Every finding on record at Bishop Spencer Place, Inc, The

Based on observation, interviews, and record review, the facility failed to maintain an appropriate infection control program to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and others; and failed to ensure appropriate infection control practices were maintained during one sampled resident's (Resident #21) wound care treatment out of 14 sampled residents. The facility census was 53 residents. Review of the facility's policy titled [NAME] Place Infection Prevention Plan dated 9/10/25 showed:-The Director of Nursing (DON) in collaboration with the Infection Prevention nurse had the authority to institute any surveillance, prevention, or control measures or study when there was reason to believe that any resident, personnel, or visitor may be in danger.-This authority and responsibility included, but was not limited to:--Developing and implementing a preventative and corrective program to minimize infection hazards.--Developing a system for identifying, reporting, and analyzing the incidence and causes of healthcare associated infections.--Developing and implementing a system for surveillance and prevention of infections, identifying, reporting, and analyzing clusters of infections, outbreaks, sentinel events, emerging pathogens, and special studies or reports.A policy related to infection control practices during wound care was requested and not provided prior to exit on 1/9/26.1. Review on 1/8/26 at 2:04 P.M. of the facility's Infection Control Log showed:-No records were found for infections that occurred in the facility from January 2025 to September 2025.-No mapping of infections was completed in the month of October 2025.-No mapping of infections was completed in the month of November 2025.-No mapping of infections was completed in the month of December 2025.During an interview on 1/8/26 at 2:04 P.M. the Infection Preventionist (IP) said:-He/She had received his/her IP certification in October 2025 and that was when he/she had taken over the program.-He/She had to build the system himself/herself because the records from previous months could not be accessed.-He/She was not educated by the facility about how the infection control program for tracking infections was done previously.-When a resident had an infection, he/she would put the resident on the infection log.-The log would indicate the resident, type of infection, and what antibiotic the resident was prescribed.-The log was also color coded to indicate the type of infection.-He/She was unaware that mapping of infections also had to be completed.-He/She understood that the current program in place did not meet regulatory requirements.During an interview on 1/9/26 at 10:25 A.M. Licensed Practical Nurse (LPN) B said:-The IP and the Quality and Risk for Post Acute Services Director worked on the infection control program.-He/She was unsure of the facility's method for tracking and trending infections.-He/She thought it was important for the facility to track infections in order to appropriately trend and monitor the infections for patterns and to place residents under the right precautions.During an interview on 1/9/26 at 10:57 A.M. Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator B said:-The IP was responsible for maintaining the facility's infection tracking log.-He/She thought it was important for infection tracking to be completed in order to keep the residents and staff safe.During an interview on 1/9/26 at 11:47 A.M. the DON said:-He/She had only been at the facility for two weeks and hadn't been able to review the infection tracking log yet.-He/She expected the IP to keep a spreadsheet or binder to track infections, wounds, and antibiotic usage.-It was important for the facility to appropriately track infections to know if there was a breakout of certain infections and to be able to educate the staff when needed.-The current infection tracking log did not meet regulatory standards.-The infection tracking log needed to include mapping of infections and everything else the Centers for Disease Control and Prevention (CDC) recommended.2. Review of Resident #21's admission Record showed the resident readmitted to the facility on [DATE] with a diagnosis of Osteomyelitis (an infection and inflammation of bone tissue).Review of the resident's Order Summary Report dated January 2026 showed:-The resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) Pressure Ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to his/her coccyx (the small bone at the bottom of the spine).-Staff were to cleanse with normal saline, pat dry, cover with mepilex (used for various exuding wounds like pressure ulcers to promote moist healing by absorbing drainage, minimizing pain and trauma on removal, and preventing maceration) border foam dressing, change every other day and as needed for soiling.Observation on 1/7/26 at 11:35 A.M. of the resident's wound care to his/her coccyx showed:-Licensed Practical Nurse (LPN) B, MDS Coordinator B, and Registered Nurse (RN) A were all in the room assisting with the resident's wound care.-RN A had performed the resident's wound care treatment to his/her coccyx while LPN B and MDS Coordinator B were assisting with the positioning of the resident.-Once the wound care to the resident's coccyx was completed, LPN B and MDS Coordinator B were changing the resident's bed linens.-RN A said to MDS Coordinator B that his/her gloved hands were dirty and that MDS Coordinator B could pull the dirty bed linens from underneath the resident.-When LPN B was assisting the resident to his/her left side, the resident's coccyx dressing had slipped from its original position.-While pulling the dirty bed linens from underneath the resident, MDS Coordinator B readjusted the dressing by sliding it back into place and patting it down to the original location.-MDS Coordinator B then removed the dirty linens from the bed, disposed of the bedding, removed his/her gloves, and went into the bathroom to wash his/her hands.During an interview on 1/8/26 at 11:04 A.M. RN A said:-He/She would not have done anything differently related to the resident's coccyx wound dressing.-He/She did not see MDS Coordinator B move the resident's coccyx dressing back into place.-MDS Coordinator B should not have touched the dressing at all.-MDS Coordinator B should have communicated with LPN B and RN A that the dressing had moved and that the treatment needed to be fixed/redone.-If he/she had noticed that MDS Coordinator B had touched and moved the dressing, then he/she would have redone the treatment.During an interview on 1/9/26 at 10:03 A.M. LPN B said:-He/She would not have done anything differently related to the resident's coccyx wound treatment.-He/She was on the other side of the resident and would not have been able to see the dressing or that MDS Coordinator B had moved the dressing.-MDS Coordinator B should not have touched the dressing and moved it back into place.-MDS Coordinator B should have verbalized that the dressing had been moved and that the treatment needed to be fixed.-If he/she had known that MDS Coordinator B had touched the dressing with his/her dirty gloves, then he/she would have assisted in redoing the treatment.During an interview on 1/9/26 at 10:32 A.M. MDS Coordinator B said:-He/She had been told by that point in time that he/she did not utilize appropriate infection control practices during the resident's coccyx wound treatment.-He/She had dirty gloves on when pulling the dirty bed linens from underneath the resident and had moved the resident's dressing back into place.-He/She should not have touched the resident's dressing with her gloves and moved it back into place.-He/She should have verbalized that the dressing had moved from its original position and that the dressing needed to be fixed.During an interview on 1/9/26 at 11:47 A.M. the DON said:-MDS Coordinator B did not utilize appropriate infection control practices during the resident's coccyx wound treatment.-MDS Coordinator B should not have moved the resident's coccyx dressing back into place after handling dirty linens.-He/She would have expected MDS Coordinator B to verbalize that the dressing had moved from its original position and the dressing needed to be fixed.-The staff should have redone the resident's coccyx treatment after MDS Coordinator B moved the dressing back into place.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) program was in place which had the potential to affect all residents in