietary Aide N wiped the area with a cloth and placed the soiled cloth in the red bucket of sanitizing solution. Approximately 75% of the cloth was soiled with the black residue. Observation on 2/4/25 at 10:13 A.M., showed a red bucket of sanitizing solution with a cloth inside was discolored brown across 25% of the cloth's surface and was not fully submerged in the solution. A green bucket sat next to the red bucket and a moist cloth lay resting between the two buckets and was not submerged fully in either solution. During an interview on 2/4/25 at 1:09 P.M., Dietary Aide N said cloths in the sanitizer solution in the red bucket should be fully submerged. Staff should change the sanitizing solution every 1.5 hours and test the solution with a chemical test strip. He/She was unsure what the chemical level of the sanitizer should be. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the red buckets in the kitchen contained sanitizing solution and the green buckets contained soapy water. Staff should change the sanitizing solution every two hours, or as needed, test the chemical level of the solution, and record the value in the sanitizer log book. Sanitizer cloths should be fully submerged in the solution and changed when visibly soiled. Record review of the Sanitizing Bucket Chemical Log, located on the preparation counter by the spice shelf in the kitchen, showed the following: -A log sheet indicated values of 100 PPM for July 25, July 29-31, August 1-5, and August 18-22 of an unidentified year. No entries were completed for July 26-28 or August 6-17 on the sheet; -A second log sheet indicated a value of 300 PPM (lunch) and 400 PPM (dinner) for 3/5/24. Values of 400 PPM were filled in for lunch and dinner on 3/7/24. No entries were completed for breakfast for 3/5/24 or 3/7/24. No other entries for March 2024 were completed; -No documentation showing sanitizer chemical levels were logged for 3/8/24 to current date. 3. Observation on 2/3/25 at 1:34 P.M., near the kitchen, showed the walk-in cooler and walk-in freezer had an excess accumulation of a brownish-red residue, trash, and dried food debris on the floor underneath the shelves. Observation on 2/3/25 at 11:46 A.M., in the kitchen, showed two of the eight range hood baffle filters, located above the fryer had a heavy accumulation of yellow grease with fuzzy debris. Observations on 2/3/25 from 1:35 P.M. to 2:37 P.M., during the dietary and sanitation tour of the facility, showed the following: -In the Gardens SCU, sticky brown residue and bits of yellow food debris were visible on the bottom interior of the kitchenette refrigerator. A white residue coated 25% of the ice machine's interior surface and a brown residue was visible along the outer edge of the door opening of the ice machine. Heavy dust and debris was visible on the front lower vent of the ice machine. Discarded cups, paper towels, and a brown residue were visible on the floor behind and below the ice machine. In the cabinet drawer next to the ice machine, there was an ice cream scoop with bits of brown dried debris on the food contact surface of the scoop. The scoop lay on the surface of the drawer which was speckled black; -In the Helping Hands Dining Room, brown sticky residue was on the floor by the refrigerator and the refrigerator's interior bottom surface had a dried pink and yellowish residue on it; -In the [NAME] dining room, the floor was sticky. Observations on 2/4/25 at 8:14 A.M., in the kitchen, showed a heavy accumulation of black fuzzy debris on a 2-foot by 3-foot wall vent located by the upright warming oven. The floor behind and under the convection oven, fryer, stoves, and steamers had a heavy accumulation of food debris, trash, wadded foil, a thermometer, paper towels, and an oily residue coated the floor and legs of cooking appliances in this area. The upright warming oven had approximately 75% of the glass surface coated with dried food drips and the door seal was warped and missing pieces of the seal across 25% of the seal's surface. The interior and exterior metal surfaces and glass doors of the convection oven had a moderate accumulation of dried brown and black residue. Grease and food debris speckled the surface of the convection oven by the fryer. Three of six burners on the 6-burner stove had a heavy black encrusted debris buildup and one of two burners on the 2-burner stove/griddle unit had a heavy black encrusted debris buildup. Observations on 2/4/25 at 9:26 A.M., in the east dining room, showed dried food debris and splatters on the floor and cove base trim by the steam table. In the nearby kitchenette, cabinets contained loose cereal, dead insects resembling cockroaches, dried black and brown stains on the interior bottom and sides of the cabinets. One upper shelf contained a thick pink residue on the shelf's surface. A plastic bag, cups, straws, and various items sat on a heavily soiled lower cabinet. Inside the ice machine there was a moderate accumulation of white and light brown staining. Below and behind the ice machine, there was an excess accumulation of trash and debris including cup lids, spoons, cups, paper towels, and plates. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the following: -He expected the range hood baffle filters to be free from an excess buildup of grease and debris. A company came to clean the filters every six months and they were due to come soon; -Dietary staff did not clean the filters because the company said the filters were very sharp and not easily able to be removed without a special tool; -Staff swept and mopped the middle walkways of the walk-in cooler and freezer but it had probably been awhile since the floors under the shelves in the walk-in units had been cleaned; -The floors under the stoves and cooking appliances were last cleaned in September when a company came to clean them. 4. Observation on 2/3/25 at 9:00 A.M., in the kitchen, showed Dietary Aide K drank from his/her personal beverage then wiped his/her hands on a paper towel and put on gloves. He/She did not wash his/her hands prior to putting on gloves and served fruit crisp for the lunch meal into bowls on the food preparation counter. Observation on 2/3/25 at 9:10 A.M., in the kitchen, showed Dietary Aide N put a glove on his/her left hand and used his/her right bare hand to move spices, a jug of oil, and a bag of bread. Without washing his/her hands or changing his/her gloves, he/she donned a glove on his/her right hand and used his/her right gloved hand to grasp shredded lettuce from a bag and place the lettuce into bowls. Observation on 2/3/25 from 9:13 A.M. to 9:30 A.M., in the kitchen, showed the following: -Cook L washed his/her hands and turned off the faucet handle with his/her clean hands; -He/She wore a hat and had 3-inch long hair on his/her head that was exposed and not covered by the hat and had approximately 1-inch long facial hair that was not covered with a hair restraint; -He/She removed his/her hat, put his/her hat back on, scratched his/her elbow, rubbed the bottom of his/her neck, and touched his/her necklace and shirt with his/her clean hands; -Without washing his/her hands, he/she went to the dry storage room and brought back a bag of macaroni and laid it on the food preparation counter; -He/She poured a cup of coffee, walked across the kitchen drinking the coffee, and sat the coffee down on the food preparation counter; -He/She picked up and drank from the cup of coffee on the food preparation counter, took a soiled cutting board to the dish room, touched his/her shirt, and opened a utensil drawer to obtain a spoon which he/she used to stir food that was cooking on the stove; -He/She went into the dry storage room, removed and replaced his/her hat, obtained a new box of food service film, and returned with the film to the kitchen food preparation counter; -He/She washed his/her hands for approximately 10 seconds and turned off the faucet with his/her clean hands and pulled up his/her pants as he/she walked around the kitchen; -He/She stood by three trays, containing approximately 15 bowls each, of uncovered fruit crisp and five trays, containing approximately 10 bowls each, of uncovered lettuce. All of his/her hair was not covered with a proper hair restraint. Observation on 2/3/25 at 9:32 A.M., in the kitchen, showed the following: -Cook L used his/her bare hands to pick pieces of raw meat left in the three-compartment sink, placed them in a tub and carried it to the dishwashing room; -He/She washed his/her hands, turned off the faucet with his/her clean hands, and used the paper towels from drying his/her hands to wipe the food preparation counter located by the food processor; -He/She went into the dietary manager's office, touched his/her shirt, donned gloves, and opened the cooler door, obtained three eggs, and placed the eggs on a box of open disposable gloves on the food preparation counter; -He/She opened the cooler door and obtained two slices of bacon and placed them on the griddle; -He/She washed his/her hands and turned off the faucet with his/her clean hands and used his/her bare hands to move one of the eggs from the box of disposable gloves and placed the egg on a roll of blank food labels; -Without washing his/her hands, he/she put a glove on his/her right hand and use his/her right gloved hand to obtain slices of bread from a bag and put the slices on the griddle; -He/She removed and replaced his/her hat on his/her head and drank from the coffee cup on the preparation counter and continued to prepare food at the griddle for the breakfast meal service. Observation on 2/3/25 at 10:25 A.M., in the kitchen showed Dietary Aide K used his/her gloved hands to touch the inside portion of a trash bag (located in a trash can) and swept food debris into the trash can. He/She removed his/her gloves, did not wash his/her hands, and used a cloth from a green bucket of soapy water and wiped the food preparation counter. He/She carried his/her phone and personal drink to the food preparation area and put his/her phone upside down on the food preparation counter and played music. He/She went to the hand washing sink, turned on the faucet and used his/her hands to put water on his/her facial hair and wiped his/her facial hair with a paper towel. He/She did not wash his/her hands, went to the food preparation counter, and rested his/her palm on the surface of the food preparation counter. Observation on 2/3/25 at 10:36 A.M., in the kitchen, showed Dietary Aide O obtained a carton of chocolate milk from the cooler, walked to the food preparation counter, and drank the milk while leaning on the food preparation counter. Observation on 2/4/25 at 8:10 A.M., showed the Dietary Manager and Dietary Aide N prepared plates of food for residents during the breakfast meal service at the food preparation and serving area in the kitchen. Both the Dietary Manager and Dietary Aide N had approximately 3-inch long facial hair and were not wearing hair restraints as they served food from the steam table and griddle. During an interview on 2/4/25 at 12:59 P.M., [NAME] Z said staff should wash their hands by wetting their hands, applying soap, singing the happy birthday song three times, and using a paper towel to turn off the faucet handle. Staff should wash their hands when they remove their gloves, touch themselves, and after completing dirty tasks. During an interview on 2/4/25 at 1:09 P.M., Dietary Aide N said staff should eat and drink personal food and beverage items in the break room. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the following: -Staff should not eat, drink, or use their cell phones in food preparation areas; -Staff should wash their hands after touching dirty items such as trash cans; after touching their self, clothing, or hair restraint; after changing their gloves; and before conducting clean tasks; -Staff changing their gloves did not substitute the need for them to wash their hands; -After washing their hands, staff should use a paper towel rather than their clean hands to turn off the faucet handle; -Staff should not handle ready-to-eat (RTE) food items with soiled gloves and should protect RTE food from contamination; -Staff should wear hair restraints properly with all hair secured to prevent potential contamination of food. He was unsure of what beard length required a hair restraint but head hair that went below the ears should be covered. 5. Observation on 2/3/25 at 10:02 A.M., in the kitchen, showed Dietary Aide O washed his/her hands, put on one glove, rubbed his/her nose, and put on the other glove. He/She put clean trays on a three-tiered cart and pushed the cart of trays to the preparation counter where he/she touched meal tickets, clean napkins, and clean silverware by the eating surface of the silverware and placed the silverware on napkins on the trays. Observation on 2/3/25 at 10:59 A.M., in the kitchen, showed Dietary Aide N pureed food for the lunch meal service at the food processor machine located near the three compartment sink. He/She used the spray nozzle at the three-compartment sink to spray out the food processor container after pureeing green beans. He/She then used the container to puree milk and slices of bread. Observation on 2/4/25 at 8:14 A.M., in the kitchen, showed the clean dish and pan storage areas located under the food preparation tables had dried white residue and several bits of food debris and encrusted debris visible. The clean container storage area, located on a three-tier metal wire shelf, showed four containers that were not inverted or covered. A large fan had a moderate accumulation of dust and debris on the wire guard and fan blade and was pointed towards the clean dish storage area. In the utensil drawers, there were dried bits of food debris in the bottom of the drawers. Multiple utensils and food scoops had dried, crusted food debris and white residue on the food surface of the utensils and scoops. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the following: -He expected dishware and utensils to be in good condition, stored clean, and for staff to handle them by the non-eating surfaces of those items; -Staff should properly clean and sanitize dishes and should not just spray them off in the three-compartment sink. 5. Review of the Food and Drug Administration Food Code, dated 2013, showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Observation on 2/3/25 at 2:05 P.M., of the Gardens SCU ice machine, showed the machine's drain did not contain an air gap. A 3-foot long 1-inch diameter PVC pipe connected to the ice machine drain and continued through the wall to an adjoining resident room (it was not visible when viewed from the resident room side). Approximately 6 inches from the ice machine drain, a 3-foot vertical 1-inch diameter PVC pipe extended upward and was located along the 3-foot horizontal drain PVC pipe. Observation on 2/4/25 at 9:26 A.M., of the east kitchenette ice machine, showed there was no air gap at the drain. A 1-inch diameter 3-foot long flexible drain hose went from the ice machine drain to a 1-inch diameter 3-foot long PVC pipe that that went to another flexible pipe through the wall and was not visible on the other side of the wall. During an interview on 2/5/25 at 10:08 A.M., the Maintenance Supervisor said the following: -The ice machines at the facility were rented from a company; -The rental company preferred to maintain the ice machines including the ice machine drains; -He expected the ice machines to have an appropriate drain air gap and assumed they did. During an interview on 2/4/25 at 9:50 A.M., the Administrator said she expected there to be an air gap at the drain to prevent potential back flow from the drain back into the machine and was unaware that the ice machines did not contain an air gap.

Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of regular maintenance program to identify areas of possible entrapment for three residents (Residents #68, #14, and #10), in a review of 18 sampled residents. The census was 71. Review of the Food and Drug Administration (FDA) document, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom, or retrieving something from a closet. 1. Review of Resident #68's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 1/24/25, showed the following: -Severely impaired cognition; -Dependent on staff for bed mobility, transfers and sitting to lying in bed, lying to sitting in bed and chair/bed-to-chair transfers. Review of the resident's care plan, last revised 1/24/25, showed the following: -Impaired activity of daily living (ADL) performance and mobility status; -Transfer with sit-to-stand or mechanical lifts; -High risk for falls due to cognitive impairment, history of falls and lack of safety awareness; -Place a fall mattress next to my bed when in bed. (No documentation to show the resident had bed rails on his/her bed.) Observation on 2/4/25 at at 6:30 A.M. showed the resident lay on his/her back in the bed with 1/4 bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress, or assist bars to identify areas of possible entrapment. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required substantial assistance with rolling from left to right, sitting to lying, and lying to sitting on the side of bed. Review of the resident's care plan, last reviewed 12/30/24, showed the following: -Diagnoses included orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position), muscle weakness, difficulty walking, unsteadiness on feet, spinal stenosis (a narrowing of the spinal canal in the lower part of the back), history of falling, and repeated falls; -He/She was at risk for falls; (No documentation to show the resident had bed rails/mobility bars on his/her bed). Observations on 02/02/25 at 10:29 A.M. and on 02/04/25 at 7:45 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. 3. Review of Resident #10's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was dependent on staff for bed mobility. Review of the resident's care plan, last reviewed 01/28/25, showed the following: -Diagnoses included osteoarthritis, joint pain, history of falling, ataxic gait (uncoordinated, awkward way of walking that's caused by poor balance and muscle control), and neuropathic arthropathy (a condition that causes progressive joint destruction and bone weakening); -He/She was at risk for falls; (No documentation to show the resident had bed rails/mobility bars on his/her bed). Observation on 02/02/25 at 11:40 A.M., 02/03/25 at 8:03 A.M., and on 02/04/25 at 8:35 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. 4. During an interview on 2/5/25 at 8:10 A.M., the Maintenance Director said he did not currently measures beds for entrapments zones. During interviews on 02/06/25 at 11:40 A.M., the Director of Nursing said she the maintenance department was responsible to measure the entrapment zones. During a phone interview on 02/06/25 at 12:50 P.M. the Administrator said she expected the maintenance department to complete measurements for entrapment zones quarterly. 47008

Based on observation, interview, and record review, the facility failed ensure harmful chemicals were kept in locked cabinets and not accessible to residents. The census was 71. 1. Observation on 2/3/25 from 1:35 P.M. to 2:37 P.M., during the dietary and sanitation tour of the facility, showed the following: -One unlabeled cup containing a pink paste substance, one unlabeled cup containing a blue liquid with a spoon in the liquid, and three cans of heavy duty cleaning spray located in an unlocked lower cabinet in the Gardens Special Care Unit (SCU - an area of the facility dedicated to care for residents with dementia who are generally ambulatory) dining room kitchenette. The label on the cans of cleaning spray read 'Keep out of reach of children'; -One gallon jug of concentrated descaler and delimer located on the open bottom shelf of the Gardens SCU dining room steam table. The label on the jug read 'Danger: causes severe skin burns and eye damage. Store locked up'; -One can of disinfectant and sanitizing spray located in an unlocked lower cabinet in the west dining room. The label on the can read 'Caution: keep out of reach of children'; -One can of stainless steel cleaner and polish located in an unlocked lower cabinet in the west kitchenette. The label on the can read 'Warning: keep out of reach of children'; -One can of furniture polish spray located in an unlocked lower cabinet in the Helping Hands dining room. The label on the can read 'Keep out of reach of children.' During an interview on 2/4/25 at 4:49 P.M., the Administrator said she expected cleaning supplies and other chemicals to be secured and inaccessible to residents. 44665

Based on observation and interview, the facility failed to maintain an environment to deter pests from entering the facility's kitchen, satellite dining rooms, kitchenettes, and food storage areas. The facility census was 71. 1. Observation on 2/3/25 at 10:49 A.M., in the kitchen above the three compartment sink, showed an approximate 1-foot by 3-foot window was open and did not contain a screen. Observation on 2/3/25 at 3:38 P.M., during the exterior and interior sanitation tour of the facility, showed the following: -Two approximately 1-foot by 3-foot windows were open to the kitchen and contained no screens on the windows; -An exterior door to the service hall, located near the outside dumpster and grease collection container, was propped fully open with a metal ramp. Both the dumpster and grease container were open. The dumpster was 25% full of garbage and did not have a lid on the top and front of the dumpster. The lid of the grease container hung off to the side of the container and the container was 90% full of grease; -Approximately 50 feet down the service hall into the facility (from the open exterior door), the door to the emergency food/water storage and dietary walk-in cooler and freezer room was propped open with a large can of food. Observation on 2/4/25 at 8:29 A.M., in the kitchen, showed a white laundry basket labeled 'Kitchen' sat near two bulk bins of rice and oats. Approximately 50 mouse droppings were located in the bottom of the laundry basket. Behind and along the wall, two boxes of fry oil sat on the floor. Mouse droppings were on the floor around the oil in this area. Observation on 2/4/25 at 8:42 A.M., showed the outside exterior door to the parking lot near the food service was chained open by the handle. No staff were around or actively working in the area. The door to the dry storage room that contained emergency food and water and paper products and the walk-in cooler and freezer had the self closer disconnected at the top of the door and was propped open with a can of food. Mouse droppings were on the floor. On the shelves in this room, multiple cups and food containers were not inverted and mouse droppings were scattered on the surface of the shelves, cups, and food containers. Observation on 2/4/25 at 9:26 A.M., in the kitchenette near the east dining room, showed the cabinets contained loose cereal and dead insects resembling cockroaches. During an interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the following: -The outside dumpster never had lids. He was unaware the outside grease collection container lid was not covering the opening of the container; -The exterior door to the service hall and the door to the emergency food/water storage and dietary walk-in cooler and freezer room should not be propped open when not in use; -The facility had mouse issues in the past and the pest control company gave him a stack of glue traps if he needed to use them. He also planned to put more items in plastic totes to protect them from mice in the dry storage room; -The kitchen windows that were open had been previously damaged and did not have screens. Maintenance staff planned to replace the windows but staff probably shouldn't open the windows until they had screens. During an interview on 2/4/25 at 4:49 P.M., the Administrator said the facility's pest control company maintained outside bait stations and had sticky traps available for mice.

Based on observation, interview, and record review, the facility failed to ensure the medical record accurately and consistently indicated the resident's code status for three residents (Residents #7, #31, and #46), in a review of 18 sampled residents. The facility census was 71. Review of the facility policy, Advance Directives, last revised [DATE], showed the following: -Advance directives are honored in accordance with state law and facility policy; -Do Not Resuscitate (DNR) - indicates that in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used; -Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form - a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. A POLST paradigm form is not an advance directive; -Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives; -The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so; -Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative; -The facility policy did not address ensuring the code status of all residents matched in all areas of the medical record and in all areas which list the resident's code status. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated [DATE], showed the following: -Cognitively intact; -No short or long-term memory loss; -Able to understand others. Review of the resident's face sheet showed he/she was his/her own responsible party. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed the resident's code status was Full Code. Observation on [DATE] at 10:16 A.M. showed a purple heart sticker (indicating the resident's code status was Do Not Resuscitate (DNR)) on the resident's name plate, located next to the door frame outside of his/her room. Review of the facility's code status binder on [DATE], [DATE], [DATE] and [DATE] showed it contained an out of hospital DNR dated [DATE] and signed by the physician. Review of the resident's care plan, dated [DATE], showed the resident was a DNR. Review of the resident's Electronic Medical Record (EMR) on [DATE] at 2:20 P.M. showed the following: -The dash board read, code status (advanced directive) Full Code; -The face sheet showed the resident's code status was Full Code. (The resident's physician's orders and documents in the EMR showed the resident was Full Code and were not consistent with the resident's wishes to be DNR.) During an interview on [DATE] at 4:50 P.M., the resident said he/she wanted his/her code status to be a DNR. He/She did not want Cardio Pulmonary Resuscitation (CPR) performed in the event his/her heart stopped beating. 2. Review of Resident #31's face sheet showed the following: -No code status was shown; -The resident's family member was listed as his/her responsible party. Review of the resident's care plan, dated [DATE], showed no documentation of code status. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately cognitively impairment; -Made self understood; -Able to understand others. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed no order for code status. Observation on [DATE] at 3:50 P.M. showed a purple heart sticker (indicating DNR code status) on the resident's name plate, located next to the door frame outside of his/her room. Review of the facility's code status binder on [DATE], [DATE], [DATE] and [DATE] showed it contained an out of hospital Do Not Resuscitate (DNR) dated [DATE] and signed by the physician. During an interview on [DATE] at 1:35 P.M the resident said he/she wanted his/her code status to be a DNR. He/She did not want CPR performed in the event his/her heart stopped beating. During an interview on [DATE] at 4:21 P.M., the resident's Power of Attorney (POA) said the resident was a DNR. (Review showed the resident's POS and care plan did not contain information to show the resident's code status was DNR.) 3. Review of Resident #46's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Able to understand others. Review of the resident's face sheet showed his/her family member was his/her durable power of attorney (DPOA). Review of the resident's POS, dated February 2025, showed no documentation of the resident's code status. Observation on [DATE] at 3:31 P.M. showed a purple heart sticker (indicating DNR code status) on the resident's name plate, located next to the door frame outside of his/her room. Review of the facility's code status binder on [DATE], [DATE], [DATE] and [DATE] showed it contained an out of hospital Do Not Resuscitate (DNR) signed by the physician. Review of the resident's care plan dated [DATE] showed the resident was a DNR. Review of the resident's Electronic Medical Record (EMR) on [DATE] at 2:20 P.M. showed the following: -The dashboard showed no documentation of the resident's code status; -The face sheet showed no documentation of the resident's code status; -Scanned copy of the resident's DNR form was located in the miscellaneous tab. (Review of the resident's POS, face sheet and dashboard, did not contain information to show the resident's code status was DNR.) 4. During interview on [DATE] at 6:05 A.M., Certified Medication Technician (CMT) said the green heart meant a resident was a full code and a purple heart on a resident's name plate indicated a DNR. He/She would also look on the resident's face sheet for a resident's code status. There used to be a binder at the nurses' station which included all the residents' code status but it was relocated downstairs about a month ago to be uploaded in the EMR. During interview on [DATE] at 3:35 P.M. and on [DATE] at 8:24 A.M., Licensed Practical Nurse (LPN) B said he/she would first check the resident's code status in the code status binder located at the nurses' station. If unable to locate the code status binder, he/she would look in the EMR to see if the full code/DNR form was scanned into the resident's record. During an interview on [DATE] at 5:00 P.M., CMT W said the following: -The hearts on the residents' name plates indicated their code status; -The code status was also in a binder at the desk and on the kardex/face sheet on the computer; -He/She would look at the resident's name plate to find the resident's code status and would look at the binder if he/she was not sure of the code status. During an interview on [DATE] at 5:08 P.M., LPN P said the following: -He/She would look at the heart sticker on the door to identify code status; -He/She would verify the code status on the physician's orders; -If there was a discrepancy, he/she would initiate CPR. During an interview on [DATE] at 10:15 A.M., the Social Service Director (SSD) said the following: -The admissions person was responsible for obtaining the resident's code status; -If there were a discrepancy in a code status, she would double check with the physician and the resident; -Either she or the Care Plan Coordinator would change the code status in the care plan as needed; -All necessary areas would be updated/corrected: door name plate, code status binder, POS, and face sheet; -The admissions person or the nurse were responsible for changing the code status in the EMR. During an interview on [DATE] at 11:21 A.M., the Care Plan Coordinator said the following: -The care plan should reflect and match the resident's correct code status; -He/She obtained the code status information from the interdisciplinary team, the family, the direct care staff, and the medical record; -He/She would correct a discrepancy in the care plan by checking the code status binder, discussions with staff and social services would let him/her know of changes. During an interview on [DATE] at 3:00 P.M., the Admissions staff said the following: -She was responsible for obtaining and adding the status to the code status book, the resident's door and the face sheet; -Either she or nursing would add the code status to the EMR; -She was not aware of any discrepancies regarding residents' code status. During an interview on [DATE] at 11:37 A.M., the Director of Nurses (DON) said the following: -A care plan should include a resident's code status; -Admissions staff and the SSD were responsible for obtaining resident's code status, obtaining necessary signatures, faxing the physician and ensuring the resident's code status was documented in all of the necessary places; -The code status should be documented in the code status binder, on the POS, in the care plan, in the electronic medical record and on the name plate outside the residents' rooms and they should all match; -The POS should contain the resident's code status; -If there was an emergency, he/she expected staff to look in the code status binder for the most accurate code status. During an interview on [DATE] at 12:10 P.M., the Administrator said the following: -Admissions staff was responsible for obtaining the code status and placing the code status in code status book, the sticker system (heart on door) and entering the code status in the electronic medical record; -The code status in all these areas should match with no discrepancies; -The SSD was responsible for updating and checking with residents annually to see if they wanted to change their code status; -She expected the code status to be on the physician's orders; -She expected staff to refer to the code status book for a resident's code status.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for incontinence care for three residents (Residents #43, #46, and #5), in a review of 18 sampled residents, and for one additional resident (Resident #175), who required assistance with their activities of daily living. Staff failed to provide oral care for three residents (#43, #46 and #5). The facility census was 71. Review of the facility's policy, Perineal Care, dated 2001 and revised February 2018, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition; -For a female resident wet washcloth and apply soap or skin cleansing agent; wash perineal area, wiping from front to back; Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.); Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia; Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.); Gently dry perineum; Instruct or assist the resident to turn to on her side with her top leg slightly bent, if able; Rinse wash cloth and apply soap or skin cleansing agent; Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia; Rinse thoroughly using the same technique; Dry area thoroughly; -For a male resident wet washcloth and apply soap or skin cleansing agent; wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.); Retract foreskin of the uncircumcised male; Wash and rinse urethral area using a circular motion; Continue to wash the perineal area including the penis, scrotum, and inner thighs. Do not reuse the same washcloth or water to clean the urethra; Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.); Gently dry perineum following same sequence; Reposition foreskin of uncircumcised male; Instruct or assist the resident to turn to on her side with her top leg slightly bent, if able; Rinse wash cloth and apply soap or skin cleansing agent; Wash the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks; Dry area thoroughly. Review of the facility's policy, Mouth Care, dated 2001 and last revised February 2018, showed the following: -The purpose of this procedure is to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection; -The facility policy did not address when staff were to provide mouth care to residents. 1. Review of Resident #43's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/6/24, showed the following: -Severely impaired cognition; -Required moderate assistance of staff for oral hygiene, personal hygiene, and dressing; -Resident was dependent on staff for toileting; -Occasional incontinent of bowel and bladder; -Diagnoses included Alzheimer's disease and dementia. Review of the resident's undated Care Plan showed the following: -The resident had impaired activities of daily living (ADL) performance and mobility related to dementia. He/She was incontinent of bowel and bladder; -Help him/her to set-up his/her morning/evening care supplies and encourage him/her to do what he/she can for himself/herself, then help him/her with the rest; -Help him/her with each incontinence episode; -He/She needed reminded to perform oral care. Please help him/her if needed. Observation on 2/4/25 at 7:33 A.M. showed the following: -The resident lay in bed; -Certified Nurse Assistant (CNA) A entered the resident's room, put on gloves, retrieved the resident's clothes from the closet and hung them in the bathroom; -CNA A assisted the resident to walk to the bathroom; -CNA A pulled down the resident's pants and soiled incontinence brief and the resident sat on the toilet; -The resident was incontinent and soiled with urine and feces; -CNA A removed the resident's pants, socks and slippers; -CNA A ran the resident's legs through the leg openings of a clean brief and pants; -CNA A assisted the resident to stand and cleaned the resident's rectal and gluteal crease area; -CNA A pulled up the resident's incontinence brief and pants and repositioned the resident's shirt; -CNA A picked up the resident's hair brush, wet the brush with water and combed the resident's hair; -CNA A assisted the resident to the dining room; -CNA A did not clean the resident's front genital area or offer/assist the resident with oral care. 2. Review of Resident #46's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Dependent on staff for oral hygiene, toileting and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included Alzheimer's disease and dementia. Review of the resident's care plan, last reviewed 12/27/24, showed the following: -The resident was at risk for decline in his/her ADLs and mobility status related to a recent left hip fracture and other comorbid conditions; -He/She needed extensive assistance with toileting; -He/She was occasionally incontinent of bladder and needed assistance with toileting; -He/She had his/her own teeth. He/She needed assistance with brushing his/her teeth. Observation on 2/4/25 at 8:15 A.M., showed the following: -The resident lay in bed; -CNA A and Licensed Practical Nurse (LPN) B entered the resident's room and selected the resident's clothes for the day; -LPN B assisted the resident to sit on the side of the bed; -The resident's incontinence brief was visibly saturated with urine; -CNA A and LPN B assisted the resident to walk to the bathroom; -LPN B left the resident's room; -CNA A pulled down the resident's soiled incontinence brief and assisted the resident to sit on the toilet; -CNA A removed the urine soaked incontinence brief; -CNA A ran the resident's legs through the leg openings of a new incontinence brief and pants; -CNA A changed the resident's shirt; -CNA A assisted the resident to stand, cleaned the resident's gluteal crease with disposable wipes; -CNA A pulled up the resident's clean incontinence brief and pants, opened the door to his/her room and walked with the resident to the dining room; -CNA A did not clean the resident's front genitalia and did not provide oral care. During interview on 2/4/25 at 2:48 P.M., CNA A said the following: -When performing peri care, staff should clean any area of the skin that was soiled; -He/She didn't provide oral care because he/she was working by himself/herself and was just trying to get everyone to breakfast. 3. Review of Resident #5's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toileting and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, last revised 1/15/25, showed the following: -At risk for skin breakdown related to impaired mobility and incontinence; -Inspect skin during AM/PM cares; -Change after incontinent episodes. Observation on 2/4/25 at 7:45 A.M. showed the following: -CNA Q and CNA R entered the resident's room to perform morning cares; -The resident lay in bed and was incontinent of urine; -CNA Q washed the resident's frontal genitalia with a wash cloth but did not cleanse all areas of the resident's skin in contact with the urine; -CNA Q and CNA R dressed the resident and transferred him/her to a chair and pushed him/her to breakfast; -The resident was edentulous and did not wear dentures; -Staff did not offer or perform oral care for the resident. 4. Review of Resident #175's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Partial to moderate assist with bed mobility; -Supervision to touch assist with personal hygiene; -Substantial to maximum assist with toileting; -Frequently incontinent of bladder. Review of the resident's care plan, last revised 1/30/25, showed the following: -Incontinent of bladder; -Provide preventative skin care as needed; -Cleanse skin as needed. Observation on 2/4/25 at 8:06 A.M. showed the following: -CNA Q and CNA R entered the room; -The resident lay in bed on a bed pan; -CNA R removed the urine filled bed pan and emptied it in the bathroom; -CNA Q assisted the resident to his/her left side. CNA R washed the resident's buttocks with a wash cloth and dried the area with toilet paper; -CNA R did not clean the resident's front perineal area. During an interview on 2/4/25 at 1:15 P.M., CNA Q said the following: -Staff should clean the perineal area, upper thighs, buttocks and any area contaminated by urine or feces when providing incontinent care; -Staff should provide oral care after every meal; -Some residents refused oral care, but staff should offer. 5. During an interview on 2/5/25 at 7:55 A.M., LPN S said the following: -Staff should clean all areas contaminated with urine or feces during perineal care, including front and back perineal areas and thighs -Staff should offer oral care with morning cares, after meals and at bedtime; -If a resident did not have teeth, staff should use a moistened toothette when providing oral care. During an interview on 2/6/25 at 11:37 A.M., the Director of Nursing said the following: -She expected staff to provide oral care in the morning, after meals, and at bedtime; -Staff should offer oral care anytime a resident's teeth were visibly soiled; -If a resident was edentulous, she expected staff to use a toothette to clean the mouth/gumline; -Staff should clean the front and back perineal areas when providing incontinence care; -If a resident urinated on the bedpan, staff should cleanse the frontal perineal area as well as the resident's backside. 32899

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for three residents (Residents #55, #46, and #19), in a review of 18 sampled residents, and one additional resident (Resident #65). The facility failed to obtain lab work as ordered for one resident (Resident #55), failed to document treatments and medication administration as completed for three residents (Residents #55, #46 and #19), and failed to ensure staff observed one additional resident (Resident #65) take his/her medications during a medication pass. The census was 71. Review of the facility's policy, Administering Medications, dated 2001 and last revised April 2019, showed the following: -Individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones; -Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. 1. Review of Resident #55's Physician Order Sheet (POS), dated January 2025, showed the following: -Diagnoses included diabetes mellitus (uncontrolled blood glucose), coronary artery disease (heart blood vessel damage) and hyperlipidemia (high levels of fat in blood); -Hemoglobin A1c (HbA1c-lab to check average blood glucose over last three months) every four months (original order dated 7/7/23); -Complete Blood Count (CBC-measurement of blood cells) and Complete Metabolic Panel (CMP-blood test measuring various substances) yearly; -Calmoseptine external ointment (0.44020.6% menthol zinc oxide) (moisture barrier), apply topically to buttocks two times daily for wound (original order dated 12/21/24); -Accucheck (blood glucose check) fasting, early in the morning related to Type II DM. Contact physician if blood glucose is less than 60 or greater than 400. Review of the resident's Treatment Administration Record (TAR), dated January 2025, showed the following: -Calmoseptine external ointment (0.44020.6% menthol zinc oxide) apply topically to buttocks two times daily for wound care. Cleanse noted stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) wound (0.5 cm x 0.5 cm) to left buttocks with normal saline, pat dry, and apply Calmoseptine two times daily (12/21/24); -Review showed no documentation staff completed the resident's wound care treatment on 1/2, 1/10, 1/12, 1/24, 1/25,1/26 and 1/30/25. Review of the resident's Medication Administration Record (MAR), dated 1/2025, showed no documentation staff completed an accucheck as ordered on 1/8, 1/11, 1/16, 1/25 or 1/31/25. Review of the resident's electronic medical record showed no documentation the facility obtained the HbA1c, CBC or CMP as ordered. During an interview on 02/06/25 at 11:23 A.M. and 12:46 P.M., the Care Plan/MDS coordinator said the following: -She would expect an HbA1C to be completed every four months as ordered; -She was just assigned the task of tracking labs the beginning of last week; -She had just recently started looking at labs; -She had assessed all current lab orders and a report was given to the Director of Nurses (DON). 2. Review of Resident #46's POS, dated December 2024, showed the following: -Tylenol (pain medication) 500 milligrams (mg) two tablets three times daily for pain; -Clonazepam (an anti-anxiety medication) 0.5 mg twice daily for anxiety; -Medi-honey wound and burn dressing external paste (a topical wound dressing made from medical-grade manuka honey used for the treatment of various types of wounds) apply to coccyx BID for open area, cleanse with normal saline, pat dry, apply Medi-honey and cover with border foam; -Diagnoses included osteoarthritis, anxiety, and low back pain. Review of the resident's MAR, dated December 2024, showed the following: -No documentation the resident received the morning dose of clonazepam on 12/7/24, 12/20/24, and 12/22/24; -No documentation the resident received the evening dose of clonazepam on 12/2/24, 12/3/24, 12/6/24, 12/7/24, 12/8/24, 12/17/24, 12/20/24, 12/22/24 and 12/25/24; -No documentation the resident received bedtime dose of Tylenol on 12/4/24; -No documentation the resident's wound care treatment was completed on 12/24/24 (bedtime), 12/27/24 (bedtime). 12/28/24 (morning and bedtime), 12/29/24 (morning and bedtime) and 12/30/24 morning scheduled times. Review of the resident's care plan, last revised 1/15/25, showed the following: -The resident received an antianxiety medication; -Potential for pain related to arthritis; -The resident had orders for Tylenol to help with his/her pain. -Administer pain medications as ordered per physician; -The resident had a sacral wound. Treat according to current orders. Review of the resident's POS, dated January 2025, showed the following: -Tylenol 500 mg two tablets three times daily for pain; -Clonazepam 0.5 mg twice daily for anxiety; -Medi-honey wound and burn dressing external paste apply to coccyx twice daily for open area, cleanse with normal saline, pat dry, apply Medi-honey and cover with border foam. Review of the resident's MARs, dated January 2025, showed the following: -No documentation the resident received morning dose of clonazepam on 1/4/25, 1/8/25, 1/9/25, and 1/23/25; -No documentation the resident received evening dose of clonazepam on 1/4/25, 1/5/25, 1/8/25, 1/9/25, 1/17/25, 1/18/25, and 1/22/25; -No documentation the resident received bedtime dose of Tylenol on 1/16/25 and morning doses on 1/22/25, 1/25/25, 1/26/25 and 1/27/25; -No morning wound care documented as completed on 1/1/25 1/2/25, 1/6/25, 1/16/25, 1/20/25, 1/24/25, 1/25/25 and 1/28/25; -No bedtime wound care documented as completed on 1/1/25, 1/2/25, 1/3/25, 1/6/25, 1/7/25, 1/10/25, 1/11/25, 1/12/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/20/25, 1/21/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25 and 1/30/25. 3. Review of Resident #19's care plan, last reviewed 12/12/24, showed the following: -The resident had a diagnosis of depression and anxiety; -Administer medications as ordered. Review of the resident's POS, dated December 2024, showed the following: -Lorazepam (a medication used to treat anxiety) 0.5 mg every morning; -Lorazepam 0.5 mg every afternoon; -Diagnosis of anxiety. Review of the resident's MARs, dated December 2024, showed the following: -No documentation the resident received morning dose of Lorazepam on 12/20/24 and 12/22/24; -No documentation the resident received afternoon dose of Lorazepam on 12/3/24, 12/7/24, 12/17/24, 12/20/24 and 12/22/24. Review of the resident's POS, dated January 2025, showed the following: -Lorazepam 0.5 mg every morning; -Lorazepam 0.5 mg every afternoon. Review of the resident's MARs, dated January 2025, showed the following: -No documentation the resident received morning dose of Lorazepam on 1/4/25, 1/5/25, 1/8/25, 1/8/25, 1/18/25, and 1/23/25; -No documentation the resident received afternoon dose of Lorazepam on 1/4/25, 1/8/25, 1/9/25 and 1/23/25. During interview on 2/5/25 at 2:01 P.M., LPN C said staff should sign the MAR when they give medications. He/She was not sure why there were days on the MARs/TARs without a signature. 4. Review of Resident #65's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Diagnoses included atrial fibrillation, atherosclerotic heart disease (ASHD), Alzheimer's disease and dementia. Review of the resident's POS, dated February 2025, showed the following: -Aspirin 81 mg every morning for high blood pressure; -Metoprolol 25 mg every morning for high blood pressure; -Diagnoses included hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), atherosclerotic heart disease (a chronic disease which cause arteries to narrow and harden), Alzheimer's disease and dementia; -No order to self-administer medications. Observation on 2/3/25 at 8:06 A.M., showed LPN B prepared the resident's aspirin 81 mg and metoprolol 25 mg. LPN B went to the resident in the dining room and handed the resident the medication cup that contained the medications. LPN B then walked back to the medication cart which was located behind the nurses station and did not observe the resident take his/her medications. During interview on 2/4/25 at 2:55 P.M., LPN B said staff should stay and watch the resident take his/her medications to ensure they take them. 5. During an interview on 2/6/25 at 11:37 A.M., the Director of Nursing said the following: -She expected staff to follow physician orders; -She expected staff to obtain labs as ordered. She recently appointed the MDS/Care Plan Coordinator to track labs to ensure they were completed; -She expected staff to complete treatments as ordered and to measure wounds weekly; -Staff were to document when all medications were administered and treatments were completed on the MAR and TAR; -She was not aware of missing documentation in the MARs/TARs; -If something was not documented, she would assume it was not completed; -She was not aware of anyone monitoring the MARs/TARs for documentation; -She expected staff to stay and observe residents take their medication to ensure they took the medication. She did not believe the facility had any residents who were able to self administer medications. 47008

Based on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks for four residents (Residents #47, #68, #14 and #10), in a review of 18 sampled residents. The facility census was 71. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 3/2022 showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan that includes measurable objectives and timeframe's, and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/20/24, showed the following: -Diagnosis included heart failure, high blood pressure, end stage renal disease (a permanent condition in which the kidneys can no longer filter waste, excess fluids, and electrolytes from the blood. It's also known as kidney failure, and diabetes; -No documentation the resident received dialysis. Review of resident's Physician Order Summary (POS) dated February 2025 showed an order for follow up with nephrologist during dialysis days with a start date 01/28/25. Review of resident's Care Plan, revised 12/05/24, showed no focus, goal or intervention for his/her dialysis care. Interview with resident on 02/05/25 at 8:39 A.M. showed the following: -He/She had been on dialysis for about three years; -He/She goes to dialysis treatment three times weekly. 2. Review of Resident #68's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 1/24/25 showed the following: -Severely impaired cognition; -Dependent for bed mobility, transfers and sitting to lying in bed, lying to sitting in bed and chair/bed-to-chair transfers; -Side rails not used. Review of the resident's care plan, last revised 1/24/25 showed the following: -Impaired ADL performance and mobility status; -Transfer with sit to stand or hoyer (mechanical lift for persons who can not bear weight) lifts; -High risk for falls due to cognitive impairment, history of falls and lack of safety awareness; -Place a fall mattress next to my bed when i am in it; -The care plan did not address the use of side rails. Observation on 2/4/25 at at 6:30 A.M. showed the resident lay on his/her back in the bed with bilateral 1/4 rails (on the top half) of his/her bed. The side rails were in the upright position. Observation on 2/4/25 at 8:11 A.M. showed the resident remained in his/her bed with the 1/4 rails in the upright position. 3. Review of Resident #14's quarterly review MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with rolling left and right; -He/She required substantial assistance with rolling from left to right, sitting to lying, and lying to sitting on the side of bed. Review of the resident's care plan, last reviewed 12/30/24, showed the following: -Diagnoses included: orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position), muscle weakness, difficulty walking, unsteadiness on feet, spinal stenosis (a narrowing of the spinal canal in the lower part of the back), history of falling, and repeated falls; -He/She was at risk for falls; -The care plan did not address the use of bed mobility bars. Observation on 02/02/25 at 10:29 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 02/04/25 at 7:45 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. 4. Review of Resident #10's quarterly review MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She could feed him/herself; -He/She was dependent on staff for all other cares and bed mobility. Review of the resident's care plan, last reviewed 01/28/25, showed the following: -Diagnoses included osteoarthritis, joint pain, history of falling, ataxic gait (uncoordinated, awkward way of walking that's caused by poor balance and muscle control), and neuropathic arthropathy (a condition that causes progressive joint destruction and bone weakening); -He/She was at risk for falls; -The care plan did not address the use of bed mobility bars. Observation on 02/02/25 at 11:40 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 02/03/25 at 8:03 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 02/04/25 at 8:35 A.M., showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. During a phone interview on 02/06/25 at 11:23 A.M., the Care Plan/MDS Coordinator said the following: -She was responsible for updating the care plans; -Care plans should be updated at minimum quarterly and as needed with changes; -When updating a resident's care plan, information was gathered from the IDT, medical records, family and floor staff; -The care plan should reflect the care needs of the resident; -If a resident was receiving dialysis, it should be included on the care plan. The care plan should reflect how often the resident are receiving dialysis and what should be monitored for the resident. During a phone interview on 02/06/25 at 11:40 A.M., the DON said the following: -The care plan should reflect the care needs of the resident; -If a resident had assist bars on their bed to help with bed mobility, she would expect to see it listed on the resident's care plan; -If a resident was receiving dialysis, she would expect to see it listed on the resident's care plan; -If a resident was receiving dialysis, she would expect to see where the resident was receiving dialysis and monitoring for the residentincluding edema, lung sound assessments; any assessment to monitor fluid overload should be listed on the resident's care plan. During an phone interview on 02/06/25 at 12:50, the Administrator said the following: -If a resident had assist bars on their bed, she would expect the information to be listed on the resident's care plan; -If a resident was receiving dialysis, she would expect the information to be listed on the resident's care plan. 47008

Based on interview and record review, the facility failed to maintain a surety bond (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) sufficient to ensure protection of all personal funds the facility held for 43 residents in the resident fund account. The facility census was 71. Request for a facility policy regarding Resident Trust Fund and/or Surety Bond was made with no policy provided. 1. Review of the facility log, listing residents the facility held resident funds for, showed 43 residents held funds in the resident trust fund account. Review of the facility surety bond, dated 02/06/13, showed the facility had an approved surety bond in the amount of $25,000.00. Review of the resident trust fund account for February 2024 to January 2025 showed an average monthly balance of $26,341.93. Calculation showed the facility required a bond in the amount of at least $39,000.00. The current ledger amount was $25,854.64. During an interview on 02/03/25 at 2:49 P.M., the Admissions/Social Services staff said she thought the administrator or Accounts Receivable (AR Business Office) staff was responsible for anything to do with the facility surety bond. During an interview on 02/04/25 at 12:15 P.M., Accounts Receivable staff said she was not responsible for the facility surety bond; she was not sure who was. During an interview on 02/04/25 at 3:30 P.M., the Administrative said the following: -She was not sure who was responsible for the resident trust fund and obtaining the surety bond for the trust; -She had not reviewed the bond to see if it was adequate.

Based on interview and record review, the facility failed to ensure residents had reasonable access to their personal funds. Residents were unable to gain access to their funds on the weekends including one resident (Resident #2) in a review of 18 sampled residents. The facility managed funds for 43 residents. The facility census was 71. Request was made of the facility for a facility policy regarding the Resident Trust Fund and no policy was provided. 1. During an interview on 02/02/25 at 2:44 P.M., Resident #2 said he/she was unable to access his/her resident funds on the weekends. Review of the facility log, listing residents the facility held resident funds for, showed Resident #2 was one of 43 residents that held funds in the resident trust fund account. During an interview on 02/03/25 at 2:49 P.M., the Admissions/Social Services staff said the following: -She handed out resident funds to residents; -The facility held funds for 43 residents; -The Business Office was not open on weekends; -The facility's banking hours were Monday through Friday, 8:00 A.M. to 4:00 P.M.; -The facility did not have banking hours on Saturday; -Residents have to ask ahead of time if they want money on the weekends. During email communication on 02/05/25 at 12:35 P.M., the administrator said she was not aware that residents should have access to resident funds for the same time a bank would be open.

Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature and taste. The facility census was 71. 1. Review of the Diet Orders, printed 2/3/25, showed the following: -13 residents with a physician-ordered mechanical soft diet; -Two residents who preferred to receive a mechanical soft diet; -Six residents with a physician-ordered pureed diet. Review of the facility's recipe binders, located on the food preparation counter and in a rack by the dietary manager's office, showed no recipes (or associated temperature guidelines) for the following food items: -Mechanical soft or pureed potato salad; -Pureed or chopped (mechanical soft) spinach; -Mechanical soft or pureed pork loin. Review of the facility's food substitution log for the lunch meal on 2/4/25 showed pork loin was substituted for pork schnitzel with sour cream dill sauce. German potato salad was substituted for potato salad. Review of temperature logs, located in the kitchen, showing the temperature of the items prior to serving the lunch meal on 2/4/25 showed the following: -Cooking Temperature Log: pork loin 185 degrees F, potato salad 45 degrees F, spinach salad 40 degrees F, cooked spinach 177 degrees F; -Mechanical Soft Temperature Log: meat 170 degrees F, starch 166 degrees F, vegetable 165 degrees F, bread 160 degrees F, dessert RT (room temperature); -Puree Temperature Log: meat 170 degrees F, starch 167 degrees F, vegetable 166 degrees F, bread 160 degrees F, dessert RT. Observation on 2/4/25 from 12:14 P.M. to 12:29 P.M., in the kitchen at the steam table, showed [NAME] L and [NAME] Z served mechanical soft and pureed diet food items onto residents' plates, added a plate cover to each plate, and placed the food items onto trays. Staff then placed the meal trays onto metal tray carts to go to the upstairs dining rooms. Observation on 2/4/25 at 12:32 P.M., in the kitchen at the steam table, showed [NAME] Z plated a test tray of mechanical soft and pureed food items after all residents had been served. He/She placed the test tray on the cart staff took to the east dining room. Observation on 2/4/25, in the east dining room, at 12:34 P.M., showed staff served trays off the meal tray cart (that arrived from the kitchen) to residents with mechanical soft and pureed diets. At 12:39 P.M., staff finished serving all resident from the cart. Observation at 12:40 P.M., of the temperature of the food items on the test tray showed the following: -Mechanical soft potato salad was 61.2 degrees Fahrenheit (F) and tasted warm; -Pureed potato salad was 89.1 degrees F and tasted lukewarm; -Pureed spinach was 108.7 degrees F and tasted cool; -Chopped (mechanical soft) spinach was 105.8 degrees F and tasted cool; -Mechanical soft pork loin was 110.7 degrees F and tasted cool; -Pureed pork loin was 111.2 degrees F and tasted cool. During an interview on 2/4/25 at 2:35 P.M., Resident #36 said he/she preferred to eat in his/her room. About three times a week, the food was medium in temperature. He/She preferred hot foods to be hot and cold foods to be cold. During interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the following: -He expected hot foods to be served to residents at a temperature of at least 135 degrees F and cold foods at less than 40 degrees F; -He expected staff to take temperatures of food items during and after cooking, before and during serving food, and to log the temperatures in the food temperature log books. 44665

Based on observation and interview, the facility failed to ensure lids on outdoor garbage and grease collection containers remained closed or covered when not in use. The census was 71. Observations on 2/3/25 at 3:38 P.M., during the outside sanitation tour near the basement service hall area, showed the following: -A dumpster, approximately 25% full of trash, did not have a lid on the top and front of the dumpster; -A grease container, approximately 90% full of grease, had a lid that hung off to the side of the container. The lid read Grease only. Close lid. A water bottle floated on the surface of the grease in the container. Black and light gray residue was visible on the grass in an approximate 4-foot by 20-foot area around and downhill of the grease container; -No staff were present or actively working in the area where the dumpster and grease container were located. During interview on 2/4/25 at 2:49 P.M., the Dietary Manager said the outside dumpster never had lids. He was unaware the outside grease collection container lid was not covering the opening of the container. During an interview on 2/4/25 at 4:49 P.M., the Administrator said the facility changed garbage disposal companies and received a new dumpster. She was unaware the new dumpster did not have the ability to close the top and front openings of the dumpster. A contracted company came periodically to empty the grease collection container.

Based on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the facility's diet spreadsheet menu. The facility census was 71. 1. Review of the Diet Orders, printed 2/3/25, showed the following: -43 residents with a physician-ordered regular diet; -Ten residents with a physician-ordered consistent carbohydrate (CCHO) (low concentrated sweets (LCS)) diet; -Seven residents with a physician-ordered heart healthy diet; -Four residents with a physician-ordered large portion diet; -Six residents with a physician-ordered pureed diet. Review of the Diet Spreadsheet, for 2/4/25 (Day 24, Tuesday) Lunch, showed the following: -Staff were to serve residents on regular, pureed, CCHO (LCS), heart healthy, mechanical soft, and large portion diets a dinner roll with margarine. (The roll/margarine was to be pureed for the pureed diet orders and a soft dinner roll for the mechanical soft diet orders); -Staff were to serve residents on pureed diets a piece of pureed frosted chocolate cake. Observation on 2/4/25 at 10:18 A.M., showed [NAME] L prepared pureed cake in the food processor and placed the pureed cake in the reach-in cooler in the kitchen. Observation on 2/4/25 from 12:14 P.M. to 12:29 P.M., in the kitchen at the steam table, showed [NAME] L and [NAME] Z prepared residents' plates of mechanical soft and pureed diet food items and placed the items onto trays on carts to go to the upstairs dining rooms. Staff did not serve dinner rolls, soft dinner rolls, pureed dinner rolls, or pureed frosted chocolate cake on the residents' trays. During an interview on 2/4/25 at 12:32 P.M., [NAME] Z said he/she thought the pureed dessert was located on the cart of regular dessert items that was sent up to the east dining room. Observation on 2/4/25 at 12:34 P.M., in the east dining room, showed the following: -Residents on a mechanical soft and pureed diet received plates on trays from a cart that were brought up from the kitchen; -Residents with a pureed diet did not have a dessert on their tray; -The residents on regular, mechanical soft and pureed diets did not receive a dinner roll or margarine. During an interview on 2/4/25 at 12:38 P.M., Certified Nurse Aide (CNA) G said pureed desserts should already be on the trays of residents with a pureed diet. These items were prepared and served on plates in the kitchen and brought up to the dining rooms on carts from the kitchen. A cart of regular dessert items was brought up from the kitchen to the east dining room and CNA G confirmed there were no pureed dessert items on the cart. During an interview on 2/4/25 at 2:26 P.M., Direct Service Aide J (who was responsible to help serve meals) said the following: -Dietary staff brought food from the kitchen to each of the dining rooms for him/her and other staff to serve residents' meals; -He/She was unaware of what items each resident should receive for their diet type; -He/She didn't have a diet spreadsheet menu; -No rolls or pureed frosted chocolate cake were brought up to the east dining room for him/her to serve to residents for the 2/4/25 lunch meal. During interview on 2/4/25 at 2:49 P.M., the Dietary Manager said he expected staff to follow physician-ordered resident diet orders, recipes, and the diet spreadsheet menus.

Based on observation, interview, and record review, the facility failed to ensure one wheelchair bound resident (Resident #7), had a proper fitting wheelchair for his/her height and weight which did not cause him/her pain. The facility also failed to ensure call lights were within reach for one resident (Resident #34). The census was 71. Review of the facility policy, Accommodation of Needs, last revised March 2021, showed the following: -The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. -The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. -In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include: providing a variety of types (for example, chairs with and without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position; -In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example, arranging personal items so that they are in easy reach of the resident. 1. Review of Resident #7's care plan, last revised 11/18/24, showed the following: -The resident wished to be physically comfortable while maintaining a sense of control; -He/She had a decline in activities of daily living (ADL) performance and mobility status related to diagnosis of multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord); -The resident will maintain highest level of functioning within limits of progressive multiple sclerosis. He/She will remain free of complications or discomfort related to multiple sclerosis. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 1/10/25, showed the following: -admitted [DATE]; -Cognitively intact; -Dependent on staff for transfers; -Used a manual wheelchair. Observation on 2/2/25 at 11:40 A.M., showed the resident sat in a wheelchair in the common area. The resident was tall in stature and too large for his/her wheelchair. The seat of the chair was too short for the resident's legs forcing him/her to sit with his/her legs at an awkward angle, with his/her right knee pointed inward. The back of the wheelchair did not rise high enough to support the resident's back and only came up to the resident's lower to mid back. During an interview on 2/4/25 at 2:00 P.M., the resident said the following: -The only wheelchair he/she had to use was the one he/she was sitting in; -The chair was too small but was the only wheelchair the facility had for him/her; -The wheelchair caused him/her to sit awkwardly and caused pain in his/her right hip; -The facility was supposed to find him/her a more suitable wheelchair, but had not. During an interview on 2/5/25 at 10:35 A.M., the Care Plan/MDS Coordinator said the following: -He/She knew the resident's wheelchair was too small and that it caused the resident pain; -The resident should not be in pain due to the chair; -A wheelchair request was in the works for the last six months; -The process for getting the resident an appropriate chair started when their last therapy group was here (services ended in December 2024). The resident had a physician order, the last therapy group measured the resident and was working on finding him/her an appropriate wheelchair. However, when the therapy group left the facility, all of their records went with them; -He/She had not tried to retrieve the therapy group's records; -He/She had not tried to find the resident a more suitable chair within the facility; -The facility was responsible for ensuring the resident had a suitable sized chair. During an interview on 2/6/25 at 11:37 A.M., the Director of Nursing said the following: -The resident should have a proper fitting wheelchair that did not cause him/her pain; -The facility was responsible for ensuring residents had proper equipment, including wheelchairs; -There was no specific staff responsible for obtaining needed equipment for residents; -Since they did not have a therapy department, they only had access to spare equipment (wheelchairs). 2. Review of Resident #34's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Able to make self understood; -Required partial to moderate assistance with bed mobility and transfers. Review of the resident's care plan, last revised 12/12/24, showed the following: -Diagnoses included history of falling, muscle weakness and difficulty walking; -The resident had chronic pain. Anticipate the resident's need for pain relief and respond immediately to any complaints of pain. Observation on 2/2/25 at 11:00 A.M., showed the resident lay in his/her bed. One call light was wrapped around the wall outlet and the second call light in the room laid on the floor. Both call lights were not within the resident's reach Observation on 2/3/25 at 12:35 P.M., showed the resident sat on the side of his/her bed with his/her lunch tray. One call light lay on the floor between the bed and the wall and the other was wrapped around the wall outlet. Neither call light was in the resident's reach. Observations on 2/4/25 at 6:40 A.M. and 9:00 A.M., showed the resident lay in his/her bed. One call light lay on the floor between the bed and the wall and the other call light was wrapped around the wall outlet. Neither call light was in the resident's reach. During an interview on 2/4/25 at 7:55 A.M., Licensed Practical Nurse (LPN) S said call lights should be in the resident's reach at all times. During an interview on 2/4/25 at 1:25 P.M., CNA R said call lights should be in reach of the residents at all times. During an interview on 2/6/25 at 11:37 A.M., the Director of Nursing said call lights should be in reach of all residents at all times.

Based on interview and record review, the facility failed to protect residents on the facility special care unit, including four residents (Resident #54, #59, #500 and #501), in a review of thirteen sampled residents, from verbal and sexual abuse by one resident (Resident #68). Resident #68 had a history of verbal and physical sexually inappropriate behavior. The resident exhibited inappropriate sexual behavior towards other residents on the unit which included touching or attempts to touch their bodies with his/her hands or mouth in a sexual manner and made sexual comments toward them. Resident #501, a cognitively intact resident, experienced psychosocial distress due to interactions with Resident #68 when the resident made him/her feel sexually harassed and mentally abused. Resident #501 demanded to be moved from the special care unit where he she resided with Resident #68, to another part of the facility as a result. The facility census was 73. On 07/13/23 at 5:30 P.M., the facility's administrator was notified of the immediate jeopardy which began on 12/7/22. The IJ was removed on 7/18/23 as confirmed by surveyor onsite verification. Review of the facility policy, Identifying Types of Abuse, revised September 2022 showed the following: -As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents; -Abuse of any kind against residents is strictly prohibited; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Abuse toward a resident can occur as resident-to-resident abuse; -Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability; -Examples of mental and verbal abuse include, but are not limited to harassing a resident, derogatory statements directed to the resident; -Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area; -Generally, sexual contact is nonconsensual if the resident appears to want the contact to occur, but lacks the cognitive ability to consent or the resident does not want the contact to occur; -Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear, or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred; -Abuse may result in psychological, behavioral, or psychosocial outcomes; -The following situations are recognized as those that are likely to cause psychosocial harm which may take months or years to manifest, and have long-term effects on the resident and his/her relationship with others and include sexual assault, unwanted sexual touching and sexual harassment. 1. Review of Resident #68's facility face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's undated facility diagnosis page showed the resident with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, dementia and sexual dysfunction. Review of the resident's facility progress notes showed staff documented the following: -On 11/10/22 at 7:14 P.M., the resident was sexually inappropriate towards staff and was educated on expectations of behavior. Will continue to monitor; -On 11/12/22 at 7:20 P.M., during the resident's shower he/she was noted to be sexually inappropriate with the CNA, making comments about the aide rubbing his/her genitalia. Resident was informed that this behavior was inappropriate. Resident was also noted to be asking this nurse and his/her CNA if we were having sex with our boyfriends/girlfriends; -On 11/14/22 at 6:58 P.M., the resident has been hard to redirect this shift; had to be redirected multiple times for sexual statements, will continue to monitor; -On 11/18/22 at 4:53 P.M., the resident was sexually inappropriate at times. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/22, showed the resident had a Brief Interview for Mental Status (BIMS) (screening tool to assess cognition) of 10, indicating the resident had mild cognitive impairment. The resident had verbal behaviors on two days ( in a seven day look back period), transferred, walked and moved in the bed independently. Review of the resident's facility progress notes showed staff documented the following: -On 12/07/22 at 6:23 P.M., Resident currently sits at the dining room table talking to other residents and trying to kiss multiple (residents of the opposite sex). Resident was redirected multiple times. Resident was educated that his/her behavior was inappropriate and upsetting other residents; -On 12/8/22 at 6:39 P.M., the resident has continued to have multiple episodes of inappropriate behaviors. Noted to be sitting at the breakfast table and said (people of the opposite sex), are like whiskey, they are all good but some are better than others in bed. He/She also asked the CNA multiple times, Do you wanna take a shower with me? You can wash me and then gestured towards his/her genitals. Resident was redirected multiple times and educated that his/her behavior was inappropriate and upsetting other residents, he/she said I will try to work on it. Review of the resident's care plan dated 12/8/22 showed no evidence the resident presented with behaviors or direction for staff to address the resident's sexually inappropriate behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 12/13/22 at 6:50 P.M., the resident has had five episodes of being inappropriate this shift; -On 12/16/22 at 6:03 P.M., the resident had two episodes of sexual inappropriate behavior this shift; -On 12/17/22 at 4:50 P.M., the resident had multiple episodes of sexual inappropriate behavior this shift as well as being verbal hateful, belligerent and verbally abusive to staff and residents; -On 12/18/22 5:39 P.M., the resident has been verbally sexually inappropriate and belligerent today; -On 12/30/22 at 7:11 P.M., has been verbally inappropriate this shift; -On 01/01/23 at 7:20 P.M., has been hateful, belligerent and verbally sexually inappropriate this shift. He/She looked at the table where residents of the opposite sex sat and said, Do you guys wanna get lucky tonight? Do you know what (named specific medication for sexual performance)? I use it so I get lucky; -On 01/02/23 at 6:54 P.M., the resident has been belligerent and sexually inappropriate this shift. He/She would walk around to residents of the opposite sex and try kissing them on the mouth. This nurse had to redirect him/her. Resident screamed, Damn, you just can't let me have no damn fun!; -On 01/15/23 at 7:12 P.M., was sexually inappropriate this shift with another resident. The residents were found in this resident's room on his/her bed, kissing on one another and inappropriately touching one another. The residents were separated and individually educated this was not an appropriate setting for these behaviors; -On 01/26/23 at 2:16 P.M., this resident noted to be sitting very close with another resident of the opposite sex, holding hands with each other and rubbing arms. This nurse attempted to relocate the resident, but this was unsuccessful due to this resident not wanting to move; -On 01/29/23 at 6:20 P.M., the resident grabbed hold of one of the dietary staff of the opposite sex and put his/her arms around him/her and squeezed, saying those are nice. This nurse told the resident that he/she could not be handling or vocalizing like that and it was inappropriate. The resident screamed, It is not inappropriate, he/she let me do it!; -On 01/30/23 at 6:48 P.M., orders received, resident not to be alone with staff or residents of the opposite sex. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 14 (cognitively intact), the resident had verbal behaviors one to three days of the seven day look back period, and was independent with walking, transfers and bed mobility. Review of the resident's facility progress notes showed staff documented the following: -On 02/21/23 at 9:35 A.M., the social worker documented in the last seven days, the resident had one incident of sexually inappropriate behavior. Earlier in February the resident had three incidents of sexually inappropriate behavior, in January-19 incidents, and in December-15 incidents of sexually inappropriate behavior; -On 02/22/23 at 6:22 P.M., the resident walked up to another resident of the opposite sex and asked the other resident to give him/her a kiss; -On 03/06/23 at 2:57 P.M., the resident went up to another resident and kissed that resident on the forehead; and was noted to do this twice during this shift; -On 03/08/23 at 8:20 A.M., noted to go up to another resident of the opposite sex while he/she was eating his/her breakfast and grab the collar of this resident's shirt and ask if he/she could see what was under there; -On 03/08/22 at 11:28 A.M., when another resident of the opposite sex was returning to his/her seat from the bathroom, this resident asked this resident, Can I rub them (breasts)? The other resident replied that no, Resident #68 could not rub his/her breasts. After this incident the resident was redirected; -On 03/10/23 at 1:20 P.M., the resident asked a resident of the opposite sex if they liked to have sex. Staff redirected the resident. The resident then went to another resident and asked him/her the same question. When attempting to redirect, he/she asked if staff was married and had sex; -On 03/11/23 at 10:58 A.M., the resident asked a resident of the opposite sex if he/she has had sex since he/she has been at the facility; -On 03/12/23 at 4:27 P.M., resident noted to rub another resident of the opposite sex's back and he/she asked him/her if he/she had ever had sex. This resident told the resident of the opposite sex, If you come to (resident's room), I'll rub on your breast and I'll rub down there so you will know what it feels like; -On 03/15/23 at 1:41 P.M., resident has had sexual behaviors towards other residents this shift. The resident told another resident He/She would like to have some good clean sex with (opposite sex) residents, while (opposite sex) residents sat at the table eating lunch. One of the residents told him/her he/she was a dirty old (person) and that he/she didn't appreciate the way he/she was talking to him/her, and not to speak to him/her anymore. This resident said okay and that he/she really looked good in his/her shirt. Staff informed this resident that he/she could not talk to other residents in that manner because it made them feel uncomfortable; -On 03/21/23 at 2:03 P.M., the resident has had some inappropriate remarks towards staff and other residents. This resident asked a resident of the opposite sex if he/she had sex recently while being in this nursing home and if he/she wanted to do so, then come to (resident's room) and they could have some. Resident of the opposite sex told him NO they can't do that in here; -On 03/25/23 at 3:04 P.M., this nurse witnessed this resident kiss another resident on the forehead; -On 03/26/23 at 3:07 P.M., this nurse overheard this resident tell a resident of the opposite sex that he/she could sit on his/her lap. Review of the resident's care plan, revised 03/28/23, showed the resident presented with sexual behaviors and now took estrogen (hormone) therapy related to sexual behaviors. The care plan did not identify any other action, other than monitoring for medication side effects, to address the resident's behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 04/03/23 at 6:58 P.M., resident noted to make multiple sexual comments towards staff and other residents; -On 04/13/23 at 6:37 P.M., the resident made multiple sexual comments during this shift to residents and staff. Unable to redirect. During morning meal, this resident was noted to be rubbing a resident of the opposite sex's breast while the other resident attempted to push the resident's hand away. Resident #68 said, Doesn't that feel good?; -On 04/17/23 at 6:28 P.M., continues with inappropriate sexual comments to residents and staff multiple times; -On 04/23/23 at 11:35 A.M., resident exhibiting inappropriate behaviors today. Resident observed in a resident of the opposite sex's room, standing over him/her and touching him/her. This resident was redirected by CNA staff and was given education on why this was not appropriate; -On 04/23/23 at 11:42 A.M., regarding previous nurse's note - CNA defined touching as the resident had his/her hand on the other resident's lap, was rubbing his/her back, and their faces were touching; -On 04/25/23 at 6:34 P.M., resident noted to be asking multiple different residents of the opposite gender to give me a kiss. Resident redirected and reminded of possible germs & infection. Resident acknowledged understanding, but has been noncompliant; -On 04/26/23 at 7:24 P.M., resident noted to be very inappropriate sexually with other residents this shift. Resident grabbed a resident of the opposite gender's breast and told him/her he/she had very nice boobies; -On 04/27/23 at 6:30 P.M., resident has had a couple of inappropriate sexual behaviors this shift; trying to kiss other residents, and asked staff if they had been sexually active before coming to work today; -On 05/11/23 at 3:04 P.M., noted during after morning meal to have his/her hands under another resident's shirt. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 10, the resident had mild cognitive impairment; -Verbal behaviors occurred on four to six days during the seven day look back period; -Independent with bed mobility, transfers and walking. Review of the resident's facility progress notes showed staff documented the following: -On 05/19/23 at 7:13 A.M., the social worker documented in the last seven days he/she had five incidents of sexually inappropriateness. Earlier in May he/she had one incident of grabbing and nine incidents of sexually inappropriateness. In April he/she had 15 incidents of sexually inappropriateness and in March, 26 incidents of sexually inappropriateness; -On 05/29/23 at 7:37 P.M., the resident stood up at the table and unzipped his/her pants and asked to feel this. Told the resident this was inappropriate to do that and asked him/her to zip his/her pants back up; -On 05/31/23 at 11:09 A.M., resident noted to have inappropriate sexual behavior toward other residents this shift; -On 06/09/23 at 5:14 P.M., staff reported that this resident and a resident of the opposite sex were in this resident's room participating in inappropriate sexual behaviors; -On 06/10/23 at 6:23 P.M., resident made frequent sexual remarks to residents of the opposite sex, and asked them if they would give him/her a kiss on the cheek; -On 06/27/23 at 5:37 P.M., resident was kissing another resident; -On 07/01/23 at 6:36 P.M., resident walked up behind a resident of the opposite sex and put his/her hands around his/her shoulders for a hug; the other resident became upset and yelled at this resident to get off of him/her; -On 07/08/23 at 6:53 P.M., resident was noted to compliment the residents and the workers frequently and requested another resident give him/her a kiss. 2. Review of Resident #501's undated face sheet showed the resident had diagnoses including mild cognitive impairment and unspecified dementia. Review of the resident's facility progress notes showed staff documented the following: -On 12/04/2022 at 6:01 P.M., this resident came to this nurse this evening and said he/she did not like another resident (of the opposite sex) and the next time the other resident came near him/her, he/she was going to hit him/her in the stomach; -On 01/04/23 at 11:44 A.M., the resident walked up to the desk while this nurse was having a conversation with another resident. He/She snapped at the other resident saying, Shut up you rude old (person of the opposite sex). This nurse told this resident, This is not a situation that involves you so let's please leave him/her alone and I will come talk to you in just a moment. This resident screamed at this nurse and CNA saying, This does involve me, I live here, he/she makes my life a living hell, I am so fed up with all of you. Review of the resident's census sheet showed he/she moved from the dementia unit (where Resident #68 resided) on 01/04/23 to a room in another part of the facility. Review of the resident's annual MDS dated [DATE] showed the following: -BIMS of 15, cognitively intact; -Adequate hearing; -No behaviors; -Has clear comprehension of others. Review of the resident's care plan, revised 05/26/23, showed the following: -He/She wanted to feel that he/she was in control of his/her life; -He/She has alteration in his/her thought process related to dementia; he/she would like to feel safe. During an interview on 7/13/23, at 2:36 P.M., Resident #501 said the following: -He/She resided on the locked unit for about a year; -He/She demanded to move off of the unit because of Resident #68; -Resident #68 would not leave him/her alone, he/she would follow Resident #501 around constantly; -Resident #68 drove me nuts; -Resident #68 would say sexual things all the time, he/she still shivers at the thought of it; -Resident #68's hands were always on somebody; -Resident #68 tried to touch Resident #501 several times; -The more Resident #501 turned Resident #68 away the more he/she tried; -If Resident #68 wasn't bugging Resident #501 he/she was staring at Resident #501; -He/She was mad at the staff because they wouldn't make Resident #68 stop, the staff would say, He/She is not hurting anyone, but the resident said, He/She was hurting me; -He/She was being sexually harassed by Resident #68, you don't have to touch someone to be sexually abused; -It is not right; -Resident #68 would try to come in his/her room; -He/She can't understand why the staff didn't make him/her leave the resident alone; -It got to the point Resident #501 was scared he/she was going to hurt Resident #68; -Even now, when Resident #68 comes out for events in the main area of the facility he/she will stare at Resident #501 from across the room; -Resident #68 hurts you in a mental way that destroys you and it turns Resident #68 on; -I wanted to pick up a chair and smash it over his/her head, like I was losing myself, I do not have those kind of thoughts; -Resident #68 knew he/she was conquering me, killing me emotionally, and following me around so much I couldn't breathe, like a prisoner; -That is why he/she demanded to move off of the unit. 3. Review of Resident #54's facility diagnosis page showed the resident had a diagnosis of dementia. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 13, (a BIMS of 15 indicates intact cognition). Review of the resident's progress notes showed staff documented on 01/15/23 at 7:14 P.M., the resident was sexually inappropriate this shift with another resident (Resident #68). They were found in the other resident's room on his/her bed, kissing on one another and inappropriately touching one another. Residents were separated and individually educated on this not being an appropriate setting for this behavior. Review of the resident's annual MDS, dated [DATE], showed the resident had a BIMS of 12; the resident had mild cognitive impairment. Review of the resident's progress notes showed the facility Social Worker documented on 02/13/23 at 8:02 A.M. that the resident's BIMS score was 13 and he/she had had one incident of being sexually inappropriate in January (2023). Review of the resident's care plan, dated 03/28/23, showed the resident has alteration in thought process related to dementia. Review of the resident's progress notes showed staff documented on 05/11/23 at 3:06 P.M., the resident was noted to have inappropriate behaviors with another resident (Resident #68). Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 3 indicating severe cognitive impairment; -Had the ability to clearly comprehend; -Made self understood. Review of the resident's progress notes showed staff documented the following: -On 05/12/23 at 1:00 P.M., the Social Worker documented that the resident's BIMS score was three and he/she had two incidents of sexually inappropriate behavior in the last seven days. Earlier in May, he/she had two incidents of sexually inappropriate behavior. In April, he/she had ten incidents of sexually inappropriate behavior and in March, three incidents. -On 06/09/23 at 5:30 P.M., staff reported this resident and another resident of the opposite sex (Resident #68) were in the other resident's room participating in inappropriate sexual behavior. This resident appeared to have his/her shirt up and the other resident had his/her mouth on this resident's breast. 4. Review of Resident #500's facility face sheet showed he/she has diagnoses that include age related cognitive decline. Review of the resident's care plan, dated 06/01/21, showed the resident has alteration in thought process related to dementia, the resident will feel safe. Review of the resident's annual MDS, dated [DATE], showed the following: -BIMS of 9; the resident was cognitively impaired; -Had clear comprehension of others; -Able to make self understood. During an interview on 07/13/23 at 4:22 P.M., the resident said the following: -He/She knew who Resident #68 was; -Resident #68 had tried some hanky panky stuff with him/her before, but he/she always told him/her to get lost; he/she didn't do that kind of stuff; -Resident #68 would try and grab at his/her chest, and kiss or touch him/her. 5. Review of Resident #59's facility diagnoses page showed he/she has diagnoses that include Alzheimer's disease and other symptoms and signs involving cognitive functions and awareness. Review of the resident's significant change MDS, dated [DATE], showed the resident had a BIMS of 4; the resident was cognitively impaired. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 99 (resident unable to complete the interview); the resident was severely cognitively impaired. During an interview on 07/13/23 at 9:45 A.M., Licensed Practical Nurse (LPN) A said the following: -The documentation in Resident #54's progress notes on 01/15/23 documented an incident between Resident #54 and Resident #68 that occurred in Resident #68's room; -He/She was sure Resident #54's progress note of 05/11/23 also documented an incident with Resident #68 that was also of a sexual nature; -The documentation in Resident #54's progress notes on 06/09/23 was again in regards to Resident #68. This was the second time the residents had been found together in Resident #68's room engaging in inappropriate behavior; -He/She had made the documentation in Resident #68's progress notes for 03/08/23 and could recall that the resident of the opposite sex was Resident #59 with that incident; -He/She had also documented in Resident #68's progress notes the incident on 03/08/23; that incident was with Resident #500; -Resident #68 flirted with several of the residents of the opposite sex as well as staff. Resident #500 Never took any stuff from Resident #68 and it always seemed to be Resident #54 that Resident #68 was more attracted to; -He/She had documented the entry in Resident #68's progress notes on 07/01/23 at 6:36 P.M., but could not recall if the other resident was Resident #54 or Resident #500. During an interview on 07/14/23 at 4:14 P.M., Registered Nurse (RN) E said he/she had made the entries in Resident #68's progress notes on 04/23/23 at 11:35 A.M. and 11:42 A.M. He/She could not recall who the resident of the opposite sex was. He/She could only recall making the documentation and that an aide had reported it to him/her. He/She would not consider this abuse. He/She did not recall checking on either resident after the reported incident. Residents in the dementia unit would not be able to give any type of consent, that is why staff needed to redirect when possible. During an interview on 07/13/23 at 10:28 A.M., LPN D said the following: -He/She made the entry in Resident #68's progress notes on 03/11/23 at 10:58 A.M. The resident she was referring to was Resident #54. Resident #68 and #54 had been found together in inappropriate acts a couple of different times. He/She was not sure if he/she would consider Resident #68's behavior abuse or not. The residents had dementia so he/she was not sure if that made a difference or not; -He/She made the entry in Resident #68's progress notes on 03/12/23 at 4:27 P.M., this incident also documented the concern between Resident #68 and #54. During an interview on 07/13/23 at 11:15 A.M., LPN B said the following: -He/She made the entry in Resident #68's progress notes on 03/15/23 at 1:41 P.M. He/She could not recall who the other resident was that was involved. He/She did document that Resident #68's behavior made other residents uncomfortable and that it was of a sexual nature, but he/she was not sure if it was abuse. He/She could not tell if Resident #68's behaviors affected other residents because they had diagnoses of dementia, he/she just knew he/she would not like to be treated that way; -He/She made the entry for 03/21/23 at 2:03 P.M. He/She could not recall the opposite sex resident who was invited back to Resident #68's room. Resident #68 was always making comments to staff in the presence of other residents who probably would feel uncomfortable if they understood what Resident #68 was saying or asking, whether it be to staff or other residents; -On 06/09/23 at 5:14 P.M., he/she made the entry in Resident #68's progress notes. The incident documented was between Resident #54 and Resident #68, Resident #54 was in Resident #68's room. Resident #54 had his/her shirt pulled up and under garment pulled down and Resident #68 had his/her mouth on Resident #54's breast. During an interview on 07/13/23 at 11:52 A.M., LPN F said the following: -He/She made the progress note entries in Resident #68's chart on 04/25/23 and 04/26/23; -On 04/26/23, the resident of the opposite sex involved was Resident #54. During an interview on 07/14/23 at 3:05 P.M., the Social Service Director said the following: -She had heard that Resident #68 had made sexually inappropriate comments and had behaviors. She heard this from staff who reported it to her, but she had been told Resident #68 was re-directable so she had no further concerns and had not reported to anyone; -She does recaps quarterly and documents in the resident progress notes. She had read the documentation that staff completed that showed the resident had sexually inappropriate behaviors; -She was aware of the incident between Resident #54 and Resident #68 that occurred on 06/09/23 when Resident #68 had his/her mouth on Resident #54's breast, but did not recall the incident when Resident #68 and #54 were found in Resident #68's bed touching and kissing; -She was not sure if these incidents were considered abuse; -She had tried to call Resident #54's power of attorney (POA) to see if it was alright for Resident #54 to engage in such behaviors if he/she wanted to; -She knew Resident #54 had a BIMS of 3; a score of three means the resident was cognitively impaired and could not make decisions for him/herself. During an interview on 07/11/23 at 5:30 P.M. and 07/12/23 at 12:22 P.M., the administrator said the following: -She was aware of Resident #68's behaviors that were both verbally and physically sexual in nature; -She had instructed staff to redirect the resident and the resident had been started on medications to help curb sexual tendencies; -She was aware Resident #54 and Resident #68 were found in bed together in January and also aware of an incident in June when Resident #68 has his/her mouth on Resident #54's breast; -She had received complaints about Resident #68 from Resident #501, and knew this resident did not like Resident #68; -She did not know there had been an incident between Resident #68 and Resident #59; -She was aware Resident #68 made advances toward Resident #500 but nothing was acted on; Resident #68 just tried to touch him/her; -She was aware there had been an order to ensure Resident #68 was not alone with staff and residents of the opposite sex. Staff ensure this with room checks every 15 minutes; -She did not consider Resident #68's behavior to be abuse; -She thought Resident #54 had sexual inappropriate behaviors towards Resident #68; specifically when he/she exposed him/herself to Resident #68 and came out of his/her room either with no clothes on or when he/she opened up his/her robe; -She did not know who the aggressor was in these incidents; -A resident with a BIMS of three and with an active power of attorney would not be able to make a determination or consent; -Sexual abuse can be both verbal and physical; -If the behavior happens over and over, it would be considered abuse. She felt like staff redirected Resident #68 and his/her behaviors were not considered abuse; -Dementia residents can be re-directed to get the unwanted behavior to stop; -She did not feel that any harm had been done so these incidents were not considered abuse; -She was not sure how the reasonable person would feel if they were exposed to Resident #68's behaviors. During an interview on 07/14/23 at 3:15 P.M., the Nurse Practitioner said the following: -Resident #68 and #54 were both residents he has seen and cared for at the facility; -He was aware of Resident #68's sexual behaviors, with both verbal and physical contacts; -Neither resident was able to give consent as they have diagnosis of dementia, are cognitively impaired and unable to make such decisions. NOTE: At the time of the abbreviated 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 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 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 to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to protect residents on the facility special care unit, including four residents (Resident #54, #59, #500 and #501), in a review of thirteen sampled residents, from verbal and sexual abuse by one resident (Resident #68). Resident #68 had a history of verbal and physical sexually inappropriate behavior. The resident exhibited inappropriate sexual behavior towards other residents on the unit which included touching or attempts to touch their bodies with his/her hands or mouth in a sexual manner and made sexual comments toward them. Resident #501, a cognitively intact resident, experienced psychosocial distress due to interactions with Resident #68 when the resident made him/her feel sexually harassed and mentally abused. Resident #501 demanded to be moved from the special care unit where he she resided with Resident #68, to another part of the facility as a result. The facility census was 73. On 07/13/23 at 5:30 P.M., the facility's administrator was notified of the immediate jeopardy which began on 12/7/22. The IJ was removed on 7/18/23 as confirmed by surveyor onsite verification. Review of the facility policy, Identifying Types of Abuse, revised September 2022 showed the following: -As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents; -Abuse of any kind against residents is strictly prohibited; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Abuse toward a resident can occur as resident-to-resident abuse; -Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability; -Examples of mental and verbal abuse include, but are not limited to harassing a resident, derogatory statements directed to the resident; -Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area; -Generally, sexual contact is nonconsensual if the resident appears to want the contact to occur, but lacks the cognitive ability to consent or the resident does not want the contact to occur; -Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear, or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred; -Abuse may result in psychological, behavioral, or psychosocial outcomes; -The following situations are recognized as those that are likely to cause psychosocial harm which may take months or years to manifest, and have long-term effects on the resident and his/her relationship with others and include sexual assault, unwanted sexual touching and sexual harassment. 1. Review of Resident #68's facility face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's undated facility diagnosis page showed the resident with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, dementia and sexual dysfunction. Review of the resident's facility progress notes showed staff documented the following: -On 11/10/22 at 7:14 P.M., the resident was sexually inappropriate towards staff and was educated on expectations of behavior. Will continue to monitor; -On 11/12/22 at 7:20 P.M., during the resident's shower he/she was noted to be sexually inappropriate with the CNA, making comments about the aide rubbing his/her genitalia. Resident was informed that this behavior was inappropriate. Resident was also noted to be asking this nurse and his/her CNA if we were having sex with our boyfriends/girlfriends; -On 11/14/22 at 6:58 P.M., the resident has been hard to redirect this shift; had to be redirected multiple times for sexual statements, will continue to monitor; -On 11/18/22 at 4:53 P.M., the resident was sexually inappropriate at times. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/22, showed the resident had a Brief Interview for Mental Status (BIMS) (screening tool to assess cognition) of 10, indicating the resident had mild cognitive impairment. The resident had verbal behaviors on two days ( in a seven day look back period), transferred, walked and moved in the bed independently. Review of the resident's facility progress notes showed staff documented the following: -On 12/07/22 at 6:23 P.M., Resident currently sits at the dining room table talking to other residents and trying to kiss multiple (residents of the opposite sex). Resident was redirected multiple times. Resident was educated that his/her behavior was inappropriate and upsetting other residents; -On 12/8/22 at 6:39 P.M., the resident has continued to have multiple episodes of inappropriate behaviors. Noted to be sitting at the breakfast table and said (people of the opposite sex), are like whiskey, they are all good but some are better than others in bed. He/She also asked the CNA multiple times, Do you wanna take a shower with me? You can wash me and then gestured towards his/her genitals. Resident was redirected multiple times and educated that his/her behavior was inappropriate and upsetting other residents, he/she said I will try to work on it. Review of the resident's care plan dated 12/8/22 showed no evidence the resident presented with behaviors or direction for staff to address the resident's sexually inappropriate behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 12/13/22 at 6:50 P.M., the resident has had five episodes of being inappropriate this shift; -On 12/16/22 at 6:03 P.M., the resident had two episodes of sexual inappropriate behavior this shift; -On 12/17/22 at 4:50 P.M., the resident had multiple episodes of sexual inappropriate behavior this shift as well as being verbal hateful, belligerent and verbally abusive to staff and residents; -On 12/18/22 5:39 P.M., the resident has been verbally sexually inappropriate and belligerent today; -On 12/30/22 at 7:11 P.M., has been verbally inappropriate this shift; -On 01/01/23 at 7:20 P.M., has been hateful, belligerent and verbally sexually inappropriate this shift. He/She looked at the table where residents of the opposite sex sat and said, Do you guys wanna get lucky tonight? Do you know what (named specific medication for sexual performance)? I use it so I get lucky; -On 01/02/23 at 6:54 P.M., the resident has been belligerent and sexually inappropriate this shift. He/She would walk around to residents of the opposite sex and try kissing them on the mouth. This nurse had to redirect him/her. Resident screamed, Damn, you just can't let me have no damn fun!; -On 01/15/23 at 7:12 P.M., was sexually inappropriate this shift with another resident. The residents were found in this resident's room on his/her bed, kissing on one another and inappropriately touching one another. The residents were separated and individually educated this was not an appropriate setting for these behaviors; -On 01/26/23 at 2:16 P.M., this resident noted to be sitting very close with another resident of the opposite sex, holding hands with each other and rubbing arms. This nurse attempted to relocate the resident, but this was unsuccessful due to this resident not wanting to move; -On 01/29/23 at 6:20 P.M., the resident grabbed hold of one of the dietary staff of the opposite sex and put his/her arms around him/her and squeezed, saying those are nice. This nurse told the resident that he/she could not be handling or vocalizing like that and it was inappropriate. The resident screamed, It is not inappropriate, he/she let me do it!; -On 01/30/23 at 6:48 P.M., orders received, resident not to be alone with staff or residents of the opposite sex. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 14 (cognitively intact), the resident had verbal behaviors one to three days of the seven day look back period, and was independent with walking, transfers and bed mobility. Review of the resident's facility progress notes showed staff documented the following: -On 02/21/23 at 9:35 A.M., the social worker documented in the last seven days, the resident had one incident of sexually inappropriate behavior. Earlier in February the resident had three incidents of sexually inappropriate behavior, in January-19 incidents, and in December-15 incidents of sexually inappropriate behavior; -On 02/22/23 at 6:22 P.M., the resident walked up to another resident of the opposite sex and asked the other resident to give him/her a kiss; -On 03/06/23 at 2:57 P.M., the resident went up to another resident and kissed that resident on the forehead; and was noted to do this twice during this shift; -On 03/08/23 at 8:20 A.M., noted to go up to another resident of the opposite sex while he/she was eating his/her breakfast and grab the collar of this resident's shirt and ask if he/she could see what was under there; -On 03/08/22 at 11:28 A.M., when another resident of the opposite sex was returning to his/her seat from the bathroom, this resident asked this resident, Can I rub them (breasts)? The other resident replied that no, Resident #68 could not rub his/her breasts. After this incident the resident was redirected; -On 03/10/23 at 1:20 P.M., the resident asked a resident of the opposite sex if they liked to have sex. Staff redirected the resident. The resident then went to another resident and asked him/her the same question. When attempting to redirect, he/she asked if staff was married and had sex; -On 03/11/23 at 10:58 A.M., the resident asked a resident of the opposite sex if he/she has had sex since he/she has been at the facility; -On 03/12/23 at 4:27 P.M., resident noted to rub another resident of the opposite sex's back and he/she asked him/her if he/she had ever had sex. This resident told the resident of the opposite sex, If you come to (resident's room), I'll rub on your breast and I'll rub down there so you will know what it feels like; -On 03/15/23 at 1:41 P.M., resident has had sexual behaviors towards other residents this shift. The resident told another resident He/She would like to have some good clean sex with (opposite sex) residents, while (opposite sex) residents sat at the table eating lunch. One of the residents told him/her he/she was a dirty old (person) and that he/she didn't appreciate the way he/she was talking to him/her, and not to speak to him/her anymore. This resident said okay and that he/she really looked good in his/her shirt. Staff informed this resident that he/she could not talk to other residents in that manner because it made them feel uncomfortable; -On 03/21/23 at 2:03 P.M., the resident has had some inappropriate remarks towards staff and other residents. This resident asked a resident of the opposite sex if he/she had sex recently while being in this nursing home and if he/she wanted to do so, then come to (resident's room) and they could have some. Resident of the opposite sex told him NO they can't do that in here; -On 03/25/23 at 3:04 P.M., this nurse witnessed this resident kiss another resident on the forehead; -On 03/26/23 at 3:07 P.M., this nurse overheard this resident tell a resident of the opposite sex that he/she could sit on his/her lap. Review of the resident's care plan, revised 03/28/23, showed the resident presented with sexual behaviors and now took estrogen (hormone) therapy related to sexual behaviors. The care plan did not identify any other action, other than monitoring for medication side effects, to address the resident's behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 04/03/23 at 6:58 P.M., resident noted to make multiple sexual comments towards staff and other residents; -On 04/13/23 at 6:37 P.M., the resident made multiple sexual comments during this shift to residents and staff. Unable to redirect. During morning meal, this resident was noted to be rubbing a resident of the opposite sex's breast while the other resident attempted to push the resident's hand away. Resident #68 said, Doesn't that feel good?; -On 04/17/23 at 6:28 P.M., continues with inappropriate sexual comments to residents and staff multiple times; -On 04/23/23 at 11:35 A.M., resident exhibiting inappropriate behaviors today. Resident observed in a resident of the opposite sex's room, standing over him/her and touching him/her. This resident was redirected by CNA staff and was given education on why this was not appropriate; -On 04/23/23 at 11:42 A.M., regarding previous nurse's note - CNA defined touching as the resident had his/her hand on the other resident's lap, was rubbing his/her back, and their faces were touching; -On 04/25/23 at 6:34 P.M., resident noted to be asking multiple different residents of the opposite gender to give me a kiss. Resident redirected and reminded of possible germs & infection. Resident acknowledged understanding, but has been noncompliant; -On 04/26/23 at 7:24 P.M., resident noted to be very inappropriate sexually with other residents this shift. Resident grabbed a resident of the opposite gender's breast and told him/her he/she had very nice boobies; -On 04/27/23 at 6:30 P.M., resident has had a couple of inappropriate sexual behaviors this shift; trying to kiss other residents, and asked staff if they had been sexually active before coming to work today; -On 05/11/23 at 3:04 P.M., noted during after morning meal to have his/her hands under another resident's shirt. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 10, the resident had mild cognitive impairment; -Verbal behaviors occurred on four to six days during the seven day look back period; -Independent with bed mobility, transfers and walking. Review of the resident's facility progress notes showed staff documented the following: -On 05/19/23 at 7:13 A.M., the social worker documented in the last seven days he/she had five incidents of sexually inappropriateness. Earlier in May he/she had one incident of grabbing and nine incidents of sexually inappropriateness. In April he/she had 15 incidents of sexually inappropriateness and in March, 26 incidents of sexually inappropriateness; -On 05/29/23 at 7:37 P.M., the resident stood up at the table and unzipped his/her pants and asked to feel this. Told the resident this was inappropriate to do that and asked him/her to zip his/her pants back up; -On 05/31/23 at 11:09 A.M., resident noted to have inappropriate sexual behavior toward other residents this shift; -On 06/09/23 at 5:14 P.M., staff reported that this resident and a resident of the opposite sex were in this resident's room participating in inappropriate sexual behaviors; -On 06/10/23 at 6:23 P.M., resident made frequent sexual remarks to residents of the opposite sex, and asked them if they would give him/her a kiss on the cheek; -On 06/27/23 at 5:37 P.M., resident was kissing another resident; -On 07/01/23 at 6:36 P.M., resident walked up behind a resident of the opposite sex and put his/her hands around his/her shoulders for a hug; the other resident became upset and yelled at this resident to get off of him/her; -On 07/08/23 at 6:53 P.M., resident was noted to compliment the residents and the workers frequently and requested another resident give him/her a kiss. 2. Review of Resident #501's undated face sheet showed the resident had diagnoses including mild cognitive impairment and unspecified dementia. Review of the resident's facility progress notes showed staff documented the following: -On 12/04/2022 at 6:01 P.M., this resident came to this nurse this evening and said he/she did not like another resident (of the opposite sex) and the next time the other resident came near him/her, he/she was going to hit him/her in the stomach; -On 01/04/23 at 11:44 A.M., the resident walked up to the desk while this nurse was having a conversation with another resident. He/She snapped at the other resident saying, Shut up you rude old (person of the opposite sex). This nurse told this resident, This is not a situation that involves you so let's please leave him/her alone and I will come talk to you in just a moment. This resident screamed at this nurse and CNA saying, This does involve me, I live here, he/she makes my life a living hell, I am so fed up with all of you. Review of the resident's census sheet showed he/she moved from the dementia unit (where Resident #68 resided) on 01/04/23 to a room in another part of the facility. Review of the resident's annual MDS dated [DATE] showed the following: -BIMS of 15, cognitively intact; -Adequate hearing; -No behaviors; -Has clear comprehension of others. Review of the resident's care plan, revised 05/26/23, showed the following: -He/She wanted to feel that he/she was in control of his/her life; -He/She has alteration in his/her thought process related to dementia; he/she would like to feel safe. During an interview on 7/13/23, at 2:36 P.M., Resident #501 said the following: -He/She resided on the locked unit for about a year; -He/She demanded to move off of the unit because of Resident #68; -Resident #68 would not leave him/her alone, he/she would follow Resident #501 around constantly; -Resident #68 drove me nuts; -Resident #68 would say sexual things all the time, he/she still shivers at the thought of it; -Resident #68's hands were always on somebody; -Resident #68 tried to touch Resident #501 several times; -The more Resident #501 turned Resident #68 away the more he/she tried; -If Resident #68 wasn't bugging Resident #501 he/she was staring at Resident #501; -He/She was mad at the staff because they wouldn't make Resident #68 stop, the staff would say, He/She is not hurting anyone, but the resident said, He/She was hurting me; -He/She was being sexually harassed by Resident #68, you don't have to touch someone to be sexually abused; -It is not right; -Resident #68 would try to come in his/her room; -He/She can't understand why the staff didn't make him/her leave the resident alone; -It got to the point Resident #501 was scared he/she was going to hurt Resident #68; -Even now, when Resident #68 comes out for events in the main area of the facility he/she will stare at Resident #501 from across the room; -Resident #68 hurts you in a mental way that destroys you and it turns Resident #68 on; -I wanted to pick up a chair and smash it over his/her head, like I was losing myself, I do not have those kind of thoughts; -Resident #68 knew he/she was conquering me, killing me emotionally, and following me around so much I couldn't breathe, like a prisoner; -That is why he/she demanded to move off of the unit. 3. Review of Resident #54's facility diagnosis page showed the resident had a diagnosis of dementia. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 13, (a BIMS of 15 indicates intact cognition). Review of the resident's progress notes showed staff documented on 01/15/23 at 7:14 P.M., the resident was sexually inappropriate this shift with another resident (Resident #68). They were found in the other resident's room on his/her bed, kissing on one another and inappropriately touching one another. Residents were separated and individually educated on this not being an appropriate setting for this behavior. Review of the resident's annual MDS, dated [DATE], showed the resident had a BIMS of 12; the resident had mild cognitive impairment. Review of the resident's progress notes showed the facility Social Worker documented on 02/13/23 at 8:02 A.M. that the resident's BIMS score was 13 and he/she had had one incident of being sexually inappropriate in January (2023). Review of the resident's care plan, dated 03/28/23, showed the resident has alteration in thought process related to dementia. Review of the resident's progress notes showed staff documented on 05/11/23 at 3:06 P.M., the resident was noted to have inappropriate behaviors with another resident (Resident #68). Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 3 indicating severe cognitive impairment; -Had the ability to clearly comprehend; -Made self understood. Review of the resident's progress notes showed staff documented the following: -On 05/12/23 at 1:00 P.M., the Social Worker documented that the resident's BIMS score was three and he/she had two incidents of sexually inappropriate behavior in the last seven days. Earlier in May, he/she had two incidents of sexually inappropriate behavior. In April, he/she had ten incidents of sexually inappropriate behavior and in March, three incidents. -On 06/09/23 at 5:30 P.M., staff reported this resident and another resident of the opposite sex (Resident #68) were in the other resident's room participating in inappropriate sexual behavior. This resident appeared to have his/her shirt up and the other resident had his/her mouth on this resident's breast. 4. Review of Resident #500's facility face sheet showed he/she has diagnoses that include age related cognitive decline. Review of the resident's care plan, dated 06/01/21, showed the resident has alteration in thought process related to dementia, the resident will feel safe. Review of the resident's annual MDS, dated [DATE], showed the following: -BIMS of 9; the resident was cognitively impaired; -Had clear comprehension of others; -Able to make self understood. During an interview on 07/13/23 at 4:22 P.M., the resident said the following: -He/She knew who Resident #68 was; -Resident #68 had tried some hanky panky stuff with him/her before, but he/she always told him/her to get lost; he/she didn't do that kind of stuff; -Resident #68 would try and grab at his/her chest, and kiss or touch him/her. 5. Review of Resident #59's facility diagnoses page showed he/she has diagnoses that include Alzheimer's disease and other symptoms and signs involving cognitive functions and awareness. Review of the resident's significant change MDS, dated [DATE], showed the resident had a BIMS of 4; the resident was cognitively impaired. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 99 (resident unable to complete the interview); the resident was severely cognitively impaired. During an interview on 07/13/23 at 9:45 A.M., Licensed Practical Nurse (LPN) A said the following: -The documentation in Resident #54's progress notes on 01/15/23 documented an incident between Resident #54 and Resident #68 that occurred in Resident #68's room; -He/She was sure Resident #54's progress note of 05/11/23 also documented an incident with Resident #68 that was also of a sexual nature; -The documentation in Resident #54's progress notes on 06/09/23 was again in regards to Resident #68. This was the second time the residents had been found together in Resident #68's room engaging in inappropriate behavior; -He/She had made the documentation in Resident #68's progress notes for 03/08/23 and could recall that the resident of the opposite sex was Resident #59 with that incident; -He/She had also documented in Resident #68's progress notes the incident on 03/08/23; that incident was with Resident #500; -Resident #68 flirted with several of the residents of the opposite sex as well as staff. Resident #500 Never took any stuff from Resident #68 and it always seemed to be Resident #54 that Resident #68 was more attracted to; -He/She had documented the entry in Resident #68's progress notes on 07/01/23 at 6:36 P.M., but could not recall if the other resident was Resident #54 or Resident #500. During an interview on 07/14/23 at 4:14 P.M., Registered Nurse (RN) E said he/she had made the entries in Resident #68's progress notes on 04/23/23 at 11:35 A.M. and 11:42 A.M. He/She could not recall who the resident of the opposite sex was. He/She could only recall making the documentation and that an aide had reported it to him/her. He/She would not consider this abuse. He/She did not recall checking on either resident after the reported incident. Residents in the dementia unit would not be able to give any type of consent, that is why staff needed to redirect when possible. During an interview on 07/13/23 at 10:28 A.M., LPN D said the following: -He/She made the entry in Resident #68's progress notes on 03/11/23 at 10:58 A.M. The resident she was referring to was Resident #54. Resident #68 and #54 had been found together in inappropriate acts a couple of different times. He/She was not sure if he/she would consider Resident #68's behavior abuse or not. The residents had dementia so he/she was not sure if that made a difference or not; -He/She made the entry in Resident #68's progress notes on 03/12/23 at 4:27 P.M., this incident also documented the concern between Resident #68 and #54. During an interview on 07/13/23 at 11:15 A.M., LPN B said the following: -He/She made the entry in Resident #68's progress notes on 03/15/23 at 1:41 P.M. He/She could not recall who the other resident was that was involved. He/She did document that Resident #68's behavior made other residents uncomfortable and that it was of a sexual nature, but he/she was not sure if it was abuse. He/She could not tell if Resident #68's behaviors affected other residents because they had diagnoses of dementia, he/she just knew he/she would not like to be treated that way; -He/She made the entry for 03/21/23 at 2:03 P.M. He/She could not recall the opposite sex resident who was invited back to Resident #68's room. Resident #68 was always making comments to staff in the presence of other residents who probably would feel uncomfortable if they understood what Resident #68 was saying or asking, whether it be to staff or other residents; -On 06/09/23 at 5:14 P.M., he/she made the entry in Resident #68's progress notes. The incident documented was between Resident #54 and Resident #68, Resident #54 was in Resident #68's room. Resident #54 had his/her shirt pulled up and under garment pulled down and Resident #68 had his/her mouth on Resident #54's breast. During an interview on 07/13/23 at 11:52 A.M., LPN F said the following: -He/She made the progress note entries in Resident #68's chart on 04/25/23 and 04/26/23; -On 04/26/23, the resident of the opposite sex involved was Resident #54. During an interview on 07/14/23 at 3:05 P.M., the Social Service Director said the following: -She had heard that Resident #68 had made sexually inappropriate comments and had behaviors. She heard this from staff who reported it to her, but she had been told Resident #68 was re-directable so she had no further concerns and had not reported to anyone; -She does recaps quarterly and documents in the resident progress notes. She had read the documentation that staff completed that showed the resident had sexually inappropriate behaviors; -She was aware of the incident between Resident #54 and Resident #68 that occurred on 06/09/23 when Resident #68 had his/her mouth on Resident #54's breast, but did not recall the incident when Resident #68 and #54 were found in Resident #68's bed touching and kissing; -She was not sure if these incidents were considered abuse; -She had tried to call Resident #54's power of attorney (POA) to see if it was alright for Resident #54 to engage in such behaviors if he/she wanted to; -She knew Resident #54 had a BIMS of 3; a score of three means the resident was cognitively impaired and could not make decisions for him/herself. During an interview on 07/11/23 at 5:30 P.M. and 07/12/23 at 12:22 P.M., the administrator said the following: -She was aware of Resident #68's behaviors that were both verbally and physically sexual in nature; -She had instructed staff to redirect the resident and the resident had been started on medications to help curb sexual tendencies; -She was aware Resident #54 and Resident #68 were found in bed together in January and also aware of an incident in June when Resident #68 has his/her mouth on Resident #54's breast; -She had received complaints about Resident #68 from Resident #501, and knew this resident did not like Resident #68; -She did not know there had been an incident between Resident #68 and Resident #59; -She was aware Resident #68 made advances toward Resident #500 but nothing was acted on; Resident #68 just tried to touch him/her; -She was aware there had been an order to ensure Resident #68 was not alone with staff and residents of the opposite sex. Staff ensure this with room checks every 15 minutes; -She did not consider Resident #68's behavior to be abuse; -She thought Resident #54 had sexual inappropriate behaviors towards Resident #68; specifically when he/she exposed him/herself to Resident #68 and came out of his/her room either with no clothes on or when he/she opened up his/her robe; -She did not know who the aggressor was in these incidents; -A resident with a BIMS of three and with an active power of attorney would not be able to make a determination or consent; -Sexual abuse can be both verbal and physical; -If the behavior happens over and over, it would be considered abuse. She felt like staff redirected Resident #68 and his/her behaviors were not considered abuse; -Dementia residents can be re-directed to get the unwanted behavior to stop; -She did not feel that any harm had been done so these incidents were not considered abuse; -She was not sure how the reasonable person would feel if they were exposed to Resident #68's behaviors. During an interview on 07/14/23 at 3:15 P.M., the Nurse Practitioner said the following: -Resident #68 and #54 were both residents he has seen and cared for at the facility; -He was aware of Resident #68's sexual behaviors, with both verbal and physical contacts; -Neither resident was able to give consent as they have diagnosis of dementia, are cognitively impaired and unable to make such decisions. NOTE: At the time of the abbreviated 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 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 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 to be taken to address Class I violation(s).

Based on observation, interview, and record review, facility staff failed to identify signs and symptoms of hyperglycemia (an excess of glucose in the bloodstream) on 4/25/23 for one resident, (Resident #32), who had a diagnosis of diabetes, when the resident presented with shaking and excessive thirst. The resident's care plan instructed staff to be alert to signs of high blood sugar and contact the physician as indicated. Facility staff did not check the resident's blood sugar or call the resident's physician to report the noted signs and symptoms. On the morning of 4/26/23, the facility failed to obtain a fasting blood sugar as ordered. On the afternoon of 4/26/23, the facility notified the resident's physician the resident had become lethargic, unresponsive and pale. The resident's physician instructed staff to check the resident's blood sugar and the reading on the facility meter resulted high. The resident was sent to the hospital and assessed with a blood sugar of 797 (normal range 80-120 mg/dl). The resident was admitted to the hospital under ICU (intensive care unit) care and placed on an insulin drip (insulin given through an IV (access to the vein) to lower his/her blood sugar. Interview with the resident's physician showed he would have wanted to be notified on 4/25/23 of the resident's condition and he/she would have instructed for the resident's blood sugar to be checked. The facility census was 76. The administrator was notified of the Immediate Jeopardy (IJ) on 4/27/23 at 5:00 P.M. which began on 4/25/23. The IJ was removed on 5/1/23 as confirmed by surveyor onsite verification. Review of the facility policy, Diabetes Clinical Protocol, revised November 2020, showed the following: -The staff will identify and report issues that may affect, or be affected by, a resident's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia; -Urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for two or more days and has fever, hypotension (low blood pressure), lethargy or confusion; -The physician will help the staff clarify and respond to these episodes. Review of the facility policy, Regarding Physician Orders, revised August 2021, showed the following: -It is the responsibility of each charge nurse to assess, document, provide and initiate interventions and to consult with that resident's Primary Care Physician with any/all abnormal findings regarding the resident; -The charge nurse is held accountable and responsible for keeping not only the family informed of potential issues found upon the resident assessment but to also keep the Primary Care Physician informed of ALL issues found concerning the resident. 1. Review of Resident #32's Care Plan, dated 10/23/18, showed the following: -Be alert to signs of high blood sugar including flushed, dry skin, drowsiness, nausea/vomiting, abnormal pain, soft sunken eye balls, red lips, decreased blood pressure, acetone breath, and increased respirations (hyperglycemia). Contact physician as indicated; -Make sure the resident's needs are met such as hunger and thirst; -Anticipate his/her needs and pay attention to nonverbal cues. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/31/23, showed the following: -Severely impaired cognition; -Diagnosis of diabetes mellitus; -No insulin orders. Review of the resident's April 2023 physician orders showed the following: -Accucheck (blood sugar check) three times a week before breakfast on Monday, Wednesday, and Friday. Notify the physician if the blood sugar is below 70 or above 400; -Push water/fluid intake when awake; -Assist with feeding with every meal and snack. Observation on 4/25/23 at 4:04 P.M., showed the resident was in main living room on the West hall. He/She was pale, had facial grimacing and a clenched mouth. He/She was gritting his/her teeth, his/her hands were in fists, and he/she was shaking. During an interview on 4/25/23 at 4:06 P.M., Licensed Practical Nurse (LPN) N said the following: -The resident was not diabetic; -The resident had not been eating much the past couple of days; -Yesterday, the resident ate breakfast, but not much lunch or dinner; -Today, the resident didn't eat much at breakfast and didn't eat any lunch; -The resident appears in pain, so he/she was going to give him/her some Tylenol. During an interview on 4/25/23 at 4:12 P.M., LPN N (after he/she reviewed the resident's medical record) said the resident was a diabetic, but was not insulin dependent. Review of the resident's Nurse's Note dated 4/25/23 at 4:16 P.M., showed the following: -Resident refused breakfast and lunch, showing signs and symptoms of pain and discomfort with facial grimace and hands in fists. Provided as needed pain medication. Observation on 4/25/23 at 4:20 P.M. showed the following: -LPN N crushed Tylenol and mixed it with applesauce and fed it to the resident; -The resident's lips and mouth were dry/crusty, and his/her tongue was covered with a white film; -LPN N provided the resident an 8-ounce cup of water, and the resident gulped it very quickly through a straw; -LPN N provided the resident a second 8-ounce cup of water, and the resident gulped it through a straw so quickly that he/she began to cough. During an interview on 4/27/23 at 1:19 P.M., LPN N said the following: -He/She didn't check the resident's blood sugar because he/she just thought the resident was thirsty since he/she had missed a meal; -The resident was not insulin dependent; -The resident normally sat with his/her hands clenched; -Excessive thirst, dry mouth, and shaking are all signs of hyperglycemia; -He/She was still trying to learn resident's baselines; -He/She did not notify the resident's family or physician because the resident didn't continue to show signs and symptoms after the pain medication was given. Review of the resident's medical record for 4/26/23 (Wednesday) showed no documentation staff checked the resident's blood sugar before breakfast as directed in his/her physician's order. Review of the resident's progress note, dated 4/26/23 at 1:55 P.M., showed the following: -The resident became lethargic during his/her shower and began to appear as if he/she was becoming non-responsive; -The resident was pale in color, clenching his/her mouth and fists; -Staff notified the resident's primary care physician and he/she directed staff to check the resident's blood sugar. The results read HIGH; -The resident was sent to the hospital. Review of the resident's hospital records, dated 4/26/23 at 3:00 P.M., showed the following: -Glucose, Plasma 797 (normal range between 70-100 mg/dL); -Labs notable for leukocytosis (an increase in the number of white cells in the blood, especially during an infection), hyperglycemia (an excess of glucose in the bloodstream) and hyponatremia (a lower than normal level of sodium in the bloodstream) and acute renal failure (AKI; a condition in which the kidneys suddenly can't filter waste from the blood) concerning for significant dehydration; -Fluid boluses given and started on insulin drip (administering insulin directly into the bloodstream through a thin tube in a vein). Review of the resident's progress note, dated 4/26/23 at 7:37 P.M., showed the resident was in the hospital ICU on an insulin drip. The resident's admitting diagnoses were hyperglycemia, dehydration (a harmful reduction in the amount of water in the body), and hypernatremia. During an interview on 4/27/23 at 10:45 A.M., the resident's physician said the following: -He would expect staff to notify him with signs and symptoms of hyperglycemia. He would have expected to staff to notify him on 4/25/23 when the resident first presented with signs and symptoms; -He would expect staff to check a resident's blood sugars with signs and symptoms of hyperglycemia or would have expected staff to at least call him to get an order to check the resident's blood sugar on 4/25/23; -He would expect staff to follow physician orders. During an interview on 4/27/23 at 11:15 A.M., the Director of Nursing (DON) said the following: -She expected staff to check a resident's blood sugar when the resident has signs and symptoms of hyperglycemia, and to complete a full assessment on the resident and notify the physician; -The blood sugar checks, assessment, and physician notification should all be documented in the electronic medical record. During an interview on 5/2/23 at 7:11 P.M., the Administrator said the following: -She expected staff to use their nursing judgement for diabetic residents with no Accucheck orders and to check a blood sugar prior to giving any insulin, as well as with any change in the condition of the resident. NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G 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). 47246

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #1 and #2) of seven sampled residents were free from verbal abuse when Certified Nurse Aide (CNA) C cursed and yelled at the residents. Staff witnessed CNA C curse and yell directly at Resident #1 and Resident #2 while providing the residents assistance with Activities of Daily Living (ADLs). The facility census was 65. The administrator was notified on 3/18/22 at 4:30 P.M. of the Immediate Jeopardy (IJ) which began on 3/1/22. The IJ was removed on 3/18/22, as confirmed by surveyor onsite verification. Review of the facility policy undated Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy showed the following in part: -An administrator, licensed nurse, employee or volunteer should not physically, mentally or emotionally abuse a residents. -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. Abuse included verbal, sexual, physical, and mental abuse and including abuse facilitated or enabled through the use of technology. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse included but were not limited to threats of harm, saying things to frighten a resident such as telling a resident they would never be able to see family again. 1. Review of the facility investigation summary, dated 3/7/22, showed the Director of Nurses (DON) documented Registered Nurse (RN) B reported on 3/2/22 complaints of alleged verbal abuse by CNA C towards two residents (Resident #1 and Resident #2). Review of the facility acquired written statement from CNA D, dated 3/4/22, showed on 3/2/22 around 1:00 A.M., CNA C was in Resident #1's room with CNA D. Resident #1 sat on the edge of his/her bed and was trying to stand up. CNA C said, what the hell are you doing, it is time for bed, not time to get up! You need to lay the fuck down, I'm not dealing with your shit tonight. CNA C proceeded to lay Resident #1 down, cover him/her up, and CNA C sat in the chair to make sure Resident #1 fell asleep. Review of the facility acquired written statement from RN B, dated 3/2/22, showed the following: -Last night (3/1/22) at the beginning of the shift, CNA C told Resident #2 Just shut up. Go to your room and I will be down there in a minute when Resident #2 asked to go to the bathroom. Resident #2 went down the wrong hall and CNA C yelled from behind the nurses' station, damn it, go to your damn room; -From the beginning of the shift until almost 12:00 A.M., CNA C was rude and talked down to the residents; -At approximately 1:20 A.M. CNA C said Resident #1 was on the floor. RN B went to the resident's room and found the resident on the floor asking what happened. CNA C said to Resident #1, you did not keep your ass in bed and you fell and landed on your ass. RN B brought Resident #1 in a wheelchair to the common area near the nurses' station and transferred the resident to a recliner. CNA C asked why the hell did you bring the resident up here, he/she was just going to scream all night and CNA C was not listening to his/her (the resident's) ass. RN B informed CNA C his/her language was enough, the resident just fell and needed brought up front where RN B could keep an eye on the resident; -CNA C yelled at other residents during the shift if they put their call light on. Review of the facility acquired written statement from Licensed Practical Nurse (LPN) A, dated 3/2/22, showed when LPN A arrived to work, CNA C was at the East side nurses station with Resident #1. CNA C said Resident #1 needed his/her ass back in the locked dementia care unit while pointing at Resident #1. LPN A told CNA C watch your mouth that was inappropriate. 2. Record review of Resident #1's Care Plan, dated 2/10/22, showed the following: -Diagnosis of Alzheimer's disease, dementia, depression, and fractured hip; -The resident had a decline in ADLs and mobility and required staff assistance with ADLs. Staff should monitor and assist as needed; -The resident took medication for depression. Staff should encourage socialization, and encourage to attend activities of choice. If behaviors were present always attempt to rule out medical or environmental stimuli as a causative factor. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/16/22, showed the following: -Severely impaired cognition; -Had little interest or pleasure in doing things, felt down, depressed or hopeless. The resident felt tired and had little energy, felt bad about his/herself, or felt he/she was a failure or had let his/herself or family down for 12 to 14 days of the previous two weeks; -Moderately depressed; -Required extensive assistance of one staff member with bed mobility, locomotion on the unit, dressing, and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting. Observation on 3/15/22 at 1:15 P.M., showed the resident seated in a wheelchair near the nurses' desk. A bedside table sat in front of the resident with items for the resident's use and activity. Staff said the resident was anxious today and needed continuous observation. During interview on 3/18/22 at 1:50 P.M., Resident #1's family member said he/she was the resident's responsible party. The resident would not have liked to be spoken to in that manner. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Short and long term memory problems; -Required extensive assistance of one staff member with bed mobility, locomotion on the unit, dressing, and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting. Review of the resident's Care Plan, updated 1/5/22, showed the following: -Diagnosis of stroke, dementia with behavioral disturbance, lung cancer, abnormal gait and mobility, chronic pain, retinopathy, history of brain cancer; -The resident had impaired mobility and activity of daily living (ADLs) performance and required extensive staff assistance with ADLs; -The resident had altered vision and impaired hearing. Staff should keep distractions to a minimum, give the resident time to respond, tell the resident what staff were doing and why, reduce the noise level before talking with the resident, maintain eye contact with speaking, stand close when speaking with the resident and provide adequate lighting; -The resident had depression and alteration in thought processes. Staff should encourage participation in activities, allow the resident to make choices whenever possible, and allow time for him/her to process thoughts and respond. Staff should offer simple instructions, be flexible and patient and encourage involvement in daily life to make the resident feel safe, physically comfortable, and experience a sense of control. Observation and interview of the resident on 3/15/22 at 3:15 P.M., showed the resident sat in a wheelchair, was visually impaired, and made loud noises at the end of a sentence. During interview on 3/29/22 at 2:02 P.M., Resident #2's family member said he/she was the resident's responsible party. The resident in his/her normal mental state would not tolerate verbal abuse. 4. During interview on 3/18/22 at 10:10 P.M., CNA D said the following: -He/She heard CNA C say to Resident #2, it was fucking late and Resident #2 needed to get in the fucking bed; -Resident #2 heard CNA C; -The resident was seated near the nurses' desk in a wheelchair at the time; -The resident started down the hall in his/her wheelchair, he/she did not say anything; -He/She heard CNA C say to Resident #1 what the hell are you doing, it was time for bed, not time to get up, you need to lay the fuck down, I am not dealing with your shit tonight; -CNA C was verbally abusive to both residents; -CNA D told RN B about the verbal abuse. During interview on 3/18/22 at 9:55 P.M., RN B said the following: -He/She was the night shift charge nurse on 3/1/22 from 11:00 P.M. to 7:00 A.M.; -CNA C was verbally abusive to Resident #1 and Resident #2 that night; -RN B heard CNA C tell Resident #2 just shut up, go to your room and I will be down there in a minute followed by damn it go to your damn room; -RN B heard CNA C tell Resident #1 you did not keep your ass in bed and you fell and landed on your ass. During interview on 3/18/22 at 10:00 A.M., LPN A said on 3/2/22 he/she arrived at the facility at 6:45 A.M. Resident #1 sat at the nurses' desk in a wheelchair. CNA C stood directly behind the resident with his/her hands on the resident's wheelchair and said you need to take his/her ass back to the locked dementia unit. The resident was able to hear what CNA C said. The resident did not respond. LPN A told CNA C that was not appropriate language. Cussing at residents was verbal and emotional abuse. During interviews on 3/15/22 at 2:30 P.M. and 3/18/22 at 2:00 P.M., the Director of Nursing (DON) said the following: -She learned of the verbal abuse from RN B the morning of 3/2/22 at approximately 8:30 A.M.; -Cussing at residents was verbal abuse. During interviews the administrator said the following: -On 3/15/22 at 4:10 P.M. she was not notified CNA C had verbally abused Resident #1 and Resident #2 during the night shift on 3/1/22 through 3/2/22. -On 3/18/22 at 1:30 P.M., she said cussing at or towards a resident was abuse. CNA C was verbally abusive towards both residents when he/she cussed and yelled at the residents. Cussing or yelling at Resident #1 could be agitating to the resident, the resident got anxious easily. MO #00197890 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).

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #1) identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive and without a pulse or respirations on [DATE] and failed to initiate CPR and call 911. The resident expired at the facility. The facility also failed to implement the facility policy addressing CPR requirements for staff and to monitor to ensure CPR certified staff were scheduled and present in the facility 24 hours a day, seven days a week. This failure affected 28 residents who were identified as full code status. The facility census was 76. The administrator was notified on [DATE] at 6:26 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, Medical Emergencies, last revised [DATE] showed it was the policy of the facility to provide treatment to consumers in the event of emergency situations. If the consumer is in an emergent situation staff should call for nearby help, assess for breathing and pulse before fully activating 911. Staff should then call 911 and immediately start CPR or alternative rescue efforts as ordered and approved by physician and guardian. After consumer is transported by emergency services staff are to notify the guardian, service coordinator, and director of homes. The charge person on duty is to call report to the emergency room nurse. Staff may then notify the physician of the transport by Emergency Medical Services (EMS) and consumer status as a courtesy call. 1. Review of Resident #1's advance directive form signed and dated on [DATE] showed the resident chose to have Life-saving Codes (CPR). Review of the resident's care plan, last revised on [DATE], did not include advanced directive information. Review of the resident's Physician Order Sheet (POS) dated ,d+[DATE] and signed by the physician showed the following: -Full code. Review of the resident's progress notes dated [DATE] at 6:42 A.M., showed Certified Nurse Assistant (CNA) called this nurse to the resident's room. When the nurse got to the resident's room the resident was in his/her bed and had passed away. Time of death was 4:27 A.M. Family was called and said for the facility to go ahead and call the funeral home. Funeral home phoned at 5:00 A.M. and resident was picked up by funeral home at 5:30 A.M. Physician was notified by fax. Coroner notified by phone and notification of death was faxed to the coroner's office. During interview on [DATE] at 2:45 P.M. CNA C said the following: -He/She worked with Licensed Practical Nurse (LPN) A and CNA I on the east unit on [DATE]; -He/She had last seen the resident around 2:30 to 2:45 A.M. on [DATE]; -The resident had not had any complaints on his/her shift and had been talking and eating. The resident was alert and oriented per his/her usual; -When he/she entered the room at 4:00 or 4:15 A.M. to check the resident, the resident's body was cold to touch and he/she did not move. He/She said the resident's name with no response. The resident's left eye was open; -He/She exited the room and called for the charge nurse (LPN A); -LPN A responded immediately and sent him/her to get LPN B from the West unit; -He/She did not see any staff initiate or perform CPR; -Staff did not take crash cart items into the room when they responded; -He/She was CPR certified, but the facility did not allow CNAs to perform CPR; -He/She found out (after the incident) that the resident was a full code. During interview on [DATE] at 5:55 P.M. LPN A said the following: -He/She worked as the east charge nurse from 7:00 P.M. to 7:00 A.M. on [DATE]; -He/She was the nurse for the resident; -He/She was currently CPR certified; -CNA C notified him/her that he/she thought the resident was gone (not breathing). Before this no one had reported the resident having any complaints or in any distress; -He/She responded immediately and observed the resident on his/her back, not breathing; -He/She checked for a pulse, breath sounds and a heart beat; -He/She ran to look at the resident's chart to find the resident's code status and according to the chart, the resident was a full code; -He/She did not initiate CPR or phone 911 as the resident was clearly gone (hands had begun to turn cold to touch, mouth open and fixed and his/her skin was yellowish (jaundice-like)). He/She did not see any mottling, purplish or blue skin, or observe stiffening of the extremities. The resident's mouth appeared stiffened and staff had to close it; -He/She had LPN B assess the resident for heart beat and breaths; -He/She was trained to initiate CPR immediately and call 911 for a resident who stopped breathing and was a full code. During interview on [DATE] at 3:12 P.M. LPN B said the following: -He/She worked as the charge nurse on west unit on the night shift on [DATE]; -CNA C arrived on his/her unit and said he/she was needed on east unit; -He/She had never seen the resident before; -LPN A asked him/her to assess the resident; -He/She auscultated for a heartbeat for one to one and a half minutes and visualized the resident for respirations. The resident did not have a heartbeat or respirations. The resident felt cold to touch, was mottled and his/her left eye and mouth were open; -Neither he/she or LPN A initiated CPR; -He/She said LPN A asked her to call it (verify death), and that it was clear the resident was deceased . 2. Review of the facility's nursing schedule dated [DATE]-[DATE] showed the facility did not have CPR certified staff in the building on the following shifts: -On [DATE] from 5:00 P.M. to 7:00 A.M.; -On [DATE] from 3:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -On [DATE] from 7:00 P.M. to 7:00 A.M.; -There were a total of 11 shifts from ,d+[DATE] to [DATE] with no CPR certified staff in the building where 28 full code residents resided. 3. During interview on [DATE] at 12:54 P.M., CNA F said CNAs were not supposed to perform CPR at the facility, only the nurses could initiate CPR. During interview on [DATE] at 7:49 P.M., the Director of Nursing (DON) said the following: -She would expect staff to initiate CPR and call 911 if they found a non-breathing, full code resident; -She would expect CPR certified staff to be available on all shifts if full code residents resided in the building; -Her CPR certification was expired upon hire and he/she had informed the previous DON who said they taught classes in the facility. During interview on [DATE] at 6:30 P.M., the administrator said the following: -She was currently responsible for the nursing schedule; -She did not have a complete list of CPR certified staff; -All of the licensed nurses should be CPR certified; -She did not know the reason, but CNAs were not able to do CPR in the facility; -She would expect staff to start CPR and call 911 if a full code resident was found unresponsive. During interview on [DATE] at 11:30 A.M. the physician said the following: -He/She would expect staff to initiate CPR on a full code resident when found unresponsive; -Calling 911 should be routine with CPR; -He/She would expect the facility to have CPR certified staff coverage on all shifts given that they had 28 full code residents in house. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious 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). MO#00193035

38016 Based on interview and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident (Resident #3) in a review of 32 sampled residents including Resident #3's closed record. Staff failed to implement fall prevention interventions as indicated on the resident's care plan and failed to provide safe transfers as directed by the resident's plan of care and physician's orders. The resident had multiple falls with injuries including a fractured right leg. The facility census was 73. Review of the facility Fall Management Program policy, dated 9/17/21, showed the following: -A fall referred to any unintentional downward motion that the resident was unable to recover from without assistance, whether they came to rest on the floor, ground, or other lower lever. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention was considered a fall. When a resident was found on the floor, unless there was suggestion otherwise, a fall was considered to have occurred; -The facility would systematically assess resident and evaluate fall situation and potential situation with the goal of identifying common fall risk factors and develop care plan interventions to mitigate potential harm; -A fall risk evaluation of preadmission information concerning lift style factors, fall history and medical information would be reviewed when available. The admission team would determine upon review of the information if the facility could safely provide appropriate care for the resident; -All resident's would be assessed by a licensed nurse on admission, quarterly, and/or upon a significant change in the resident's condition; -An interdisciplinary team would meet on a regular basis to discuss individuals who had a history or at a high risk of falling and develop a plan to lower the risk potential for future falls; -All staff members were responsible for seeking out, removing, and reporting potential fall hazards; -A fall prevention checklist included, in part, knowing the residents mobility status and follow the resident care plan for proper transfers and ambulation. Utilize fall risk assessments on admission, quarterly, and as needed. For most residents, keep bed in the lowest position, except during care, being careful to insure bed was in the low position before exiting the room after care. Dress the resident with easy to manage clothing when possible. Do visual checks often on all residents; -Equipment use checklist included, in part, to check wheelchairs, bed, walkers, and canes often and report any non-working brakes and broken equipment. Use all seating items ordered for each resident. Report to the charge nurse, any resident who leaned over, slid down, or leaned to one side while seated in a wheelchair. Use gait belts for all transfers and ambulation with those resident who needed assistance. Mechanical lifts were to be used with two staff members for resident safety; -Post fall management section included assessment of the resident immediately at the time of fall, evaluate resident vital signs, mental status change, and physical injury, keep resident immobile until assessment completed. Note any injury or complaints of pain. If a fracture was suspected or obvious obtain an x-ray and/or medical evaluation. Place the resident on alert charting list and document every shift for three days. Report all falls to the physician and family and provide neurological assessments as indicated. Complete the incident report form and initiate an investigation to determine the cause of the fall at the time of first assessment following the fall. The care plan team would discuss the falls on a regular basis and would develop a care plan about potential fall prevention measures and measures to minimize injury related to falls. 1. Review of Resident #3's undated face sheet (no date) showed the resident had diagnoses of stroke, kidney disease, history of falling, dementia, anxiety disorder, muscle weakness, arthritis, difficulty walking, unsteadiness on feet, abnormal gait and mobility, and altered mental status. Review of the resident's Fall Risk Assessment, dated 4/17/20, showed staff documented the resident had a history of one to two or more falls in the past month, was confused, and had a history of stroke and arthritis. He/She had decreased vision and hearing, incontinence of bladder, used a wheelchair or walker assistive device, had transfer difficulties, and unsteady gait. He/She took two medications that increased his/her risk of falls. Staff scored the resident at 17 indicating the resident was a high risk for falls (8 points or more indicated high fall risk). Review of the resident's care plan, updated 2/26/21, showed the resident was at high risk for falls related to multiple disease processes. Staff should not push the resident in the wheelchair without feet positioned on foot pedals. Staff should keep the bed against the wall and locked at all times, keep the call light within reach, glasses clean and free from scratches, and never leave the resident unattended while restless. Staff should keep items the resident might want within reach, staff should ensure the resident wore non-skid socks when legs were edematous instead of shoes, and keep the mechanical pad under the resident while in the recliner and wheelchair. Two staff members should transfer the resident until therapy deemed safe to change transfer status. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/16/21, showed the following: -Short and long term memory problems; -Required extensive assistance of one staff member with bed mobility, dressing, and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting; -Walking in room and corridor did not occur; -Not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers between bed and chair or wheelchair; -Impairment in functional range of motion on one side of the lower extremity; -Frequently incontinent of bowel and bladder; -No falls since admission or readmission. Review of the resident's care plan, updated 5/17/21, showed staff discontinued two staff member transfer intervention and implemented staff should transfer the resident with the mechanical lift (a mechanical device used for transfers that required a sling and hoist to raise and lower the resident from one surface to another) for all transfers. Review of the resident's nurses' note, dated 6/4/21 at 6:30 P.M., showed staff documented the following: -At 12:40 P.M. the resident was on the floor on his/her back with feet near the bed and head by his/her roommate's bed. The resident had external rotation to his/her left leg (leg turned out away from the body) and complained of pain when touched or rolled. A V-shaped skin tear to the left elbow was noted and a laceration on the bridge of the resident's nose. The resident had multiple bruises on his/her forehead, nose, and under the eyes. Bruising was noted on the resident's finger, hands, arms, and legs. The physician was notified and physician orders received to send the resident to the emergency room . The resident's family member was notified and the resident left the facility at 1:20 P.M. Staff asked the resident what happened and the resident said, I fell and cannot get up. Certified Nurse Assistant (CNA) staff said the resident had one leg behind the other and was trying to move in his/her wheelchair. The CNA staff turned around and saw the resident lean forward and before staff could get to the resident, the resident fell face first out of the wheelchair. The resident wore a gown and slippers. The resident returned from the hospital at 5:00 P.M. and sat in his/her recliner for supper; -At 6:44 P.M. the resident had returned with no fractures of nose, hip, or knees. Review of the resident's care plan showed no updated fall prevention interventions following the 6/4/21 documented fall. During interview on 11/10/21 at 8:10 A.M., Nursing Assistant (NA) J said the following: -On 6/4/21 he/she and CNA K were attempting to transfer the resident from the bed to the wheelchair with a two person assist and a gait belt. They could not get the resident to stand up. CNA K told him/her to go get the sit to stand mechanical lift. NA J left the resident's room and when he/she returned with the mechanical lift the resident was on the floor and bleeding from his/her elbow and had hit his/her face on the floor. CNA K said he/she transferred the resident by him/herself, the resident's feet got crossed during the transfer and the resident tried to reposition his/herself in the wheelchair. The resident fell out of the wheelchair onto the floor; -The resident usually had bruising on his/her arms, legs and to his/her rib areas. He/She thought the bruising was from staff trying to transfer the resident with a gait belt and staff pulling and lifting on the resident's arms and under the resident's arms. The resident previously could stand and hold his/her own weight, but the resident's balance was poor. The resident had poor eyesight and poor hearing. He/She required a bariatric bed (wider bed and mattress than a standard bed), a fall mat on the floor, and the bed in the lowest position near the floor. During interview on 11/10/21 at 12:55 P.M., CNA K said the following: -On 6/4/21 the resident was in bed and he/she transferred the resident from the bed to the wheelchair by him/herself with a gait belt. The resident's legs crossed during the transfer and he/she did not notice at the time the resident's legs were crossed. He/She lowered the resident into the wheelchair, turned around to place the gait belt in a chair and when he/she turned back around the resident tried to lift him/herself up and uncross his/her legs. The resident fell out of the wheelchair on his/her face and was transferred to the hospital by ambulance; -The resident sometimes required more assistance than other times during transfers; -He/She could transfer the resident by him/herself, because the resident trusted him/her; -Staff should keep the resident's bed close to the floor in the lowest position when the resident was in bed and place a fall mat on the floor; -He/She should follow the resident's care plan and transfer the resident with two person assist and a mechanical lift. During interview on 11/10/21 at 12:20 P.M., Licensed Practical Nurse (LPN) M said the following: -The resident's history included a stroke with inability to walk, but on admission could bear weight and pivot during a transfer to and from the chair. The resident should be a two person transfer and required staff to hold onto him/her at all times. The resident's balance was not good. The sit to stand lift caused bruising under the resident's arms and the mechanical lift caused bruising under the resident's legs. Staff obtained and started using a larger mechanical lift pad and staff could not find the larger lift pad on 6/4/21; -LPN M was the charge nurse on 6/4/21. NA J came out of the resident's room and said he/she was going to get the sit to stand lift. While NA J was out of the resident's room CNA K transferred the resident by him/herself. CNA K should not have transferred the resident by him/herself. The resident fell because staff transferred the resident inappropriately. The resident required a two person transfer at that time; -The resident's bed was supposed to be against the wall and in the lowest position with a mat on the floor. The mat was taken out of the room at some point and not brought back into the room. No mat was in the room on 6/4/21. Review of the resident's nurses' note, dated 6/14/21, showed LPN M documented the following: -At 1:17 P.M. LPN M assisted a CNA to get the resident out of bed and the resident required both staff to physically lift him/her during the transfer. (Review of the care plan showed the resident required a mechanical lift for all transfers). The CNA took the resident to the shower and called for assistance to transfer the resident back to the chair. The resident would not take initiative to pull up on the grab bar on his/her own. The two staff members had to physically lift the resident into a standing position. Once standing the resident held onto the grab bar while his/her buttocks were dried. The resident could not stand long enough for proper drying and his/her clothing applied. LPN M spoke with therapy about interventions to try. The resident was changed from the sit to stand mechanical lift (mechanical device used for transfers that required an upper body sling wrapped around the resident's back and under the arms, attached to a machine that raised the resident to a standing position and allowed staff to roll the resident while standing on the lift platform from one surface to another and then lowered onto the alternate surface such as the toilet) due to bruising on the resident's back, flanks and upper arms from a mechanical lift. The resident was changed from the mechanical lift back to a two person assist due to the bruising left on the backs of the resident's mid-thigh. Staff planned to try a larger mechanical lift pad to see if it would work without bruising the resident; -At 7:06 P.M. the resident was now a mechanical lift transfer with his/her own lift pad with the resident's name on the pad. The lift pad was a larger size. Review of the resident's nurses' notes, dated 6/15/21 at 4:07 P.M., showed the resident's transfer status had changed to a mechanical lift with his/her own lift pad labeled with the resident's name. If the first pad became soiled another pad would be provided. Review of the resident's care plan showed no updated interventions directing staff on the resident's current transfer assistance requirements on 6/15/21. Review of the resident's Fall Risk Assessment, dated 7/9/21, showed staff documented the resident was incontinent of bowel and bladder, no longer required a walker, but continued to require a wheelchair assistive device. Staff scored the resident at 17 indicating the resident remained a high risk for falls (8 points or more indicated high fall risk). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long term memory problems; -Required total assistance of two staff members with transfers; -Always incontinent of bowel and bladder; -One fall with injury since admission or readmission. Review of the resident's physician's order sheet, dated 7/20/21, showed the resident could be up to the chair with two staff member assistance and a mechanical lift transfer. Review of the resident's nurses' notes showed staff documented the following: -On 8/17/21 at 5:00 A.M. the resident was on the floor beside his/her own bed lying on his/her back. The resident was unable to rotate his/her left leg. Bruising and deformity noted to the right leg. The resident's pupils were not equal and would not dilate (not respond to light), the right pupil was pin sized. The resident complained of head pain and right leg pain. Upon observation the resident's call light was not within reach, appropriate footwear was not in place, the head of bed was elevated and in the highest position, and the room was dim. The resident was incontinent of bowel and bladder. The resident reported he/she attempted to transfer and walk to make breakfast. The resident was increasingly confused at this time and alert to self. Skin was warm/dry with edema (swelling), lungs diminished and wheezing noted (irregular lung sounds), heart rate irregular. Three staff assisted with the mechanical lift and transferred the resident to bed. The resident was transferred by ambulance to the hospital; -On 8/17/21 at 11:46 A.M. the resident returned to the facility at 10:30 A.M. with tibia and fibula fractures (both bones in the lower leg). The resident's family said they decided not to go with surgery as they did not want to put the resident through this. Review of the resident's x-ray report, dated 8/17/21, showed right thigh and leg pain. Fall at the facility that morning with previous history of hip and knee replacement. Findings of acute right proximal tibia and fibula fractures (both bones broken in the leg near the knee located in the lower leg). Review of the resident's care plan, updated 8/17/21, showed staff should keep the resident's bed in the low position when not providing the resident's care and place a mattress on the floor beside the resident's bed while the resident was in bed. During interview on 11/10/21 at 12:00 P.M., LPN L said the following: -He/She was the charge nurse on 8/17/21 when the resident fell out of bed. He/She was pretty sure the resident's leg was broken and he/she was worried both legs were injured as well as the resident's arm; -The resident was found on the floor. His/Her bed was against the wall in the high position and no fall mat or mattress was on the floor; -The resident's bed should have been in the lowest position with a mat or mattress on the floor; -The resident required a mechanical lift transfer and the bed in the lowest position while the resident was in bed; -The resident could not follow commands and other staff said the resident did not get up on his/her own. Review of the resident's Fall Risk Assessment, dated 10/8/21, showed staff documented the resident had history of two or more falls in the past month, and took three medications that increased his/her risk for falls. Staff scored the resident at 17 indicating the resident remained a high risk for falls (8 points or more indicated high fall risk). Review of the resident's annual MDS, dated [DATE], showed the following: -Short and long term memory problems; -Required total assistance of two staff members with transfers; -Required total assistance of one staff member with toileting and personal hygiene; -One fall with major injury since admission or readmission. Review of the resident's x-ray report, dated 10/18/21, showed no evidence of union (healing) at the proximal tibia fibular fractures. Review of the resident's nurses' note, dated 10/18/21 at 4:09 P.M., showed staff documented the resident's x-ray showed the tibia and fibula were not healing, repeat x-ray monthly for four months. Review of the resident's nurses' note, dated 10/19/21 at 6:37 A.M., showed staff documented the resident was found sitting on the floor next to his/her bed at 5:10 A.M. The resident said he/she was trying to get to the recliner and slid off the bed onto the floor. During interview on 11/10/21 at 8:05 A.M., LPN N said the resident fell on [DATE]. CNA staff found the resident on the floor and the resident's roommate said the resident wiggled out on to the floor. The resident's bed was in the low position, but no fall mat was on the floor. Review of the resident's nurses' note, dated 10/23/21 at 6:30 P.M., showed staff documented the resident continued to try to climb out of bed and said he/she had to use the bathroom. Staff redirected the resident and a mattress was put by the bedside. Record review showed no documentation new interventions were put in place when the resident fell out of bed on 10/19/21 or when the resident continued to try to climb out of bed. During interview on 11/9/21 at 4:45 P.M., the MDS coordinator said he/she was in charge of completing residents' MDS' and care plans. A comprehensive care plan was completed as the admission MDS was completed. All residents care plans were posted in binders at the nurses' desk and all CNA staff had access to the residents care plans in the binders. Staff should assess the resident following a fall for injuries and provide care. Staff should then complete the fall investigation report. The Interdisciplinary Team (IDT) met weekly and updated resident care plans following the meeting with new fall prevention interventions or changes in the residents' care plans. The new interventions were reviewed at the change of shift team report and CNA staff signed the new care plan acknowledging they were aware of the changes or new interventions. During interview on 11/9/21 at 1:45 P.M., the Director of Nursing (DON) said staff should assess residents after every fall for injuries, complete a fall investigation report, figure out why the fall occurred and update the resident's care plan with new or changed interventions. The charge nurses should inform the CNA staff of any new fall interventions during the change of shift report. During interview on 11/10/21 at 2:00 P.M., the DON said staff should follow the resident's care plan and transfer residents with the specified transfer equipment. If the care plan indicated a mechanical lift for all transfers, staff should not transfer the resident with a gait belt. Staff should ensure the residents are safe on all surfaces and during all transfers. Staff should place fall mats on the floor and place beds in the lowest position as directed. Staff should lower the resident's bed following cares before leaving the room. Staff should not leave the resident alone in the bed without placing the bed to the lowest position near the floor. The resident was a fall risk for a long time and required a fall mat and the bed in the lowest position at all times when not providing care. These interventions should have been in place prior to the 8/17/21 fall. During interview on 11/9/21 at 1:50 P.M., the administrator said staff should follow the fall policy and implement interventions to prevent falls. MO#192366 MO#191123 MO#186569 MO#186584 MO#185021

38016 Based on observation, interview, and record review, the facility failed to follow the facility's weight loss policy for weekly weights, re-evaluate the care plan and interventions with continued weight loss, and to acquire dental services for ill-fitting dentures for one sampled resident (Resident #22) of 32 sampled residents and three closed records. The resident had a total weight loss of 39 pounds (lbs) (26% weight loss) over the course of eight months, the most significant weight loss occurred after the resident's diet was changed from a mechanical soft diet to a pureed diet when the resident lost 24 lbs in two months (18%, severe weight loss) and expressed he/she did not like his/her food pureed. The facility census was 73. Review of the facility's policy Weight Gain and Loss, revised [DATE], showed the following: -Inform physician and family of resident weight gain and weight losses; -Obtain all resident weights monthly no later than the 8th of the month; -Notify primary physician of resident weight gain or loss when at least 5% in a month, 7.5 % in three months or 10% in six months; -Discuss at care plan meeting with the interdisciplinary team; -Report weight loss or gains to the dietary manager, dietary manager is to report to the dietitian; -Document per guidelines; -Complete dietary assessment form until weight is stable; -Obtain weight weekly on significant loss/gain until weight is stable; -Make referral to speech therapy for weight loss. Review of the facility's policy Modifying Diet Consistency, undated, showed the following: -Each resident is admitted with the written recommendation of a physician regarding their diet; -Each resident remains under the care of a physician at all times; -The resident's diet is supervised by a physician who participates in the resident's assessments and care planning; -Each resident's ability to tolerate a specific dietary consistency may change over time due to changing medical conditions and/or temporary health conditions; -Nursing staff should respond if a resident has difficulty with the consistency of their current diet to maintain their optimal nutritional status; -Nursing staff may down-grade dietary consistency to see if the new consistency is tolerated for a period no longer than one week without getting a change in diet orders from the physician; -While attempting the diet modification the resident is to be placed on the dietary monitoring list; The results are to be reported to the physician at the end of the trial period for possible change in physician order sheet, the results should include body weight at the beginning and the end of the week and estimated daily intake on the previous diet consistency and on the new trial consistency. 1. Review of Resident #22 face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Weight Record, dated [DATE], showed the resident's weight as 149 lbs. Review of the resident's admission Minimum Data Set (MDS), a federally required assessment, dated [DATE], showed the following: -Moderate cognitive impairment, Brief Interview for Mental Status (BIMS) 12 (score of 0 being most severe cognitive impairment, and 15 being cognitively intact); -Diagnosis of anemia, atrial fibrillation (rapid heart beat), coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, hyperlipidemia (high cholesterol), arthritis, other fractures, chronic pain syndrome, non-pressure ulcer of the ankle, and presence of pacemaker; -Weight 149 lbs; -No weight loss; -Not on mechanically altered diet; -Did not have loosely fitting dentures, and was not edentulous (no teeth); -Did not have a condition or chronic disease that may result in a life expectancy of less than six months; -Did not have a diagnosis of Alzheimer's disease or dementia. Review of the resident's Care Plan, dated [DATE], showed the following: -Nutritional risk related to vascular wounds, history of diabetes, ill-fitting dentures with chewing problems, and decreased vision and hearing; -Monitor labs as ordered and refer to physician as needed; -Monitor wounds and edema; -Provide no added salt, regular consistency diet; -Record intake at each meal; -Provide set up help at meals; -Weigh as ordered and record, monitor for significant change and refer to physician as needed. Review of the resident's Registered Dietitian note, dated [DATE], showed the resident denied swallowing problems, but reports chewing issues due to ill-fitting upper and lower dentures and wanted soft meats. Review of the resident's medical record showed no documentation staff requested or communicated the need for a referral to a dentist for ill-fitting dentures. Review of the resident's record showed he/she was sent to the hospital on [DATE]. Review of the resident's Admission Assessment, dated [DATE], showed staff documented the resident's dentures fit. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 138.4 lbs, (down 10.6 lbs.) a 7% weight loss in 30 days. Review of the resident's Care Plan, updated [DATE], showed house supplement two times daily and monitor acceptance of supplement. Review of the resident's Dietitian Note, dated [DATE], showed the following: -Diet Mechanical soft, no added salt, house supplements two times a day; -Height is 67 inches, Weight 146 lbs; -2+ edema (swelling of tissue in arms or legs); -Goals: weight stability, adequate intake, and wound healing; -Recommend: Add multivitamin with minerals, monitor weights. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 134 lbs. (a loss of 4.4 additional lbs. for a total of 15 lbs., a 10% weight loss since [DATE], less than 60 days). Review of the resident's medical record showed no evidence staff reviewed the resident's care plan. There were no additional interventions to prevent further weight loss. Review of the resident's Dietitian Note, dated [DATE], showed the following: -Referral from nursing due to weight; -Most recent weight 134 lbs, shows significant 9% weight loss in one month; -May be some fluid loss, and resident had decrease appetite with a urinary tract infection; -Hopefully appetite will improve with antibiotics; -No new recommendations. Review of the resident's Nurses Notes, dated [DATE], showed staff documented the resident complained about pain in his/her mouth and tongue. The resident said his/her dentures and gums had build on them and needed them cleaned. After his/her dentures were brushed he/she said it felt like there was something under them and he/she couldn't wear them. Review of the resident's Dietitian Note, dated [DATE], showed the following: -Resident's weight was 134 lbs (no new weight was taken, same weight recorded on [DATE]); -Weight was down significantly over one month mostly due to diuresis (increased or excessive production of urine), but there was also some decline in appetite; -Diet was mechanical soft, no added salt, house supplement two times per day; -Will monitor weights; -No new recommendations. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 128.5 lbs. Review of the resident's Nurses Notes, dated [DATE], showed the resident complained about his/her dentures, he/she does not want Fixodent. The staff documented they would recommend a denture consult to the resident's durable power of attorney. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 122.1 lbs. During an interview on [DATE] at 1:08 P.M., the resident's durable power of attorney/family member said the facility never approached him/her about the resident needing to be seen for ill-fitting dentures. He/She would have taken the resident to a dental appointment and paid for new dentures if the resident needed them. In [DATE] he/she met the resident at an audiology appointment. During the audiology appointment, the resident told the clinic that the facility lost his/her dentures and he/she had not had them for a while, and staff told the resident he/she would be okay. The facility told him/her they had found the resident's dentures and they fit better. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 124.7 lbs. Review of the resident's Nurses Note, dated [DATE], showed the following: -Resident's DPOA notified about the resident not wanting to use Fixodent; -Resident not wearing his/her dentures during the day; -Discussed resident may need a dental consult since his/her dentures do not fit properly, DPOA to discuss with resident. The resident's medical record did not contain any follow up documentation about a dental consult. Review of the resident's Dietitian Note, dated [DATE], showed the following: -Resident's weight is 125 lbs; -Weight was down over three months; -Recommendation for the resident's house supplement to increase to three times a day due to continued weight loss; -Will monitor weights and labs. Review of the resident's nurses notes, physician orders, and care plan showed no evidence the resident's house supplement was increased to three times a day. Review of the resident's Dietitian note, dated [DATE], showed the following: -Most recent weight of 124.7 lbs showed weight loss appears to be stabilizing; -Appetite more consistent since urinary tract infection resolved and intake of supplements better with nursing supervision; -Resident with a history of not wearing dentures during meals and on mechanically altered diet with no swallowing problems reported; -Supplements are twice a day; -Continue weekly weights to more closely monitor. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 129.8 lbs. Review showed staff did not document weights from [DATE]-[DATE]. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 136.8 lbs. Review showed staff did not document weights from [DATE]-[DATE]. Review of the resident's Dietitian Note, dated [DATE], showed the resident's weight was up to 137 lbs., fluctuates, continue regimen and will monitor weight trends. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 134.6 lbs. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 134.6 lbs. Review showed staff did not document weights from [DATE]-[DATE]. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 128.3 lbs down another 6.3 lbs in one month, another 0.5 from the previous month with no review or addition of interventions documented. Review of the resident's medical record showed no evidence staff reviewed the resident's care plan and did not add any interventions to prevent further weight loss. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 130.9 down 12% in five months since admission. Review of the resident's Physician's Orders, dated [DATE], showed the resident's diet order changed to mechanical soft. Review of the resident's Dietitian Note, dated [DATE], showed the resident's weight as 128 lbs and was down slightly. Continue regimen to help promote weight stability and healing. Review showed staff did not document weights from [DATE]-[DATE]. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 125 lbs. Review of the resident's medical record showed no evidence staff reviewed the resident's care plan, or added any interventions to prevent further weight loss. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment, BIMS 11; -Weight 125 lbs.; -Significant weight loss; -Dental section left blank; -Mechanically altered diet; -The resident did not have a condition or chronic disease that may result in a life expectancy of less than six months; -The resident did not have a diagnosis of Alzheimer's disease or dementia. Review of the resident's Physician's Orders, dated [DATE], showed the resident's diet order was changed to pureed. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 134.8 lbs. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 132 lbs. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 128.5 lbs. Review of the resident's Physician's Note, dated [DATE], showed the resident complained he/she did not like his/her food. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 125 lbs. Review of the resident's medical record showed no evidence staff reviewed the resident's care plan, or added any interventions to prevent further weight loss. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 117 lbs. Review of the resident's medical record showed no evidence staff reviewed the resident's care plan, or added any interventions to prevent further weight loss. There were no weights recorded from [DATE]-[DATE]. Review of the resident's Weight record, dated [DATE], showed the resident's weight at 112.6 lbs. Review of the resident's Physician's Order, dated [DATE], showed an order for supplement of choice bid (same as before) and Paxil 20 milligrams daily for depression and appetite. Review of the resident's Weight Record, dated [DATE], showed the resident's weight as 114.4 lbs down 23%, 34.6 lbs since admit in May. Review of the resident's Physician's Orders, dated [DATE], showed an order for mechanical soft diet for pleasure feedings. Review of the resident's Weight Record, dated [DATE], showed the resident's weight at 110.2 lbs. During an interview on [DATE] at 12:15 P.M., CNA O said the following: -The resident had dentures when he/she first came, but they went missing; -He/She doesn't know if they were found or not but the resident stopped wearing them; -The resident liked chicken noodle soup, peppermints, and 7-Up soda; -The resident complained about being nauseated all the time, and he/she would often get sick after he/she ate. During an interview on [DATE] at 1:08 P.M., the resident's durable power of attorney, a family member, said the following: -The facility did not notify him/her of any weight loss until January and only said the resident lost 8 lbs.; -He/She was not notified the resident's dentures weren't fitting, there was only one conversation about him/her not liking Fixodent; -The resident did not have a dental appointment while at the facility; -The resident told him/her the facility would give the resident food he/she could not chew like pork chops; -The resident said he/she did not like the food, and after they started grinding up his/her food he/she complained that he/she did not like the food and did not want his/her food ground up; -The resident complained that he/she did not get the snacks his/her family brought him/her. During an interview on [DATE] at 2:20 P.M., the hospice Family Nurse Practitioner said the following: -The resident's hospice admission diagnosis was late onset Alzheimer's, dysphagia (difficulty swallowing), failure to thrive, and the resident lost 22 lbs in two months; -Admission note said the resident was edentulous; -The resident was referred to hospice on [DATE], admitted to hospice on [DATE], and expired on [DATE]. During an interview on [DATE], the resident's physician said the following: -The resident was put on a mechanical soft diet in [DATE]; -He would expect the facility to make dental appointments for ill-fitting dentures, but during COVID we were not sending people to the dentist; -You can eat without teeth; -He did not know if the resident was on a pureed diet or not- but he/she stopped eating; -He tried to feed the resident chocolate pudding once, the resident said he/she didn't like chocolate, and complained about getting the same meat every day; -The facility could try different interventions, but they probably wouldn't have worked. During an interview on [DATE] at 1:30 P.M., LPN R said the following: -He/She monitored the weights during the time this resident had weight issues; -The resident did have problems with his/her dentures, but he/she doesn't know if the resident got a dental appointment; -The Dietitian would make recommendations, but the DON at that time (not the current DON) would cancel them, so the Dietitian felt uncomfortable documenting his/her recommendations and then they would not be put into place; -He/She would notify the physician about significant weight changes, but he would not respond to faxes about weight loss; -He/She faxed the physician with all weight loss findings and reviewed with the physician when he/she made rounds; -He/She would put out which weekly weights needed to be completed and the CNA's would not do them, the previous DON would not help with the issue; -The resident's family member tried to help the resident and would bring him/her his/her favorite home cooked meals, and it helped for a while; -The resident did not like his/her pureed diet, he/she would give the resident foods he/she specifically asked for but no one changed his/her diet back. During an interview on [DATE] at 11:09 A.M., the Registered Dietitian said the following: -He/She expected residents with weight loss to have weekly weights; -When a resident had weight loss the resident was evaluated to find the cause of their weight loss, and interventions are individualized based on the findings; -Interventions were evaluated with continued weight loss to ensure the interventions are effective; -Residents are evaluated to see if there are issues with chewing, swallowing, acceptance of their diet, depression, dentition, etc.; -During the time the resident experienced weight loss there were process issue in getting the weekly weights, follow up with the weight losses, and follow up with recommendations for weight loss; -He/She was not able follow the resident during the whole course of his/her weight loss; -Review of the notes showed there was some weight loss from edema and diuretic use from [DATE] to [DATE], there is no documentation of edema from [DATE] to [DATE]. MO00173981 MO00180281

See Event ID 7SYM12 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/12/19. Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of multiple falls over three days for one resident (Resident #1) in a review of five sampled residents, who received [MEDICATION NAME] head trauma, lacerations and bruises on the face, nasal (nose), zygoma (cheek bone), and maxilla (jaw) fractures. The facility census was [AGE]. Record review of the facility's Falls Management Program Policy, dated as revised 7/20/09, showed the following: -A Fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -An Un-witnessed fall occurs when a resident is observed on the floor and neither the resident nor anyone else knows how he/she got there; -Post-Fall Management: Place individual on the HOT LIST (a form of charting which is problem-focused to obtain needed assessment data to evaluate needs and effectiveness of treatments and/or orders) and document on every shift for three days and perform neurological checks as guided; -All falls will be logged by the clinical supervisor or authorized person and reviewed regularly by the interdisciplinary team; -All incident report forms will be sent to the clinical supervisor for review. The clinical supervisor will track all falls for each individual and investigate the initial cause of the fall(s). The care plan team will discuss the falls on a regular basis and confer about potential preventative fall measures and measures to minimize injuries from falls. 1. Review of Resident #1's current, undated care map (a mini care plan kept at the nurse's station) showed the following: -Confused; -Walker with one assistance for walking; -Keep call light within reach and answer promptly; -Non-skid shoes/socks on at all times; -Keep items resident may want within reach; -Provide adequate lighting; -One on one when possible was crossed through; -Offer assistance with toileting frequently (8/23/19); -Frequent visual checks (10/11/19); -15 minute checks (10/24/19); -Encourage resident to request assistance with ambulation; -Keep eye glasses clean and free from scratches; -Keep pathways clean and free of clutter; -Keep walker within reach at all times; -Never leave resident unattended while restless. Review of the resident's nurse's notes dated 10/24/19 at 6:45 P.M., showed the following: -Staff spoke to the resident's family due to the resident requested to go to bed and became very agitated because he/she wanted to sleep in bed. The resident's family said if the resident wanted to go to bed, then let him/her go to bed because they wanted the resident to be comfortable and did not want the resident to be combative with staff; -Staff told the family they would initiate 15 minute checks while the resident was in bed, but told family the resident was very quick and when he/she gets up, he/she could possibly fall within the 15 minutes; -The family said as long as the resident was comfortable and requesting to go to bed, they were to let him/her go to bed; -Staff initiated 15 minute checks while the resident was in bed. Review of the resident's 15 Minute Safety/Visual Checks sheet dated 10/25/19 showed staff began documentation of 15 minute checks at 6:45 P.M. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 10/25/19, showed the following: -Severely impaired cognition; -Physical behaviors occurred one to three days; -Rejection of care occurred one to three days; -Extensive assistance of one staff for bed mobility, transfers, walk in room and corridor, toilet use; -Walking not steady, only able to stabilize with human assistance; -Surface to surface transfer not steady, only able to stabilize with human assistance; -Used a walker for mobility; -[DIAGNOSES REDACTED]. -Two or more falls since admission with no injury; -Two or more falls since admission with injury (except major) such as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall related injury that caused the resident to complain of pain; -One fall with major injury-bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma (a collection of blood within the skull that can be within the brain tissue or underneath the skull, pressing on the brain) Review of the resident's nurse's notes dated 10/25/19, showed the following: -Ambulates with walker and staff assistance; -Attempted to ambulate unassisted and redirected to walker with staff assistance. Review of the resident's nurse's notes dated 10/26/19, showed the following: -At 4:30 A.M., staff checked the resident who was in bed asleep; -At 4:45 A.M., staff checked on the resident who was walking near the bathroom door; -Staff attempted to hold onto the resident and help the resident into the bathroom; -The resident began to walk through the door, lost his/her balance, and fell into the door/door frame; -Staff prevented the resident from completely falling; -The resident obtained two skin tears to the right elbow; -Staff faxed the physician for a treatment order for the skin tear; -At 2:22 P.M., the resident continued to try and get up unassisted and frequently without the walker; -Staff noted bruising to the left eye, right knee, and swelling above the left eye. Review of the resident's medical record showed no evidence staff evaluated current fall interventions or implemented new interventions after the 10/26/19 fall. Review of the resident's nurse's notes dated 10/31/19, showed the following: -The resident remained on 15 minute checks; -Staff noted continued bruising around the left eye area. Review of the resident's nurse's notes dated 11/04/19, showed the resident made multiple attempts to walk unattended and was redirected with some difficulty. Review of the resident's nurse's notes dated 11/06/19, showed the following: -The CNA checked the resident at 11:30 P.M. per 15 minute checks and noted the resident to be asleep -At 11:45 P.M. check, the CNA heard a trash can move; -At 11:45 P.M., unknown CNA (Certified Nurse Aide) called for the nurse who was not in the secured unit; -The CNA found the resident sitting on the floor by the sink with his/her back up against the trash can and legs outstretched towards the bathroom; -No injuries observed; -Staff assisted the resident to the bathroom and clothing changed due to incontinence. Review of the resident's medical record showed on 11/7/19, staff initiated prompted voiding program to attempt to assist the resident to the bathroom prior to him/her attempting to toilet self. (Staff assess the resident every hour whether he/she was wet or dry. Then staff toileted the resident or offered to toilet the resident); Review of the resident's nurse's notes dated 11/07/19, showed the following: -Staff took the resident to the bathroom every 30 minutes and continued with 15 minute checks; -Staff received an order for [REDACTED]. Review of the resident's care plan revised 11/7/19, showed the following: -High risk for falls related to unsteady gait; -Prompted voiding program initiated to attempt to assist resident to the bathroom prior to the resident attempting to toilet self; -Encourage resident to wear his/her glasses since the resident did not always wear his/her glasses; -Keep pathways clean and free from clutter. Review of the resident's nurse's notes dated 11/09/19, showed the resident continued to get up unassisted without the walker. Review of the resident's 15 Minute Safety/Visual Checks sheet dated 11/10/19 showed at 6:30 A.M. and 6:45 A.M., staff did not document location of the resident nor initial this time. Review of the resident's nurse's notes dated [DATE] at 6:11 A.M. showed the following: -At 12:00 A.M. (on [DATE]), staff called the nurse to the secured unit due to resident found on the floor in his/her room; -The resident sat on the floor on buttocks with legs stretched straight out facing away from the door; -The resident wore non-slip socks and the walker was near the resident; -The resident had blood on the middle of the forehead and noted a skin tear; -The resident complained of pain all over and then complained of chest pain; -Staff notified the physician; -911 was called due to change in resident's condition; -The resident went to the emergency room ; -The resident returned to the facility with a left nasal fracture, but unsure if the fracture was new or old. Review of the resident's CT (computerized tomography to detect bone and joint problems like complex bone fractures) scan dated [DATE] at 2:03 AM., showed acute left nasal fracture and a left frontal scalp hematoma (collection of blood outside a blood vessel). Review of the emergency department summary dated [DATE] at 3:08 A.M., showed the following: -Visit problem: bilateral knee pain, chest wall pain, [MEDICAL CONDITION]; -Discharge Diagnosis: [REDACTED]. Review of the 15 Minute Safety/Visual Checks dated [DATE] at 10:45 P.M. showed staff did not document the resident's location and did not initial the documentation. Review of the resident's medical record showed no evidence staff evaluated current fall interventions or implemented new interventions after the [DATE] fall. Review of the 15 Minute Safety/Visual Checks dated 11/12/19, showed the following: -At 4:45 A.M., staff documented the resident was in the core area and then to the bathroom; -At 5:00 A.M., 5:15 A.M., 5:30 A.M., 5:45 A.M., 6:00 A.M., 6:15 A.M., 6:30 A.M., and 6:45 A.M., staff did not document the resident's location and did not initial the documentation. Review of the resident's nurse's notes dated 11/12/19 at 6:10 A.M., showed the following: -Staff found the resident on the floor in the room during 15 minute checks. The resident sat on his/her buttocks next to the bed with legs stretched out straight and faced the door; -No new injuries noted at this time, but the resident continued to complain of right knee pain. Review of the resident's nurse's notes dated 11/12/19 at 10:15 P.M., showed the following: -Staff found the resident sitting on buttocks in the middle of the floor with blood coming from the head; -There was bleeding from a small cut on the forehead and a cut to the nose; -Staff noted swelling of the nose and a golf ball size knot to the middle of the forehead; -Staff notified the physician and sent the resident to the ER for evaluation and treatment. Review of the resident's CT scan dated 11/12/19 at 11:35 P.M., showed acute bilateral nasal bone fractures, forehead and paranasal soft tissue swelling/hematoma and laceration. Review of the emergency department disposition summary dated 11/12/19, showed the following: -Visit problem: multiple falls, [MEDICATION NAME] head trauma; -Discharge Diagnosis: [REDACTED]. Review of the resident's nurse's notes dated 11/13/19, showed the following: -At 3:30 A.M., the resident returned with sutures to the nose and forehead with a large bandage on the forehead; -There was a bruise to the left hip and buttocks; -The resident returned with orders for [MED] 500 mg (an antibiotic) four times a day for five days; -Staff called the emergency room and was told the antibiotic was for the nasal fracture; -Staff put the resident to bed and put staff one on one due to trying to get up; -Staff brought the resident to the core area for better oversight; -At 5:13 P.M., the resident's walking gait was so poor, it required the resident to sit down on a chair before reaching his/her destination; -Staff monitored the resident every 15 minutes. Review of the resident's medical record showed no documentation of 15 minute checks on 11/13/19. Review of the resident's nurses' notes dated 11/13/19 at 9:40 P.M., showed the following: -Staff called for a nurse; -The resident lay on his/her left side on the bedroom floor in front of the sink; -There was blood to the center of the resident's forehead as well as under his/her head; -There was a laceration to the middle of the forehead and the resident complained of pain to left knee and pain to back; -Staff called 911 and transported the resident to the emergency room . Review of the emergency department disposition summary dated 11/13/19, showed the following: -Discharge Diagnosis: [REDACTED]. -Patient education for zygoma (cheek bones) fracture. Review of the resident's CT (computed tomography) scan dated 11/14/19 at 12:05 A.M., showed the following: -Head without contrast x-ray showed multiple nasal bone fractures; -Maxillofacial without contrast showed comminuted (break or splinter of the bone into more than two fragments) rightward displaced fractures of the right and left nasal bones. Displaced [MEDICAL CONDITION] and mid aspects of the perpendicular plate of the ethmoid (skull bone that separates the nasal cavity from the brain); -Facial bones: There are comminuted, displaced, bilateral nasal fracture; -Nasal septum is deviated to the right; -Mildly displaced fractures of the anterior spine of the maxilla (jaw bone). Review of the resident's nurse's notes dated 11/14/19, showed the following: -At 1:25 A.M., the hospital called and said the resident was returning to the facility with a maxilla fracture (upper fixed bone of the jaw including the front of the mouth); -The hospital physician was unable to suture the laceration to the forehead due to other lacerations on the forehead. Observation on 11/14/19 at 9:45 A.M., showed the resident's face was bruised black and blue, and stitches on the forehead and bridge of the nose. Both eyes were swollen, black and blue, and the skin tissue below each eye was swollen. The resident opened his/her eyes which were like slits in the skin and the left eye appeared red and inflamed. The resident's breathing was loud and labored through his/her nose and could be heard four to five feet away. The resident was restless and moved his/her feet up and down repetitiously. During interview on 11/14/19 at 12:50 P.M., CNA E said the following: -The resident was on 15 minute checks and the resident was quick; -He/she kept the resident in the core area during the day to watch him/her; -Over the past few evenings after 7:00 P.M., there was no nurse in the secured unit since the nurse went over to another hall to assist staff. There were two aides who worked in the secured unit. During interview on 11/14/19 at 3:15 P.M., CNA F evening aide, said the following: -They try to keep no slip socks on the resident; -Staff do 15 minute checks on the resident; -The resident had a low bed, but no fall mat since they do not use them back in the secured unit; -The resident was awake off and on the night of 11/12/19; -On 11/12/19, they had just checked the resident and heard something like a door closing. He/She ran to the room and the resident was near the door on the floor; -Last night (11/13/19), CNA I was back in the unit. They were by the nurse's station and heard the resident moan and found the resident on the floor. It was very quick, not even five minutes from when they checked the resident. During interview on 11/14/19 at 3:20 P.M., Nurse Aide (NA) G said the following: -They tried to have the resident stay in the core area, but the resident couldn't sleep due to noise; -It was on 10/24/19, when staff called the resident's spouse and the spouse wanted the resident to go sleep in his/her room (NA G knew this was the date, because there had been a posted sign at the nurse's desk to remind staff); -He/she had just checked on the resident when he/she heard the resident's walker and boom, the resident was on the floor at the foot of the bed; -The resident had a low bed, but no fall mat on the floor; -The resident shuffled his/her feet when he/she walked; -On 11/12/19, he/she was in a room on another hall changing the trash bag, when CNA F yelled for him/her; -The resident was on the floor bleeding; -He/She went to call for the nurse who was out on the west hall (outside the secured unit). During interview on 11/14/19 at 3:30 P.M., Licensed Practical Nurse (LPN) H evening charge nurse said the following: -He/She worked until 8:30 P.M. on the evening of 11/12/19; -It was a typical evening for the resident with no increased restlessness; -They did routine 15 minute checks on the resident; -The resident's family member said previously to put the resident in bed at night to sleep; -The resident had been falling in his/her room. During interview on 11/14/19 at 3:35 P.M., LPN J said the following: -When the resident was in bed, he/she could be up within five minutes; -The resident was very impulsive and because of the dementia, the resident could forget within two seconds; -Staff would take the resident to the bathroom and within a few seconds, the resident forgot he/she went to the bathroom; -When the resident was restless, staff sat with him/her; -If the resident was restless in the room, staff would bring him/her out to the core area; -On 11/7/19, they began prompted voiding toileting program; -A lot of the times, the resident was getting up on his/her own to toilet and would fall; -Last night (11/13/19), they moved the resident out of the secured unit since his/her risk for elopement was minimal; -There were more staff out in the other units. During interview on 11/14/15 at 10:25 A.M. Registered Nurse (RN) D said the following: -The staff did 15 minute checks while the resident was in his/her room; -The resident would get up without his/her walker in his/her room; -The resident usually fell by the bathroom in his/her room; -There was no fall mat on the floor in the resident's room; -The fall mat was a hazard since the resident got up so much; -The resident usually sat in the core area during the day; -The resident was nonstop trying to get up and many times did not use the walker; -The resident had a shuffling gait at times and staff tried to walk with the resident; -The resident was stubborn and did not want staff help. -Staff tried to keep a close eye on the resident; -The resident needed a lot of supervision. During interview on 11/14/19 at 10:35 A.M., the MDS/care plan coordinator said the following: -The resident's falls were at night; -The resident wanted to go to bed; -They had done a fall intervention of prompted toileting and many other interventions with the resident; -They had done everything but one on one at night time. During interview on 11/20/19 at 12:12 P.M., the resident's family member said the following: -The resident was wobbly; -The resident would get up whenever he/she wanted to. During interview on 11/26/19 at 12:55 P.M., the physician said the following: -The resident had an old stroke, [MEDICAL CONDITION], and did not have good balance; -He was aware the resident fell four nights in a row and was in the emergency room for stitches one time, broke the stitches open on another fall and also had four CT scans; -He felt the secured unit had more room and a bigger space, but this was not good for a resident who had fallen many times; -The resident needed a smaller room and more staff closer to him/her like it was in the regular nursing home where staff were 10-20 feet away; -Staff did not notify him of every fall. During interview on 11/20/19 at 11:34 A.M., and 12/3/19 on 10:09 A.M. the Director of Nursing (DON) said the following: -The resident fell on ,[DATE], 11/12, and 11/13/19; -The resident had been on 15 minute checks and was on directed toileting for prevention of falls; -There were no 15 Minute Safety/Visual Checks sheets completed after 11/12/19 at 4:45 A.M.; -On 11/12/19, he initiated one on one supervision in the morning for the resident; -After the resident fell on the night 11/12/19, they moved the resident out of the secured unit on 11/13/19; -The resident did not have a fall mat since it would put him/her at more risk since he/she was getting up on his/her own; -The resident was currently one on one supervision to check the resident's routine after he/she moved to the medical floor. MO 8 and MO 9

See Event ID 7SYM12 Based on observation, interview, and record review, the facility staff failed to notify the physician and re-evaluate interventions when a resident's wound deteriorated, stage a wound according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, or use air mattresses according to manufacturer's instructions to prevent development or worsening of pressure ulcers for one resident (Resident #6) in a review of two sampled residents with pressure ulcers, resulting in deterioration of the wound from a suspected deep tissue injury (pressure injury with of persistent non-blanchable deep red, maroon, purple discoloration, skin can be intact or non-intact) to a Stage IV wound (full-thickness loss of skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The facility census was [AGE]. Review of NPUAP guidelines, dated September 2016, showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury 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 injury 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 injury 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 injury 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 NAME] 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 injury (unstageable, Stage III or Stage IV pressure injury). Review of the Resident Assessment Instrument (RAI manual), dated 10/1/17, directed staff to code the Minimum Data Set (MDS) for Stage II pressure ulcers by definition as ulcers with partial-thickness loss of the dermis. Granulation tissue, slough or eschar are not present in Stage II pressure ulcers. Therefore, Stage II pressure ulcers should not be coded as having granulation, slough or eschar tissue. Review of the Manufacturer's Operator Manual, dated 2016, for the facility alternating pressure and low air loss mattress showed the following: -Pressure of the mattress is adjusted by choosing the patient's (resident's) corresponding weight setting using the weight setting buttons (+) or (-); -Follow the hand check procedure to ensure an appropriate pressure level. Review of the facility's Skin Integrity Management Program, undated, showed the following: -Residents' skin will be assessed by licensed personnel on admission; -Skin assessments will be conducted weekly; -Staff will be encouraged to report all skin changes to the charge nurse; -Staff instructed to report any reddened or open area to the charge nurse. 1. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment assessment instrument completed by facility staff dated 9/6/19, showed the following: -Severe cognitive impairment; -Independent with bed mobility and eating; -Requires limited physical assistance with toilet use; -Not at risk to develop pressure ulcers; -No pressure ulcers present; -No pressure reducing device to bed or chair; -Weight 138 pounds (lbs.); -Occasionally incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's care plan, dated [DATE], showed the following: -At risk for alteration in skin integrity; -Moisturize skin; -Do not massage bony prominences; -Weekly skin assessment; -Report red areas to the charge nurse. Review of the resident's skin assessment, dated 9/21/19, showed the resident with bruising to his/her forehead, right wrist, right foot, and [MEDICAL CONDITION] to the right foot. The note did not describe any other skin changes. Review of the resident's nurses notes, dated 9/21/19, showed the following: -Dark area to inner right and left buttocks, from pressure; -Area is not currently open at this time; -Cream (Super Duper Diaper Doo, a barrier cream) applied per physician's orders [REDACTED].>-Requested an order for [REDACTED]. Review of the resident's nurses notes dated 9/22/19, showed staff documented the buttocks remained dark red/purple. Review of the resident's nurses notes, dated 9/24/19, showed the following: -readmitted to facility on 9/20/19; -Stage I pressure ulcer to each buttock, area noted to be dark red/purple; -Stage I pressure ulcer to right buttock and two ulcers to left buttock; -Blood noted to be draining from all areas; -Requested change of treatment from the physician from Super Duper Diaper Doo to [MEDICATION NAME] (moisturizer to treat dry, rough skin and minor skin irritations); -Roho cushion placed on wheelchair and pressure relieving mattress placed on bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 9/24/19, showed the following: -Right buttock Stage II pressure ulcer measures 2.3 centimeter (cm) in length, and 2.2 cm in width; -Left buttock (a) Stage II pressure ulcer measures 0.6 cm in length, and 0.5 cm in width; -Left buttock (b) Stage II pressure ulcer measures 2.6 cm in length, and 1.3 cm in width; -Small amount of bloody drainage noted to all wounds; -No documentation staff notified the physician the wounds had opened. Review of the resident's nurses notes, dated 9/27/19, showed staff documented the open area to the resident's buttock had sloughing skin to the wound bed. The note did not contain documentation of physician notification the wound had sloughing skin. (Slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/28/19, showed staff documented the resident's bilateral buttock wound was beefy red with yellow sloughing skin. The resident complained of pain in his/her buttock. The note did not contain documentation of physician notification the wound was beefy red with yellow sloughing skin and pain. (Beefy red (granulation tissue) and slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/29/19, showed staff documented the open areas on the resident's buttock wound bed as dark brown with pink peri wound. The note did not contain documentation of physician notification the wound bed was dark brown. Review of the resident's nurses notes, dated 10/2/19, showed the following: -The resident complains of pain/burning to buttocks; -Buttocks wound bed red with yellow slough present; -Some areas of white macerated (dead skin/tissue that turns white from moisture) tissue noted around wound edges. The note did not contain documentation of physician notification the wound had areas of macerated tissue around the wound edges. Review of the resident's nurses notes, dated 10/3/19, showed staff documented the buttocks wound bed pink with yellow thickened area to middle of the wound bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/4/19, showed the following: -Right buttock Stage II pressure ulcer measures 5.2 cm in length, 3.1 cm in width, 0.1 cm in depth; -Left buttock (a) Stage II pressure ulcer measures 5.5 cm in length, and 2.7 cm in width, 0.1 cm in depth; -Small amount of serosanguinous (blood and the liquid part of blood that is clear to yellow) drainage noted to both wounds; -Wound deteriorating. Review of the resident's Nurses Notes, dated 10/4/19, showed staff documented extension of wound assessment: -Ulcer to left buttock and coccyx (tailbone) areas wound bed noted to have yellow/greenish slough present, slight odor present; -Ulcer to right buttock wound bed noted to have yellow/greenish slough present. The note did not contain documentation of physician notification the wound deteriorated, with yellow/greenish slough and odor present. Review of the resident's care plan, revised [DATE], showed the following: -Pressure ulcers to coccyx; -Assess, record, monitor wound healing weekly to include: a. measurements of length, width, and depth; b. assess and document status of perimeters; c. wound bed and healing progress; d. keep the physician informed; -Encourage assist with repositioning every two hours; -Monitor for signs and symptoms of infection and report to the physician: i.e. foul odor, purulent (consisting of pus) drainage, or elevation in temperature; -Weekly assessment by licensed nurse; -Pressure relieving mattress on bed, cushion in wheelchair; -Treatment as ordered by the physician. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/11/19, showed the following: -Coccyx Stage II pressure ulcer measures 3.8 cm in length, 6.7 cm in width, and 0.1 cm depth; -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of bloody drainage noted to wound. Review of the resident's nurses notes, dated 10/11/19, showed the following: -Stage II pressure ulcer to coccyx/buttocks noted to have slight odor present; -Wound bed noted to have thick yellow slough present; -Granulation tissue noted around wound bed edges; -Requested physician change the treatment order from [MEDICATION NAME] to [MEDICATION NAME] (medication used to treat or prevent infection). The nurse's note did not contain documentation of physician notification the wound deteriorated, with white/gray non-viable tissue, and increased measurements. Review of the resident's Wound/Pressure Sore Progress Record, dated [DATE], showed the following: -Sacrum Stage II pressure ulcer measures 6.9 cm in length, 4.9 cm in width, and 0.2 cm depth; -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of foul purulent drainage noted to wound; -Wound deteriorating. Review of the resident's Nurses Notes, dated [DATE], showed the following: -Stage II pressure ulcer to coccyx/buttocks; -Dressing removed noted to be saturated with foul purulent drainage; -Wound bed noted to have dark grayish slough present, granulation tissue noted around wound bed edges; -A dark area above pressure ulcer noted and measures 1.4 cm x 1.4 cm; -Surgical consult set up; -Family notified of surgical consult. Review of the resident's significant change in status assessment (SCSA) MDS dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive physical assistance of two or more staff members with bed mobility, transfers, and toilet use; -At risk for developing pressure ulcers -One Stage II pressure ulcer present; -One unstageable pressure ulcer with suspected deep tissue injury in evolution; -Weight 137 lbs.; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised [DATE], showed staff to encourage the resident to lay in bed to relieve pressure to his/her buttocks. Review of the resident's physician note, dated 10/21/19, showed the following: -Sacral wound approximately 4 cm in length, and 3 cm in width; -Moderate amount of [MEDICATION NAME] slough over the surface; -Wet to dry dressings two times daily; -Imperative to keep the pressure off his/her coccyx at all times, so the wound can heal; -If the wound progresses his/her prognosis was very poor. Review of the resident's nurses notes, dated 10/24/19, showed the following: -Pressure ulcer to coccyx; -Moderate amount of purulent drainage with foul odor on dressing when removed; -Yellow slough present to wound bed, with wound edge noted to have granulation tissue; -Pressure ulcer located above coccyx to left buttock; -Wound bed is dark brown in color; -Wet to dry dressing placed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/24/19, showed the following: -Sacrum Stage II pressure ulcer measures 6.7 cm in length, 4.2 cm in width, and 0.2 cm depth; -Sacrum unstageable pressure ulcer measures 3.4 cm in length, 1.9 cm in width, -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue pink &/dull, dusky red; -Moderate amount of foul, purulent drainage noted to wound; -Wound deteriorating. Review of the resident's nurses notes, dated 10/25/19, showed staff documented: -Pressure wound located on coccyx; -Drainage noted to dressing when removed; -Slough present in wound bed (right & left upper buttock wounds); -Dark brown/yellow in color; -Superior wound on upper sacral area has necrotic center, edges appear to be detaching from periwound where granulated tissue is present; -Very foul odor from wound. Review of the resident's care plan, revised 10/25/19, showed staff to encourage/assist with repositioning at least every two hours. Review of the resident's nurses notes, dated 10/28/19, showed staff documented: -Coccyx wound bed 100% yellow green adherent slough; -Moderate amount of green drainage with foul odor; -Complained of moderate amount of pain. Review of the resident's discharge MDS, dated [DATE], showed staff assessed the resident with two Stage II pressure ulcers. Review of the resident's Hospital Wound/Ostomy Nurse Initial Assessment, dated 10/29/19, showed the following: -Arrived to the emergency department with a coccyx (sacrum) wound; -Unstageable wound with black eschar, and yellow slough; -Measures 7 cm length, 7 cm width, and 2.5 cm depth; -Recommend debridement of the wound if the resident is admitted ; -If discharged , recommend an enzymatic (enzyme that eats dead tissue) debridement and fill the rest of the wound depth with moistened [MED] (type of gauze). Review of the resident's Hospital Pressure Ulcer Discharge Assessment, dated [DATE], showed the following: -Midline coccyx, Stage IV pressure ulcer; -Moist drainage; -Measures 7 cm in length, 6.4 cm in width, 2.8 cm in depth, 0.5 cm undermining; -Weight 130 lbs. Review of the resident's record showed the resident readmitted to the facility on [DATE]. Review of the resident's nurses notes, dated [DATE], showed the following: -Stage III pressure ulcer noted to bilateral buttocks and coccyx (hospital identified the wound as a Stage IV); -Ulcer noted to have soft, black eschar present; -Located to center of black eschar on left buttock; -Open area that measures 1.9 cm x 2.2 cm with undermining present that measures 1.3 cm; -Ulcer to buttocks and coccyx measures 6.9 cm x 7.2 cm.; -Located to bottom of wounds to each buttock, to have dull pink granulation tissue present; -Skin surrounding ulcer noted to be bright pink and blanchable; -Wound noted to have odor present; -Noted left buttock to have a small open area that measures 0.04 cm x 0.2 cm round; -Order for ulcer is wet to dry dressing, change every 6 hours, alternate normal saline and Dakins solution (normal saline and bleach mixture) 0.25% solution, apply Vaseline to healthy skin before dressing; -Pressure relieving mattress in place and Roho cushion in wheelchair. Review of the resident's Wound/Pressure Sore Progress Record, dated 11/4/19, showed the following: -Sacrum Stage III pressure ulcer measures 6.9 cm in length, 7.2 cm in width, and 1.3 cm depth; -Adherent soft black eschar; -Granulation tissue pink &/dull, dusky red; -Moderate amount of serosanguinous drainage noted to wound; -Wound deteriorating. Observation on 11/5/19 at 11:00 A.M., showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:20 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:30 P.M., showed the following: -Licensed Practical Nurse (LPN) C changed the resident's dressing; -Coccyx wound, a Stage IV; -Fibrous white connective tissue at the base of the wound; -Half dollar size opening, black tissue around the wound edges, and deep undermining and tunneling; -Foul odor; -Periwound has Stage III superficial areas on both lower sides of the wound on both sides; -Left area is long, and approximately the size of an egg; -Right area is quarter sized; -Periwound around the left lateral part of the wound is deep red tissue that is non-blanchable, above the wound is purple and non-blanchable; -Air mattress pump on the end of bed the resident's bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 2:00 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on 11/5/19 at 2:07 P.M., LPN C said the following: -The sacral wound is now a Stage IV; -The main opening is half dollar size with deep tunneling and undermining; -There is black tissue and slough; -Not sure what the fibrous white tissue was; -Superficial areas are open and connected to the wound, and extend down the left and right of the wound on each side of the buttock; -A medical equipment company sets up the air mattresses and the settings on the air mattress pump and facility staff do not adjust them; -Staff are expected to ensure the mattress is on and the hoses and plugs fastened; -The medical equipment company sets the mattress to the resident's weight when the mattress is first delivered to the facility; -Facility staff do not have access to the settings, they are locked. Observation on 11/5/19 at 2:57 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on [DATE] at 10:26 P.M., the facility wound nurse LPN K said the following: -If staff find a pressure ulcer the charge nurse notifies him/her; -He/She is expected to measure the wound, notify the physician, obtain a treatment order, and document a wound assessment; -He/She uses Bates and Jensen 2001 and an assessment tool for staging wounds dated 2001; -Wound assessments are done weekly on Fridays; -Charge nurses look at the wounds daily with treatments; -Charge nurses are expected to report to him/her if a wound deteriorates, then; -He/She is expected to contact the physician if the wound deteriorates i.e. tissue type, odor, drainage, or increased size; -Pressure wounds should be covered if open; -Wounds with granulation or slough should be covered; -He/She staged the wound wrong, because he/she was using information from 2001, and granulation and slough cannot be in a Stage II wound; -[MEDICATION NAME] cream is not recommended for a Stage III wound; -He/She did not notify the physician when the wound opened or when it deteriorated with new slough, purulent drainage, or with odor until [DATE], when the physician ordered a surgical consult, because he/she did not know it was a Stage III wound; -He/She did not see the hospital documentation that the wound was a Stage IV; -Air mattress are expected to be used according to the manufacturers instructions and set to the resident's weight; -Charge nurses were responsible for monitoring the air mattresses. During an interview on 11/5/19, at 12:57 P.M., the Director of Nursing (DON) said the following: -The wound nurse measures and assesses wounds weekly; -The wound nurse is expected to notify the physician if a wound deteriorates; -Resident's equipment and air mattresses should be used according to manufacturer's recommendations. During an interview on 11/25/19, at 5:03 P.M., the resident's physician said the following: -He expected facility staff to notify him of any deterioration of any pressure ulcer; -Facility staff notified him on 9/21/19 by fax, that the resident's buttocks were breaking down, right and left buttock turning colors, and requested a Roho cushion and Super Duper Diaper Doo cream to continue, the physician replied to consult the facility wound nurse; -Facility staff notified him on 9/24/19 by fax and requested an order for [REDACTED].>-From 9/25/19 through 10/8/19 there were no notifications from the facility in regard to the resident; -Facility staff notified him on 10/11/19 by fax to request to change the buttocks treatment from [MEDICATION NAME] to [MEDICATION NAME] for Stage II wounds. He replied to agree to the request, the fax did not include a wound description; -On [DATE] he ordered to consult the surgeon for wound care; -He received no further notification of wound deterioration or that the wound progressed to a Stage IV pressure wound when the resident returned from the hospital on [DATE]; -Staff are expected to notify him every time a wound deteriorates; -[MEDICATION NAME] is not recommended with a Stage III, or unstageable wound with slough, it should be covered and he would have used a different dressing if he had been informed; -All equipment is expected to be used according to the manufacturer and if there is a setting to be set to the resident's weight it should be set appropriately; -Staff are expected to alert him of a wound deteriorating prior to becoming a Stage IV wound so a different course of action can be attempted; -Earlier intervention and advanced treatments may have helped the wound to heal or prevented deterioration of the wound to a Stage IV. He would have ordered the surgical consult when the wound became a Stage III; -The resident did not have a [DIAGNOSES REDACTED]. MO 525

Based on observation, interview, and record review, the facility staff failed to notify the physician and re-evaluate interventions when a resident's wound deteriorated, stage a wound according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, or use air mattresses according to manufacturer's instructions to prevent development or worsening of pressure ulcers for one resident (Resident #6) in a review of two sampled residents with pressure ulcers, resulting in deterioration of the wound from a suspected deep tissue injury (pressure injury with of persistent non-blanchable deep red, maroon, purple discoloration, skin can be intact or non-intact) to a Stage IV wound (full-thickness loss of skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The facility census was 97. Review of NPUAP guidelines, dated (MONTH) (YEAR), showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury 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 injury 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 injury 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 injury 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 NAME] 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 injury (unstageable, Stage III or Stage IV pressure injury). Review of the Resident Assessment Instrument (RAI manual), dated 10/1/17, directed staff to code the Minimum Data Set (MDS) for Stage II pressure ulcers by definition as ulcers with partial-thickness loss of the dermis. Granulation tissue, slough or eschar are not present in Stage II pressure ulcers. Therefore, Stage II pressure ulcers should not be coded as having granulation, slough or eschar tissue. Review of the Manufacturer's Operator Manual, dated (YEAR), for the facility alternating pressure and low air loss mattress showed the following: -Pressure of the mattress is adjusted by choosing the patient's (resident's) corresponding weight setting using the weight setting buttons (+) or (-); -Follow the hand check procedure to ensure an appropriate pressure level. Review of the facility's Skin Integrity Management Program, undated, showed the following: -Residents' skin will be assessed by licensed personnel on admission; -Skin assessments will be conducted weekly; -Staff will be encouraged to report all skin changes to the charge nurse; -Staff instructed to report any reddened or open area to the charge nurse. 1. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment assessment instrument completed by facility staff dated 9/6/19, showed the following: -Severe cognitive impairment; -Independent with bed mobility and eating; -Requires limited physical assistance with toilet use; -Not at risk to develop pressure ulcers; -No pressure ulcers present; -No pressure reducing device to bed or chair; -Weight 138 pounds (lbs.); -Occasionally incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's care plan, dated 9/11/19, showed the following: -At risk for alteration in skin integrity; -Moisturize skin; -Do not massage bony prominences; -Weekly skin assessment; -Report red areas to the charge nurse. Review of the resident's skin assessment, dated 9/21/19, showed the resident with bruising to his/her forehead, right wrist, right foot, and [MEDICAL CONDITION] to the right foot. The note did not describe any other skin changes. Review of the resident's nurses notes, dated 9/21/19, showed the following: -Dark area to inner right and left buttocks, from pressure; -Area is not currently open at this time; -Cream (Super Duper Diaper Doo, a barrier cream) applied per physician's orders [REDACTED].>-Requested an order for [REDACTED]. Review of the resident's nurses notes dated 9/22/19, showed staff documented the buttocks remained dark red/purple. Review of the resident's nurses notes, dated 9/24/19, showed the following: -readmitted to facility on 9/20/19; -Stage I pressure ulcer to each buttock, area noted to be dark red/purple; -Stage I pressure ulcer to right buttock and two ulcers to left buttock; -Blood noted to be draining from all areas; -Requested change of treatment from the physician from Super Duper Diaper Doo to [MEDICATION NAME] (moisturizer to treat dry, rough skin and minor skin irritations); -Roho cushion placed on wheelchair and pressure relieving mattress placed on bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 9/24/19, showed the following: -Right buttock Stage II pressure ulcer measures 2.3 centimeter (cm) in length, and 2.2 cm in width; -Left buttock (a) Stage II pressure ulcer measures 0.6 cm in length, and 0.5 cm in width; -Left buttock (b) Stage II pressure ulcer measures 2.6 cm in length, and 1.3 cm in width; -Small amount of bloody drainage noted to all wounds; -No documentation staff notified the physician the wounds had opened. Review of the resident's nurses notes, dated 9/27/19, showed staff documented the open area to the resident's buttock had sloughing skin to the wound bed. The note did not contain documentation of physician notification the wound had sloughing skin. (Slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/28/19, showed staff documented the resident's bilateral buttock wound was beefy red with yellow sloughing skin. The resident complained of pain in his/her buttock. The note did not contain documentation of physician notification the wound was beefy red with yellow sloughing skin and pain. (Beefy red (granulation tissue) and slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/29/19, showed staff documented the open areas on the resident's buttock wound bed as dark brown with pink peri wound. The note did not contain documentation of physician notification the wound bed was dark brown. Review of the resident's nurses notes, dated 10/2/19, showed the following: -The resident complains of pain/burning to buttocks; -Buttocks wound bed red with yellow slough present; -Some areas of white macerated (dead skin/tissue that turns white from moisture) tissue noted around wound edges. The note did not contain documentation of physician notification the wound had areas of macerated tissue around the wound edges. Review of the resident's nurses notes, dated 10/3/19, showed staff documented the buttocks wound bed pink with yellow thickened area to middle of the wound bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/4/19, showed the following: -Right buttock Stage II pressure ulcer measures 5.2 cm in length, 3.1 cm in width, 0.1 cm in depth; -Left buttock (a) Stage II pressure ulcer measures 5.5 cm in length, and 2.7 cm in width, 0.1 cm in depth; -Small amount of serosanguinous (blood and the liquid part of blood that is clear to yellow) drainage noted to both wounds; -Wound deteriorating. Review of the resident's Nurses Notes, dated 10/4/19, showed staff documented extension of wound assessment: -Ulcer to left buttock and coccyx (tailbone) areas wound bed noted to have yellow/greenish slough present, slight odor present; -Ulcer to right buttock wound bed noted to have yellow/greenish slough present. The note did not contain documentation of physician notification the wound deteriorated, with yellow/greenish slough and odor present. Review of the resident's care plan, revised 10/9/19, showed the following: -Pressure ulcers to coccyx; -Assess, record, monitor wound healing weekly to include: a. measurements of length, width, and depth; b. assess and document status of perimeters; c. wound bed and healing progress; d. keep the physician informed; -Encourage assist with repositioning every two hours; -Monitor for signs and symptoms of infection and report to the physician: i.e. foul odor, purulent (consisting of pus) drainage, or elevation in temperature; -Weekly assessment by licensed nurse; -Pressure relieving mattress on bed, cushion in wheelchair; -Treatment as ordered by the physician. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/11/19, showed the following: -Coccyx Stage II pressure ulcer measures 3.8 cm in length, 6.7 cm in width, and 0.1 cm depth; -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of bloody drainage noted to wound. Review of the resident's nurses notes, dated 10/11/19, showed the following: -Stage II pressure ulcer to coccyx/buttocks noted to have slight odor present; -Wound bed noted to have thick yellow slough present; -Granulation tissue noted around wound bed edges; -Requested physician change the treatment order from [MEDICATION NAME] to [MEDICATION NAME] (medication used to treat or prevent infection). The nurse's note did not contain documentation of physician notification the wound deteriorated, with white/gray non-viable tissue, and increased measurements. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/18/19, showed the following: -Sacrum Stage II pressure ulcer measures 6.9 cm in length, 4.9 cm in width, and 0.2 cm depth; -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of foul purulent drainage noted to wound; -Wound deteriorating. Review of the resident's Nurses Notes, dated 10/18/19, showed the following: -Stage II pressure ulcer to coccyx/buttocks; -Dressing removed noted to be saturated with foul purulent drainage; -Wound bed noted to have dark grayish slough present, granulation tissue noted around wound bed edges; -A dark area above pressure ulcer noted and measures 1.4 cm x 1.4 cm; -Surgical consult set up; -Family notified of surgical consult. Review of the resident's significant change in status assessment (SCSA) MDS dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive physical assistance of two or more staff members with bed mobility, transfers, and toilet use; -At risk for developing pressure ulcers -One Stage II pressure ulcer present; -One unstageable pressure ulcer with suspected deep tissue injury in evolution; -Weight 137 lbs.; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised 10/18/19, showed staff to encourage the resident to lay in bed to relieve pressure to his/her buttocks. Review of the resident's physician note, dated 10/21/19, showed the following: -Sacral wound approximately 4 cm in length, and 3 cm in width; -Moderate amount of [MEDICATION NAME] slough over the surface; -Wet to dry dressings two times daily; -Imperative to keep the pressure off his/her coccyx at all times, so the wound can heal; -If the wound progresses his/her prognosis was very poor. Review of the resident's nurses notes, dated 10/24/19, showed the following: -Pressure ulcer to coccyx; -Moderate amount of purulent drainage with foul odor on dressing when removed; -Yellow slough present to wound bed, with wound edge noted to have granulation tissue; -Pressure ulcer located above coccyx to left buttock; -Wound bed is dark brown in color; -Wet to dry dressing placed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/24/19, showed the following: -Sacrum Stage II pressure ulcer measures 6.7 cm in length, 4.2 cm in width, and 0.2 cm depth; -Sacrum unstageable pressure ulcer measures 3.4 cm in length, 1.9 cm in width, -White/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue pink &/dull, dusky red; -Moderate amount of foul, purulent drainage noted to wound; -Wound deteriorating. Review of the resident's nurses notes, dated 10/25/19, showed staff documented: -Pressure wound located on coccyx; -Drainage noted to dressing when removed; -Slough present in wound bed (right & left upper buttock wounds); -Dark brown/yellow in color; -Superior wound on upper sacral area has necrotic center, edges appear to be detaching from periwound where granulated tissue is present; -Very foul odor from wound. Review of the resident's care plan, revised 10/25/19, showed staff to encourage/assist with repositioning at least every two hours. Review of the resident's nurses notes, dated 10/28/19, showed staff documented: -Coccyx wound bed 100% yellow green adherent slough; -Moderate amount of green drainage with foul odor; -Complained of moderate amount of pain. Review of the resident's discharge MDS, dated [DATE], showed staff assessed the resident with two Stage II pressure ulcers. Review of the resident's Hospital Wound/Ostomy Nurse Initial Assessment, dated 10/29/19, showed the following: -Arrived to the emergency department with a coccyx (sacrum) wound; -Unstageable wound with black eschar, and yellow slough; -Measures 7 cm length, 7 cm width, and 2.5 cm depth; -Recommend debridement of the wound if the resident is admitted ; -If discharged , recommend an enzymatic (enzyme that eats dead tissue) debridement and fill the rest of the wound depth with moistened kerlix (type of gauze). Review of the resident's Hospital Pressure Ulcer Discharge Assessment, dated 11/1/19, showed the following: -Midline coccyx, Stage IV pressure ulcer; -Moist drainage; -Measures 7 cm in length, 6.4 cm in width, 2.8 cm in depth, 0.5 cm undermining; -Weight 130 lbs. Review of the resident's record showed the resident readmitted to the facility on [DATE]. Review of the resident's nurses notes, dated 11/1/19, showed the following: -Stage III pressure ulcer noted to bilateral buttocks and coccyx (hospital identified the wound as a Stage IV); -Ulcer noted to have soft, black eschar present; -Located to center of black eschar on left buttock; -Open area that measures 1.9 cm x 2.2 cm with undermining present that measures 1.3 cm; -Ulcer to buttocks and coccyx measures 6.9 cm x 7.2 cm.; -Located to bottom of wounds to each buttock, to have dull pink granulation tissue present; -Skin surrounding ulcer noted to be bright pink and blanchable; -Wound noted to have odor present; -Noted left buttock to have a small open area that measures 0.04 cm x 0.2 cm round; -Order for ulcer is wet to dry dressing, change every 6 hours, alternate normal saline and Dakins solution (normal saline and bleach mixture) 0.25% solution, apply Vaseline to healthy skin before dressing; -Pressure relieving mattress in place and Roho cushion in wheelchair. Review of the resident's Wound/Pressure Sore Progress Record, dated 11/4/19, showed the following: -Sacrum Stage III pressure ulcer measures 6.9 cm in length, 7.2 cm in width, and 1.3 cm depth; -Adherent soft black eschar; -Granulation tissue pink &/dull, dusky red; -Moderate amount of serosanguinous drainage noted to wound; -Wound deteriorating. Observation on 11/5/19 at 11:00 [NAME]M., showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:20 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:30 P.M., showed the following: -Licensed Practical Nurse (LPN) C changed the resident's dressing; -Coccyx wound, a Stage IV; -Fibrous white connective tissue at the base of the wound; -Half dollar size opening, black tissue around the wound edges, and deep undermining and tunneling; -Foul odor; -Periwound has Stage III superficial areas on both lower sides of the wound on both sides; -Left area is long, and approximately the size of an egg; -Right area is quarter sized; -Periwound around the left lateral part of the wound is deep red tissue that is non-blanchable, above the wound is purple and non-blanchable; -Air mattress pump on the end of bed the resident's bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 2:00 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on 11/5/19 at 2:07 P.M., LPN C said the following: -The sacral wound is now a Stage IV; -The main opening is half dollar size with deep tunneling and undermining; -There is black tissue and slough; -Not sure what the fibrous white tissue was; -Superficial areas are open and connected to the wound, and extend down the left and right of the wound on each side of the buttock; -A medical equipment company sets up the air mattresses and the settings on the air mattress pump and facility staff do not adjust them; -Staff are expected to ensure the mattress is on and the hoses and plugs fastened; -The medical equipment company sets the mattress to the resident's weight when the mattress is first delivered to the facility; -Facility staff do not have access to the settings, they are locked. Observation on 11/5/19 at 2:57 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on 11/27/19 at 10:26 P.M., the facility wound nurse LPN K said the following: -If staff find a pressure ulcer the charge nurse notifies him/her; -He/She is expected to measure the wound, notify the physician, obtain a treatment order, and document a wound assessment; -He/She uses[NAME]and[NAME]2001 and an assessment tool for staging wounds dated 2001; -Wound assessments are done weekly on Fridays; -Charge nurses look at the wounds daily with treatments; -Charge nurses are expected to report to him/her if a wound deteriorates, then; -He/She is expected to contact the physician if the wound deteriorates i.e. tissue type, odor, drainage, or increased size; -Pressure wounds should be covered if open; -Wounds with granulation or slough should be covered; -He/She staged the wound wrong, because he/she was using information from 2001, and granulation and slough cannot be in a Stage II wound; -[MEDICATION NAME] cream is not recommended for a Stage III wound; -He/She did not notify the physician when the wound opened or when it deteriorated with new slough, purulent drainage, or with odor until 10/18/19, when the physician ordered a surgical consult, because he/she did not know it was a Stage III wound; -He/She did not see the hospital documentation that the wound was a Stage IV; -Air mattress are expected to be used according to the manufacturers instructions and set to the resident's weight; -Charge nurses were responsible for monitoring the air mattresses. During an interview on 11/5/19, at 12:57 P.M., the Director of Nursing (DON) said the following: -The wound nurse measures and assesses wounds weekly; -The wound nurse is expected to notify the physician if a wound deteriorates; -Resident's equipment and air mattresses should be used according to manufacturer's recommendations. During an interview on 11/25/19, at 5:03 P.M., the resident's physician said the following: -He expected facility staff to notify him of any deterioration of any pressure ulcer; -Facility staff notified him on 9/21/19 by fax, that the resident's buttocks were breaking down, right and left buttock turning colors, and requested a Roho cushion and Super Duper Diaper Doo cream to continue, the physician replied to consult the facility wound nurse; -Facility staff notified him on 9/24/19 by fax and requested an order for [REDACTED].>-From 9/25/19 through 10/8/19 there were no notifications from the facility in regard to the resident; -Facility staff notified him on 10/11/19 by fax to request to change the buttocks treatment from [MEDICATION NAME] to [MEDICATION NAME] for Stage II wounds. He replied to agree to the request, the fax did not include a wound description; -On 10/18/19 he ordered to consult the surgeon for wound care; -He received no further notification of wound deterioration or that the wound progressed to a Stage IV pressure wound when the resident returned from the hospital on [DATE]; -Staff are expected to notify him every time a wound deteriorates; -[MEDICATION NAME] is not recommended with a Stage III, or unstageable wound with slough, it should be covered and he would have used a different dressing if he had been informed; -All equipment is expected to be used according to the manufacturer and if there is a setting to be set to the resident's weight it should be set appropriately; -Staff are expected to alert him of a wound deteriorating prior to becoming a Stage IV wound so a different course of action can be attempted; -Earlier intervention and advanced treatments may have helped the wound to heal or prevented deterioration of the wound to a Stage IV. He would have ordered the surgical consult when the wound became a Stage III; -The resident did not have a [DIAGNOSES REDACTED]. MO 525

Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for two residents (Resident #55 and #96), and failed to properly use a gait belt and safely transfer one resident (Resident #96), in a review of 20 sampled residents. The facility census was 99. 1. Record review of the facility's Falls Management Program Policy, dated as revised 7/20/09, showed the following: -A Fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -An Un-witnessed fall occurs when a resident is observed on the floor and neither the resident nor anyone else knows how he/she got there; -Post-Fall Management: Place individual on the HOT LIST (a form of charting which is problem-focused to obtain needed assessment data to evaluate needs and effectiveness of treatments and/or orders) and document on every shift for three days and perform neurological checks as guided; -All falls will be logged by the clinical supervisor or authorized person and reviewed regularly by the interdisciplinary team; -All incident report forms will be sent to the clinical supervisor for review. The clinical supervisor will track all falls for each individual and investigate the initial cause of the fall(s). The care plan team will discuss the falls on a regular basis and confer about potential preventative fall measures and measures to minimize injuries from falls. 2. Review of Resident #96's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 8/6/19 showed the following: -Moderately impaired cognition; -No behaviors; -Independent with transfers; -Walking, not steady but able to stabilize without human assistance; -Surface to surface transfer, not steady but able to stabilize without human assistance; -Used a walker for mobility; -[DIAGNOSES REDACTED]. -No falls in the last month prior to admission; -Had a fall in the last 2-6 months prior to admission. Review of the resident's undated fall risk assessment showed a score of 12 indicating high risk for falls. Review of the resident's care plan revised 8/9/19 showed the following: -High risk for falls related to multiple disease processes and history of falls; -Keep call light within reach and answer promptly; -Keep glasses clean and free from scratches; -Keep items resident may want within reach; -Keep non-skid socks or shoes on at all times; -Keep pathways clear and free of clutter. Review of the resident's nurse's notes dated 8/9/19 at 2:44 P.M. showed the following: -Therapy reports resident is minimum assist with bed mobility and transfers and ambulating 75 feet with front wheeled walker; -Needs cues for safety awareness set up/supervision with dressing and toileting. Review of the resident's nurses' notes dated 8/13/19 at 3:16 P.M. showed the resident ambulates with a walker and has a steady gait. Review of the resident's nurses' notes dated 8/16/19 at 2:41 P.M. showed the following: -Resident continues to complain of right hip being sore; -Able to walk and sit with minimal difficulty; -Refuses assistance from staff; -Received new order this morning for X-ray of right hip and pelvis. Review of the resident's nurses' notes dated 8/19/19 at 3:32 P.M. showed the resident was unable to ambulate with his/her walker as he/she usually had. Review of the resident's nurse's notes dated 8/19/19 at 8:15 P.M. showed the following: -Resident continues with increased confusion; -Resistive to care; -Striking out at staff; -Unable to ambulate with assist and walker requiring use of wheelchair; -Currently resting in recliner in core area. Review of the resident's nurse's notes dated 8/19/19 at 11:52 P.M. showed the following: -CNA alerted nurse that resident had fallen straight forward out of his/her wheelchair; -This nurse responded to unit and observed resident laying on his/her left side with his/her head towards the nurses' station; -His/her arms and legs were curled up in fetal position and his/her face and forehead were against the ground; -Resident assessed and noted to have large knot to middle of forehead; -He/She also had a skin tear to left forearm measuring 0.5 centimeters (cm); -Skin tear dressed with Vaseline gauze and gauze wrap, edges approximated; -Arms and legs noted to be in proper alignment, but resident not able to follow commands to move them; -Resident unresponsive so unable to perform full neuro checks; -Staff reports that resident has been confused and combative throughout the shift, but had slumped over in his/her wheelchair around 10 P.M. and was not responding to them; -Resident assisted to recliner by staff x3; -Resident sent out per ambulance. Review of the resident's medical record showed no evidence staff evaluated current fall interventions or implemented new interventions after the 8/19/19 fall. Review of the resident's nurses' notes dated 8/20/19 at 7:59 P.M. showed the following: -Resident unable to ambulate requiring use of wheelchair; -Resistive to care; -Continues with increased confusion; -Fax sent to physician with information from visit to ER; -Return fax received with no new orders; -Family member here and fed resident. Review of the resident's nurses' notes dated 8/21/19 at 6:06 [NAME]M. showed the following: -Resident resting in recliner in core area. Has slept fairly well here all night; -Continues on fall follow-up; -Neuro checks remain WNL except resident had difficulty understanding the hand grasp portion early in the shift. That has improved this [NAME]M.; -Abrasion remains to center of forehead; -Resident noted to be unable to ambulate; -One assist, two at times, needed to transfer to wheelchair; -Resident seems to be having difficulty with vision as well, especially with depth perception. Noted to be reaching out for items such as the grab bar or water cup, but is not reaching far enough to actually grab the item; -This nurse asked if the resident if he/she was seeing double and he/she said no. Will continue to monitor. Review of the resident's nurses' notes dated 8/22/19 at 7:51 [NAME]M. showed the following: -Resident was in a recliner in the special care unit and refused to get up for bathroom or to go to bed; -Resident was combative with staff and verbally abusive; -Contacted physician at 9:35 P.M. after resident continued to try and hit aides; -Physician ordered [MEDICATION NAME] (anti-anxiety medication)2 mgg by mouth now, and1 mgg every 8 hours as needed for aggression; -Can give intramuscular (IM) [MEDICATION NAME] if unable to take orally. Resident has a wound to left forearm 2L x 1/4 diameter. Review of the resident's nurses' notes dated 8/22/19 at 8:30 [NAME]M. showed the following: -Resident was found on floor in his/her room at bed check; -Resident had earlier been kicking and pinching staff at bed checks; -Aide went into room at 5:10 [NAME]M. and found resident on floor with blood on floor and resident had a head wound; -Resident was laying on right side with right arm under body, blood on face, and was alert; -Resident was assessed head to toe, wounds also noted on right elbow two skin tears, small skin tear on right wrist, cut to upper right lip, bruise on nose, and open laceration above left eyebrow, and bruising to right hip with abrasion; -Resident complains also of left leg pain; -Sent out to ER via ambulance at 5:45 [NAME]M. Review of the resident's nurses' notes dated 8/22/19 at 7:30 [NAME]M. showed the following: -Received report from nurse at ER; -Resident is ready to return to facility; -Resident has had a negative head CT scan (imaging to assess for injury), and has 2-3 sutures in his/her fore head which will dissolve on their own. Review of the resident's significant change MDS dated [DATE] showed the following: -Severe cognitive impairment; -Physical behavioral symptoms occurred 4-6 days of the last seven days; -Verbal behavioral symptoms occurred 4-6 days of the last seven days; -Rejection of care 1-3 days of the last seven days; -Required extensive assist of two or more staff for transfers; -Two or more non-injury falls since prior assessment; -Two or more injury falls (not major) since prior assessment. Review of the resident's fall risk assessment dated [DATE] showed a score of 17 indicating high risk for falls. Review of the resident's care plan revised 9/11/19 showed the following: -Decline in ADL and mobility performance related to low endurance and weakness from recent hospital stay; -Resident requires extensive assist of two with transfers. Observation on 9/10/19 at 10:29 [NAME]M. at the nurses' station showed the following: -The resident sat in a recliner; -CNA Q and CNA I placed a gait belt around the resident's waist; -CNA Q and CNA I pivoted the resident from the recliner to the wheelchair; -Both staff pulled up on the back of the resident's pants during the transfer; -The resident did not bear weight; -During the transfer, the resident's feet slid across the floor and his/her knees were bent. Observation on 9/10/19 at 10:40 [NAME]M. in the resident's room showed the following: -The resident sat in his/her wheelchair beside the bed; -CNA Q and CNA I placed a gait belt around the resident's waist; -CNA Q and CNA I pivoted the resident from the wheelchair to the bed; -Both staff pulled up on the back of the resident's pants during the transfer; -The resident did not bear weight; -During the transfer, the resident's feet slid across the floor and his/her knees were bent. During interview on 09/11/19 at 1:27 P.M. CNA Q said the following: -The resident was not bearing weight well at all during the transfers; -The resident's knees were bent and his/her feet slid across the floor; -The resident did not seem to follow simple commands; -He/She and CNA I had to pull up on the back of the resident's pants to transfer him/her. 2. Record review of Resident #55's quarterly MDS dated [DATE], showed the following: -Severe cognitive impairment for daily decision making; -Independent with no help from staff with bed mobility, transfer, walking in room, walking in corridor, and toileting; -Required supervision with setup help only for dressing and personal hygiene; -Was not steady, but able to stabilize without staff assistance with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer; -Had no functional limitation in range of motion of the upper and lower extremity; -Used a walker for mobility; -Had no falls since last assessment (1/11/19). Review of the resident's nurse's notes, dated 6/25/19 at 12:49 [NAME]M., showed the resident had been wandering the halls, leaving his/her walker in various places at times. Review of the resident's nurse's notes, dated 7/1/19 at 1:31 P.M., showed the nurse was called to the resident's room and it was reported a housekeeper went into the resident's room and heard the resident calling for help. Upon opening the bathroom door, the resident was noted to be sitting on the floor. The housekeeper called for staff to help assist the resident. When staff entered the room they noted the resident scooting out of the bathroom on his/her buttocks. The nurse walked into the room shortly after and noted the resident sitting outside the bathroom door on his/her buttocks. There was bowel movement noted to the floor of the bathroom and appeared the resident had slipped and fallen on the stool. The resident's walker was found beside his/her bed. The resident had walked to the bathroom unassisted. No apparentinjuriess noted. The resident denied hitting his/her head, but neurological assessment initiated. Review of the resident's nurse's notes, dated 7/27/19 at 3:56 P.M., showed the resident was observed in the dining area sitting on the floor beside his/her walker. No injuries noted. Neurological assessment initiated. Review of the resident's nurse's notes, dated 8/14/19 at 2:39 P.M., showed the resident observed by the nurse sitting on the floor in the dining area with his/her walker to his/her side. No injuries noted. Neurological assessment initiated. Review of the resident's care plan, dated as last reviewed 9/3/19, showed the following: -Focus: High risk for falls related to history of falls and multiple disease processes (date initiated: 2/18/2015); -Interventions: Keep glasses clean and free from scratches (date initiated: 2/18/2015). Keep items theresidentt may want within reach (date initiated: 2/18/2015). Keep non skid socks or shoes on at all times (date initiated: 2/18/2015). Keep walker within reach at all times (date initiated: 2/18/2015). Provide adequate lighting (date initiated: 2/18/2015). Encourage the resident to request assistance with making his/her bed (date initiated: 11/3/2015). Up as needed in the facility with four wheeled walker, make sure walker is always within reach (date initiated 1/19/2017). Keep call light within reach and answer promptly (date initiated: 7/21/2017). Encourage and assist theresidentt to the bathroom at least every two hours (date initiated: 10/22/2018); -Staff failed to modify or implement new interventions after the resident fell on [DATE], 7/27/19, and 8/14/19. During an interview on 9/12/19 at 3:20 P.M., Licensed Practical Nurse (LPN) BB said the following: -Nurses can add interventions to the care plan after a fall to ensure another fall doesn't occur; -In some situations staff may need to increase monitoring of the resident to prevent falls and those interventions should be on the care plan. During an interview on 9/12/19 at 4:52 P.M., the Director of Nursing (DON) said the following: -After a fall, staff should look at the interventions and see if those interventions were in place and if not may need to re-educate the resident or staff; -If there are any new interventions that needed to be added to prevent future falls or injury, staff should let the Minimum Data Set (MDS) nurse know, so those interventions can be added to the care plan; -The facility does have a falls committee that looks at all the falls, including the times of the falls and the locations; -It would not be appropriate for staff to transfer a resident who is not bearing weight with a gait belt; -Staff should not pull up on the back of a resident's pants during gait belt transfers.

Based on observation, interview, and record review, the facility staff failed to notify the physician and re-evaluate interventions when a resident's wound deteriorated, stage a wound according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, or use air mattresses according to manufacturer's instructions to prevent development or worsening of pressure ulcers for one resident (Resident #6) in a review of two sampled residents with pressure ulcers, resulting in deterioration of the wound from a suspected deep tissue injury (pressure injury with of persistent non-blanchable deep red, maroon, purple discoloration, skin can be intact or non-intact) to a Stage IV wound (full-thickness loss of skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The facility census was 97. Review of NPUAP guidelines, dated (MONTH) (YEAR), showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness). Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury 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 injury 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 injury 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 injury 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 NAME] 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 injury (unstageable, Stage III or Stage IV pressure injury). Review of the Resident Assessment Instrument (RAI manual), dated 10/1/17, directed staff to code the Minimum Data Set (MDS) for Stage II pressure ulcers by definition as ulcers with partial-thickness loss of the dermis. Granulation tissue, slough or eschar are not present in Stage II pressure ulcers. Therefore, Stage II pressure ulcers should not be coded as having granulation, slough or eschar tissue. Review of the Manufacturer's Operator Manual, dated (YEAR), for the facility alternating pressure and low air loss mattress showed the following: -Pressure of the mattress is adjusted by choosing the patient's (resident's) corresponding weight setting using the weight setting buttons (+) or (-); -Follow the hand check procedure to ensure an appropriate pressure level. Review of the facility's Skin Integrity Management Program, undated, showed the following: -Residents' skin will be assessed by licensed personnel on admission; -Skin assessments will be conducted weekly; -Staff will be encouraged to report all skin changes to the charge nurse; -Staff instructed to report any reddened or open area to the charge nurse. 1. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment assessment instrument completed by facility staff dated 9/6/19, showed the following: -Severe cognitive impairment; -Independent with bed mobility and eating; -Requires limited physical assistance with toilet use; -Not at risk to develop pressure ulcers; -No pressure ulcers present; -No pressure reducing device to bed or chair; -Weight 138 pounds (lbs.); -Occasionally incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's care plan, dated 9/11/19, showed the following: -At risk for alteration in skin integrity; -Moisturize skin; -Do not massage bony prominences; -Weekly skin assessment; -Report red areas to the charge nurse. Review of the resident's skin assessment, dated 9/21/19, showed the resident with bruising to his/her forehead, right wrist, right foot, and [MEDICAL CONDITION] to the right foot. The note did not describe any other skin changes. Review of the resident's nurses notes, dated 9/21/19, showed the following: -Dark area to inner right and left buttocks, from pressure; -Area is not currently open at this time; -Cream (Super Duper Diaper Doo, a barrier cream) applied per physician's orders [REDACTED].>-Requested an order for [REDACTED]. Review of the resident's nurses notes dated 9/22/19, showed staff documented the buttocks remained dark red/purple. Review of the resident's nurses notes, dated 9/24/19, showed the following: -readmitted to facility on 9/20/19; -Stage I pressure ulcer to each buttock, area noted to be dark red/purple; -Stage I pressure ulcer to right buttock and two ulcers to left buttock; -Blood noted to be draining from all areas; -Requested change of treatment from the physician from Super Duper Diaper Doo to [MEDICATION NAME] (moisturizer to treat dry, rough skin and minor skin irritations); -Roho cushion placed on wheelchair and pressure relieving mattress placed on bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 9/24/19, showed the following: -Right buttock Stage II pressure ulcer measures 2.3 centimeter (cm) in length, and 2.2 cm in width; -Left buttock (a) Stage II pressure ulcer measures 0.6 cm in length, and 0.5 cm in width; -Left buttock (b) Stage II pressure ulcer measures 2.6 cm in length, and 1.3 cm in width; -Small amount of bloody drainage noted to all wounds; -No documentation staff notified the physician the wounds had opened. Review of the resident's nurses notes, dated 9/27/19, showed staff documented the open area to the resident's buttock had sloughing skin to the wound bed. The note did not contain documentation of physician notification the wound had sloughing skin. (Slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/28/19, showed staff documented the resident's bilateral buttock wound was beefy red with yellow sloughing skin. The resident complained of pain in his/her buttock. The note did not contain documentation of physician notification the wound was beefy red with yellow sloughing skin and pain. (Beefy red (granulation tissue) and slough would not be present in a Stage II wound.) Review of the resident's nurses notes, dated 9/29/19, showed staff documented the open areas on the resident's buttock wound bed as dark brown with pink peri wound. The note did not contain documentation of physician notification the wound bed was dark brown. Review of the resident's nurses notes, dated 10/2/19, showed the following: -The resident complains of pain/burning to buttocks; -Buttocks wound bed red with yellow slough present; -Some areas of white macerated (dead skin/tissue that turns white from moisture) tissue noted around wound edges. The note did not contain documentation of physician notification the wound had areas of macerated tissue around the wound edges. Review of the resident's nurses notes, dated 10/3/19, showed staff documented the buttocks wound bed pink with yellow thickened area to middle of the wound bed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/4/19, showed the following: -Right buttock Stage II pressure ulcer measures 5.2 cm in length, 3.1 cm in width, 0.1 cm in depth; -Left buttock (a) Stage II pressure ulcer measures 5.5 cm in length, and 2.7 cm in width, 0.1 cm in depth; -Small amount of serosanguinous (blood and the liquid part of blood that is clear to yellow) drainage noted to both wounds; -Wound deteriorating. Review of the resident's Nurses Notes, dated 10/4/19, showed staff documented extension of wound assessment: -Ulcer to left buttock and coccyx (tailbone) areas wound bed noted to have yellow/greenish slough present, slight odor present; -Ulcer to right buttock wound bed noted to have yellow/greenish slough present. The note did not contain documentation of physician notification the wound deteriorated, with yellow/greenish slough and odor present. Review of the resident's care plan, revised 10/9/19, showed the following: -Pressure ulcers to coccyx; -Assess, record, monitor wound healing weekly to include: a. measurements of length, width, and depth; b. assess and document status of perimeters; c. wound bed and healing progress; d. keep the physician informed; -Encourage assist with repositioning every two hours; -Monitor for signs and symptoms of infection and report to the physician: i.e. foul odor, purulent (consisting of pus) drainage, or elevation in temperature; -Weekly assessment by licensed nurse; -Pressure relieving mattress on bed, cushion in wheelchair; -Treatment as ordered by the physician. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/11/19, showed the following: -Coccyx Stage II pressure ulcer measures 3.8 cm in length, 6.7 cm in width, and 0.1 cm depth; -[NAME]/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of bloody drainage noted to wound. Review of the resident's nurses notes, dated 10/11/19, showed the following: -Stage II pressure ulcer to coccyx/buttocks noted to have slight odor present; -Wound bed noted to have thick yellow slough present; -Granulation tissue noted around wound bed edges; -Requested physician change the treatment order from [MEDICATION NAME] to [MEDICATION NAME] (medication used to treat or prevent infection). The nurse's note did not contain documentation of physician notification the wound deteriorated, with white/gray non-viable tissue, and increased measurements. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/18/19, showed the following: -Sacrum Stage II pressure ulcer measures 6.9 cm in length, 4.9 cm in width, and 0.2 cm depth; -[NAME]/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue bright beefy red; -Small amount of foul purulent drainage noted to wound; -Wound deteriorating. Review of the resident's Nurses Notes, dated 10/18/19, showed the following: -Stage II pressure ulcer to coccyx/buttocks; -Dressing removed noted to be saturated with foul purulent drainage; -Wound bed noted to have dark grayish slough present, granulation tissue noted around wound bed edges; -A dark area above pressure ulcer noted and measures 1.4 cm x 1.4 cm; -Surgical consult set up; -Family notified of surgical consult. Review of the resident's significant change in status assessment (SCSA) MDS dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive physical assistance of two or more staff members with bed mobility, transfers, and toilet use; -At risk for developing pressure ulcers -One Stage II pressure ulcer present; -One unstageable pressure ulcer with suspected deep tissue injury in evolution; -Weight 137 lbs.; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised 10/18/19, showed staff to encourage the resident to lay in bed to relieve pressure to his/her buttocks. Review of the resident's physician note, dated 10/21/19, showed the following: -Sacral wound approximately 4 cm in length, and 3 cm in width; -Moderate amount of [MEDICATION NAME] slough over the surface; -Wet to dry dressings two times daily; -Imperative to keep the pressure off his/her coccyx at all times, so the wound can heal; -If the wound progresses his/her prognosis was very poor. Review of the resident's nurses notes, dated 10/24/19, showed the following: -Pressure ulcer to coccyx; -Moderate amount of purulent drainage with foul odor on dressing when removed; -Yellow slough present to wound bed, with wound edge noted to have granulation tissue; -Pressure ulcer located above coccyx to left buttock; -Wound bed is dark brown in color; -Wet to dry dressing placed. Review of the resident's Wound/Pressure Sore Progress Record, dated 10/24/19, showed the following: -Sacrum Stage II pressure ulcer measures 6.7 cm in length, 4.2 cm in width, and 0.2 cm depth; -Sacrum unstageable pressure ulcer measures 3.4 cm in length, 1.9 cm in width, -[NAME]/gray non-viable tissue and/or non-adherent yellow slough; -Granulation tissue pink &/dull, dusky red; -Moderate amount of foul, purulent drainage noted to wound; -Wound deteriorating. Review of the resident's nurses notes, dated 10/25/19, showed staff documented: -Pressure wound located on coccyx; -Drainage noted to dressing when removed; -Slough present in wound bed (right & left upper buttock wounds); -Dark brown/yellow in color; -Superior wound on upper sacral area has necrotic center, edges appear to be detaching from periwound where granulated tissue is present; -Very foul odor from wound. Review of the resident's care plan, revised 10/25/19, showed staff to encourage/assist with repositioning at least every two hours. Review of the resident's nurses notes, dated 10/28/19, showed staff documented: -Coccyx wound bed 100% yellow green adherent slough; -Moderate amount of green drainage with foul odor; -Complained of moderate amount of pain. Review of the resident's discharge MDS, dated [DATE], showed staff assessed the resident with two Stage II pressure ulcers. Review of the resident's Hospital Wound/Ostomy Nurse Initial Assessment, dated 10/29/19, showed the following: -Arrived to the emergency department with a coccyx (sacrum) wound; -Unstageable wound with black eschar, and yellow slough; -Measures 7 cm length, 7 cm width, and 2.5 cm depth; -Recommend debridement of the wound if the resident is admitted ; -If discharged , recommend an enzymatic (enzyme that eats dead tissue) debridement and fill the rest of the wound depth with moistened kerlix (type of gauze). Review of the resident's Hospital Pressure Ulcer Discharge Assessment, dated 11/1/19, showed the following: -Midline coccyx, Stage IV pressure ulcer; -Moist drainage; -Measures 7 cm in length, 6.4 cm in width, 2.8 cm in depth, 0.5 cm undermining; -Weight 130 lbs. Review of the resident's record showed the resident readmitted to the facility on [DATE]. Review of the resident's nurses notes, dated 11/1/19, showed the following: -Stage III pressure ulcer noted to bilateral buttocks and coccyx (hospital identified the wound as a Stage IV); -Ulcer noted to have soft, black eschar present; -Located to center of black eschar on left buttock; -Open area that measures 1.9 cm x 2.2 cm with undermining present that measures 1.3 cm; -Ulcer to buttocks and coccyx measures 6.9 cm x 7.2 cm.; -Located to bottom of wounds to each buttock, to have dull pink granulation tissue present; -Skin surrounding ulcer noted to be bright pink and blanchable; -Wound noted to have odor present; -Noted left buttock to have a small open area that measures 0.04 cm x 0.2 cm round; -Order for ulcer is wet to dry dressing, change every 6 hours, alternate normal saline and Dakins solution (normal saline and bleach mixture) 0.25% solution, apply Vaseline to healthy skin before dressing; -Pressure relieving mattress in place and Roho cushion in wheelchair. Review of the resident's Wound/Pressure Sore Progress Record, dated 11/4/19, showed the following: -Sacrum Stage III pressure ulcer measures 6.9 cm in length, 7.2 cm in width, and 1.3 cm depth; -Adherent soft black eschar; -Granulation tissue pink &/dull, dusky red; -Moderate amount of serosanguinous drainage noted to wound; -Wound deteriorating. Observation on 11/5/19 at 11:00 [NAME]M., showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:20 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 1:30 P.M., showed the following: -Licensed Practical Nurse (LPN) C changed the resident's dressing; -Coccyx wound, a Stage IV; -Fibrous white connective tissue at the base of the wound; -Half dollar size opening, black tissue around the wound edges, and deep undermining and tunneling; -Foul odor; -Periwound has Stage III superficial areas on both lower sides of the wound on both sides; -Left area is long, and approximately the size of an egg; -Right area is quarter sized; -Periwound around the left lateral part of the wound is deep red tissue that is non-blanchable, above the wound is purple and non-blanchable; -Air mattress pump on the end of bed the resident's bed set with the resident's weight at 450 lbs. Observation on 11/5/19 at 2:00 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on the end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on 11/5/19 at 2:07 P.M., LPN C said the following: -The sacral wound is now a Stage IV; -The main opening is half dollar size with deep tunneling and undermining; -There is black tissue and slough; -Not sure what the fibrous white tissue was; -Superficial areas are open and connected to the wound, and extend down the left and right of the wound on each side of the buttock; -A medical equipment company sets up the air mattresses and the settings on the air mattress pump and facility staff do not adjust them; -Staff are expected to ensure the mattress is on and the hoses and plugs fastened; -The medical equipment company sets the mattress to the resident's weight when the mattress is first delivered to the facility; -Facility staff do not have access to the settings, they are locked. Observation on 11/5/19 at 2:57 P.M., showed the resident lay in his/her bed. Additional observation showed the resident's air mattress pump on end of bed his/her bed set with the resident's weight at 450 lbs. During an interview on 11/27/19 at 10:26 P.M., the facility wound nurse LPN K said the following: -If staff find a pressure ulcer the charge nurse notifies him/her; -He/She is expected to measure the wound, notify the physician, obtain a treatment order, and document a wound assessment; -He/She uses[NAME]nd[NAME]2001 and an assessment tool for staging wounds dated 2001; -Wound assessments are done weekly on Fridays; -Charge nurses look at the wounds daily with treatments; -Charge nurses are expected to report to him/her if a wound deteriorates, then; -He/She is expected to contact the physician if the wound deteriorates i.e. tissue type, odor, drainage, or increased size; -Pressure wounds should be covered if open; -Wounds with granulation or slough should be covered; -He/She staged the wound wrong, because he/she was using information from 2001, and granulation and slough cannot be in a Stage II wound; -[MEDICATION NAME] cream is not recommended for a Stage III wound; -He/She did not notify the physician when the wound opened or when it deteriorated with new slough, purulent drainage, or with odor until 10/18/19, when the physician ordered a surgical consult, because he/she did not know it was a Stage III wound; -He/She did not see the hospital documentation that the wound was a Stage IV; -Air mattress are expected to be used according to the manufacturers instructions and set to the resident's weight; -Charge nurses were responsible for monitoring the air mattresses. During an interview on 11/5/19, at 12:57 P.M., the Director of Nursing (DON) said the following: -The wound nurse measures and assesses wounds weekly; -The wound nurse is expected to notify the physician if a wound deteriorates; -Resident's equipment and air mattresses should be used according to manufacturer's recommendations. During an interview on 11/25/19, at 5:03 P.M., the resident's physician said the following: -He expected facility staff to notify him of any deterioration of any pressure ulcer; -Facility staff notified him on 9/21/19 by fax, that the resident's buttocks were breaking down, right and left buttock turning colors, and requested a Roho cushion and Super Duper Diaper Doo cream to continue, the physician replied to consult the facility wound nurse; -Facility staff notified him on 9/24/19 by fax and requested an order for [REDACTED].>-From 9/25/19 through 10/8/19 there were no notifications from the facility in regard to the resident; -Facility staff notified him on 10/11/19 by fax to request to change the buttocks treatment from [MEDICATION NAME] to [MEDICATION NAME] for Stage II wounds. He replied to agree to the request, the fax did not include a wound description; -On 10/18/19 he ordered to consult the surgeon for wound care; -He received no further notification of wound deterioration or that the wound progressed to a Stage IV pressure wound when the resident returned from the hospital on [DATE]; -Staff are expected to notify him every time a wound deteriorates; -[MEDICATION NAME] is not recommended with a Stage III, or unstageable wound with slough, it should be covered and he would have used a different dressing if he had been informed; -All equipment is expected to be used according to the manufacturer and if there is a setting to be set to the resident's weight it should be set appropriately; -Staff are expected to alert him of a wound deteriorating prior to becoming a Stage IV wound so a different course of action can be attempted; -Earlier intervention and advanced treatments may have helped the wound to heal or prevented deterioration of the wound to a Stage IV. He would have ordered the surgical consult when the wound became a Stage III; -The resident did not have a [DIAGNOSES REDACTED]. MO 525

Based on interview and record review, the facility failed to identify and care plan risk factors for falls, failed to put appropriate interventions in place to prevent falls, and failed to provide supervision and monitoring for one (Resident #3) of seven sampled residents with a history of falls. The resident was admitted to the facility with a fractured arm sustained during a fall at another facility. Following admission to the facility, the resident had five falls between [DATE] and [DATE]. Four of the five falls resulted in injuries which included a hematoma (localized collection of blood outside the blood vessels) to the back of the head, a laceration to back of head requiring eight staples to repair and a right hip fracture requiring hospitalization and surgical repair. The fifth fall resulted in a subarachnoid hemorrhage (bleeding into an area that surrounds the brain), subdural hematoma (collection of blood in the space between the outer and middle layers of the covering of the brain) and skull fracture, resulting in the resident's death. The facility census was 100. 1. Review of the facility's fall management program, dated [DATE], showed the facility would systematically assess residents and evaluate fall risk situations and potential situations with the goal of identifying common fall risk factors and develop care plan interventions to mitigate potential harm. The Clinical Supervisor would track all falls for each individual and investigate the initial cause of the fall. The Care Plan Team would discuss falls on a regular basis and confer about potential preventative fall measures and measures to minimize injuries from falls. Review of Resident #3's physician's orders [REDACTED]. Review of the resident's nursing assessment, dated [DATE], showed staff documented he/she was "blind in both eyes and walked independently." Staff did not plan interim interventions to address the resident's blindness while walking independently. Review of the resident's nurse's notes, dated [DATE] at 2:30 P.M., showed staff documented they observed the resident had trouble seeing things. At 10:15 P.M., the resident was wandering/confused. Review of the resident's assessment of risk for falls, dated [DATE], showed staff assessed the resident as a high risk for falls due to falls in the past month, mental status, recent fracture, decreased vision, and the use of laxatives. Review of the resident's nurse's notes, dated [DATE], showed staff documented they discussed the resident's care plan during the weekly care plan meeting. Review of information faxed to the resident's physician, dated [DATE], showed staff documented the resident was standing at the nurse's station and lost his/her balance, fell back and hit his/her head causing a 6 centimeter (cm) by 5 cm hematoma. Review of the resident's nurse's notes, dated [DATE] at 10:15 P.M., showed staff documented he/she had bruising to the back of his/her head. During an interview on [DATE] at 2:32 P.M., Clinical Supervisor Licensed Practical Nurse (LPN) D said when the resident fell on [DATE], the intervention put in place at that time to prevent further falls was for the resident to continue with therapy services. Review of the resident's physician's orders [REDACTED]. Staff did not plan any new interventions to prevent additional falls. Review of the nurse's notes, dated [DATE] at 3:15 P.M., showed staff observed the resident attempting to sit in a chair. The resident sat on the arm of the chair and the chair flipped over. The resident fell to the floor on his/her right side. Review of information faxed to the resident's physician, dated [DATE] (the following day), showed the resident was observed by staff on [DATE] attempting to sit in a chair. The resident sat on the arm of the chair and fell to the floor on his/her right side. Review of the resident's care plan, dated [DATE], showed the resident had the potential for falls related to dementia and history of falls. The care plan directed staff to administer antipsychotic medications (these types of medications often create a greater fall risk) and monitor for side effects, assess the resident for underlying physiological reasons such as pain or constipation and address accordingly, call light within reach (may be unable to use related to cognitive impairment), keep bed in locked position appropriate for this resident, keep bed low to the floor when not providing care, maintain fall assessment quarterly, make sure the resident's needs such as hunger, thirst and toileting are met, the resident has a history of falls with RUE (right upper extremity) fracture prior to admission, up ad lib (on own), monitor for unsteady gait, wanders until exhausted, monitor for needed rest periods to prevent falls, and goes to bed early after supper. Review of the resident's care plan showed staff did not document any information regarding the [DATE] and [DATE] falls. Additionally, review shows staff did not plan interventions to address the resident's blindness related to walking independently. During an interview on [DATE] at 2:32 P.M., LPN D said when the resident fell on [DATE] the intervention put in place at that time to prevent further falls was to obtain a vitamin D level on the resident. Review of the resident's nurse's notes, dated [DATE] at 2:30 P.M., showed an order was received from the physician for a Vitamin D level related to multiple falls (two days after the resident's fall). Review of the resident's vitamin D laboratory test, dated [DATE], showed normal results. Review of the resident's medical record did not show the facility planned any new interventions to address the resident's falls after the Vitamin D levels were normal. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as: -Has short and long term memory problems; -Severely impaired cognitive skills for daily decision making; -Has hallucinations (perceptual experiences in the absence of real external sensory stimuli); -Wanders daily; -Required limited assistance of one staff member with toileting, dressing, and personal hygiene; -Frequently incontinent of bowel and bladder; -Had dementia; -fell in the last two to six months prior to admission; -Sustained a fracture in the last six months prior to admission; -Had one fall without injury and one fall with injury since admission. Review showed staff did not assess the resident's blindness. Review of the resident's monthly summary, dated [DATE], showed staff assessed the following: -Severely impaired vision, no vision or sees only light, colors or shapes; -Disorganized thinking; -Memory problems; -Severely impaired cognitive skills; -Wanders -Hallucinations; -Delusions; -Independent with bed mobility, transfers, eating and toilet use; -Did not use mobility devices. Staff did not plan interventions to address the resident's blindness and increased potential for falls due to walking independently. Review of the resident's monthly summary, dated [DATE], showed staff assessed the following: -Severely impaired vision, no vision or sees only light, colors or shapes; -Disorganized thinking; -Memory problems; -Severely impaired cognitive skills; -Wanders; -Hallucinations; -Delusions; -Independent with bed mobility, transfers and eating and supervision with toilet use; -Did not use mobility devices. Staff did not plan interventions to address the resident's blindness and increased potential for falls due to walking independently Review of the resident's monthly summary, dated [DATE], showed facility staff assessed the following: -Severely impaired vision, no vision or sees only light, colors or shapes; -Disorganized thinking; -Memory problems; -Severely impaired cognitive skills; -Wanders; -Hallucinations; -Delusions; -Independent with bed mobility, transfers and eating and supervision with toilet use; -Did not use mobility devices. Staff did not plan interventions to address the resident's blindness and increased potential for falls due to walking independently Review of the resident's assessment for risk for falls, dated [DATE], showed staff assessed the resident as high risk for falls related to falls in the past month, mental status, recent fracture, decreased vision and the use of laxatives. Review of the resident's nurse's notes, dated [DATE] at 10:35 A.M., showed staff documented that at approximately 9:10 A.M., staff found the resident on his/her back with a dining room chair on top of him/her. Blood was present on the floor and on the back of the resident's head. The resident had a cut on the lower back of the head requiring stitches. The resident was sent to a local hospital emergency room . The resident returned at approximately 2:00 P.M. with eight staples to the back of his/her head. Review of the resident's transfer form, dated [DATE], showed staff documented the resident was transferred to a local hospital due to injury sustained to the back of the head with stitches needed. Staff documented the resident was alert and confused, and independent with walking. Staff documented they informed the emergency room nurse on the telephone and the emergency medical technicians that the resident had his/her eyes wide open, but did not respond for approximately two minutes. During an interview on [DATE] at 2:32 P.M., LPN D said when the resident fell on [DATE], the intervention put in place at that time to prevent further falls was to request an ophthalmology consult for the resident. LPN D said this was never obtained because a couple of days later the resident fell again and fractured his/her hip. Staff did not implement any new interventions to prevent additional falls after the resident fell on [DATE] resulting in injury. Review of information faxed to the resident's physician, dated [DATE] (12 days after the resident's last fall), showed staff requested an order for [REDACTED]. Review of the resident's medical record showed staff did not obtain an ophthalmology consult for the resident. Review of the resident's nurse's notes, dated [DATE] at 8:30 A.M., showed staff documented they observed the resident on the floor on his/her right hip with his/her head against the wall. The resident complained of right hip pain and was unable to straighten or bend his/her right leg. At 9:00 A.M., the resident was transferred to the hospital by ambulance. At 12:00 P.M. the resident was admitted to the hospital. Review of the resident's hospital History and Physical, dated [DATE], showed hospital staff documented they evaluated the resident in the emergency department and determined the resident had a right hip fracture. Hospital staff documented the resident was to be admitted and expected to undergo surgical intervention once the family provided consent. Review of the resident's nurses notes, dated [DATE] at 2:00 P.M., showed staff documented the resident was readmitted to the facility from the hospital. Staff documented the resident was awake, alert and confused to person, place and time. The resident was transferred to his/her bed by mechanical lift. The resident had 35 staples to the right hip as a result of surgical intervention for a right hip fracture. The resident was incontinent of bowel and bladder. Review of the resident's physician orders, dated [DATE], showed a medication order for Coumadin (blood thinner) 2 mg (milligrams) by mouth daily. Review of the resident's fall risk assessment, dated [DATE], showed staff assessed the resident as high risk for falls related to two or more falls in past month, mental status, resident non-compliance, Alzheimer's Disease, recent fracture ([DATE]), severe arthritis, decreased vision, decreased hearing, incontinence, use of assistive devices, transfer difficulties, unsteady gait, and the use of laxatives. Review of the resident's nursing assessment, dated [DATE], showed staff assessed the resident as disoriented to person, place and time, blind in both eyes and required total assistance with mobility. Review of the resident's care plan, dated [DATE], showed staff documented the resident had impaired activities of daily living and mobility related to dementia and hip fracture. The care plan directed staff to walk the resident using a gait belt and assistance of one or two staff. Staff documented the resident had the potential for falls related to dementia and a history of falls. The care plan directed staff to: -Administer antipsychotic medications and monitor for side effects; -Assess the resident for underlying physiological reasons such as pain or constipation and address accordingly; -Call light within reach (may be unable to used related to cognitive impairment); -Keep bed in locked position appropriate for this resident; -Keep bed low to floor when not providing care; -Maintain fall assessment quarterly; -Ensure resident's needs such as hunger, thirst, and toileting are met; -Resident has a history of falls; -Resident is up with gait belt and assist of one staff, and assist of two staff as needed; -Monitor for unsteady gait; -Wanders until exhausted; -Monitor for needed rest periods to prevent falls; -Goes to bed early after supper. Review of the resident's care plan, dated [DATE], showed staff did not plan care to address potential risks/side effects associated with the resident's use of Coumadin, including but not limited to excessive bleeding. Additionally, review showed the only change made to the [DATE] care plan from the [DATE] care plan regarding the resident's falls was that the resident now required the use of a gait belt and the assistance of ,[DATE] staff for transfers. During an interview on [DATE] at 2:32 P.M., LPN D said after the resident fell on [DATE] interventions put in place (at that time) to prevent the resident from falling again included a fall mat beside his/her bed, body pillow, and sensor alarm on his/her bed. Review of the resident's monthly summary, dated [DATE], showed staff assessed the following: -Severely impaired vision, no vision or sees only light and or colors; -Disorganized thinking; -Memory problems; -Short tempered and easily annoyed at times; -Hallucinations; -Required extensive assistance with transfers, dressing, toilet use and bathing; -Used a walker for mobility; -Always continent of bladder and occasionally incontinent of bowel. Review of the resident's nurse's notes, dated [DATE] at 2:30 P.M., showed the resident was moved from the Alzheimer's Unit to a room in the general population portion of the facility. Review of the resident's nurse's notes, dated [DATE] at 6:15 P.M., showed staff documented the resident attempted to get up and walk and fell to the floor. The fall took place in the entrance in the south hallway. The resident hit the right side of his/her head on the wooden floor. Staff observed a laceration to the right temporal region. The resident was unresponsive for five minutes. When the resident became responsive, he/she was very agitated. The resident had significant bleeding. Staff applied pressure to the laceration. Staff was unable to obtain neurological checks related to the resident's agitation. The physician directed staff to send the resident to the hospital. At 10:40 P.M., the resident was admitted to the hospital with [REDACTED]. Review of the resident's emergency room notes, dated [DATE], showed: -The resident was on Coumadin and had a ground level fall; -The resident fell at the facility and experienced loss of consciousness for approximately three minutes with questionable seizure activity; -The resident had a two centimeter laceration to the scalp; -The resident did not follow commands; -treatment plan: [REDACTED]. They agreed that stopping aggressive testing and medications was appropriate. Will give him/her a single dose of Vitamin K (for blood clotting) and place him/her on comfort measures with medications for pain, agitation and anxiety to allow progression of the disease however it will proceed. Review of the resident's History and Physical from an area hospital, dated [DATE], showed the following: -On [DATE] the resident presented to the hospital from the facility following a fall; -The resident was bleeding significantly from the scalp and had increased agitation afterwards; -The resident was transferred to the emergency room where the resident was found to have a subdural and subarachnoid hemorrhage and pneumoencephalitis (inflammation of the brain) with air in his/her brain, maxillary sinus fracture, skull fracture and hematoma; -The resident had a laceration that was sutured by the emergency room physician; -The resident had just stopped taking his/her Coumadin the day prior (was on for prophylaxis following a recent hip fracture repair); -The resident was still anticoagulated from the Coumadin use; -Discussion was held with the family by the emergency room physician about treatment to reverse the resident's Coumadin and discussion about neurosurgical intervention; -Due to the resident's baseline and severe dementia, the family felt they wanted comfort measures only; -The resident was admitted to the hospital overnight for pain control. Review of the resident's nurse's notes, dated [DATE] through [DATE], showed: -On [DATE] at 11:00 A.M., the resident was readmitted to the facility (from the hospital); -The resident was unresponsive with a large jagged laceration of the scalp (closed with four staples), right hip scar with purple/green bruising and bruising to both knees; -At 1:15 P.M., staff observed the resident had facial grimacing and increased respirations; -At 2:00 P.M., the resident was admitted to hospice services; -At 6:30 P.M., the resident remained unresponsive; -At 8:00 P.M., the resident was restless, pulling at blankets; -On [DATE] at 7:00 P.M., the resident's family member reported the resident was really restless with facial grimacing; -The resident continued to be unresponsive to verbal stimuli; -On [DATE] at 8:30 P.M., the resident continued to be unresponsive; -On [DATE] at 4:30 P.M., the resident remained unresponsive; -On [DATE] at 10:45 A.M., the resident remained unresponsive; -At 12:22 P.M., staff observed the resident had no heartbeat or blood pressure. During an interview on [DATE] 10:50 A.M., MDS Coordinator F (MDS C F) said staff planned a new intervention for Resident #3 after he/she broke his/her hip. MDS C F said staff were directed to provide staff assistance at all times when up. She said the resident was always "up and going" on her own and she never noticed the resident to have any vision problems. She said that was never a concern for her. During an interview on [DATE] at 1:45 P.M., Certified Nurse Aide (CNA) A said: -He/she worked the evening of [DATE]; -He/she had never taken care of the resident before because the resident has just been transferred to that area (general population) of the facility; -He/she did not receive any report or information about the resident before his/her scheduled shift; -When his/her shift began, the resident was sitting in a recliner across from the big TV and piano; -The resident kept getting up (more than once); -The resident would rock back and forth and get his/her balance; -The resident would stand up and one of the other CNAs would assist the resident to sit back down; -After supper, staff took the resident from the dining room and put him/her in a recliner by a piano; -CNA A saw the resident try to get up and helped the resident to sit back down; -The resident sat down and staff walked back into the dining room; -Another CNA saw the resident get up and so that CNA walked the resident to the other side of the nurse's station and sat the resident in a recliner there; -CNA A was in another resident's room down the hall when he/she heard staff hollering for help; -CNA A came out of the other resident's room and saw the resident on the floor; -At that time he/she didn't know the resident was bleeding and he/she stayed with the resident until the ambulance arrived; -It was the first time he/she had cared for the resident and he/she did not know the resident was a fall risk; -The nurses told him/her to watch the resident during the shift because the resident kept getting up. During an interview on [DATE] at 2:00 P.M., CNA G said on [DATE] he/she had walked with Resident #3, but the resident still tried to get up a few times. Staff also toileted the resident several times. The charge nurse instructed staff to ask if the resident was thirsty, if he/she needed to go to the bathroom, or change positions. On [DATE] there was nothing significant going on with the resident until about 20 minutes before his/her shift was over. The resident was in the common area in a recliner and was trying to get up and stand without assistance. The resident "probably did this twice." The resident was close to the nursing desk and the charge nurse saw him/her. CNA G did not report anything to the next shift. Staff did not report the resident's attempts to rise without assistance to increase monitoring and assist in preventing additional falls. During an interview on [DATE] at 2:30 P.M., LPN B (who worked the 7:00 A.M. to 3:00 P.M. shift on [DATE] and [DATE]) said on [DATE] the resident would lean forward and try to get up and staff would give him/her a snack or take him/her to the bathroom. LPN B said that on [DATE] the resident made attempts to get up. He/she did report to the evening shift charge nurse, LPN C, that the resident had been trying to get out of his/her chair. During an interview on [DATE] at 4:04 P.M., LPN C (who worked the 3:00 P.M. to 11:00 P.M. shift) said LPN B reported the resident was restless and had been moving around in his/her chair but had not actually been trying to get up. The resident was restless at the start of LPN C's shift and made a couple of attempts to get up. Staff toileted the resident between 5:00 PM. and 6:00 P.M. and the resident seemed content. LPN C said he/she was in another resident's room and a new staff orientee found the resident on the floor at the south hall entrance. He/she said the fall was not witnessed by anyone. LPN C said no CNAs reported to him/her the resident tried to get up. During interview on [DATE] at 2:30 P.M. with LPN B, she said she received report on the resident from the Activity Director who said the resident had a fractured hip, was up with assistance of two staff, would walk some but not all of the time. During an interview on [DATE] at 3:30 P.M., Careplan Coordinator E (CC E) said: Staff discussed the resident's falls that occurred on [DATE], [DATE], and [DATE], during a care plan meeting, but did not update the resident's care plan with new interventions. CC E said the resident was legally blind and this should have been identified on the resident's MDS assessment. During an interview on [DATE] at 4:00 P.M., the Director of Nursing (DON) said: -Staff are directed to communicate residents' needs when transferring from one unit to another in the facility. -The Activity Director gave report on Resident #3 to the charge nurse; -Resident #3 had a sensor alarm attached to his/her bed on the Alzheimer's unit. The sensor alarm was not on the resident while he/she sat in the recliner in the common area on [DATE]. Review of the resident's death certificate, filed [DATE], showed the resident died on [DATE] from underlying causes including subarachnoid hemorrhage, subdural hematoma, and skull fracture. During an interview on [DATE] at 12:20 P.M., hospital Physician A said he saw the resident in the hospital on [DATE]. The resident had sustained extensive fractures to the head and he told the family the resident would probably die within five to seven days. The family wanted to keep the resident comfortable and opted to send the resident back to the facility on hospice services. The resident died as a result of trauma from the fall. MO 795 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began inservicing/training staff on safety interventions for residents at high risk for falling including observation of the residents for restlessness, interventions for said restlessness and reporting the restless behavior to the charge nurse on duty. The facility began education on interventions to alleviate restlessness and to not leave any resident unattended when attempting to rise unassisted when assistance is needed. The facility began education on when any resident exhibiting restlessness that could result in a fall and staff had exhausted all interventions, the charge nurse on duty would notify the physician of behaviors and interventions that have been exhausted. The facility began education of monitoring restless residents when in the common area. The facility began reviewing resident care plans to determine if the interventions addressed on the care plans were appropriate for each resident. The facility began assessing each resident currently residing at the facility for fall risk. The facility planned to connect with Quip Mo staff for consultation with facility MDS staff. The facility began implementation to address each resident at risk on the cardex and in report at change of shift. The facility had not completed corrective actions including staff education, resident assessments, care plan review and MDS consultant. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation.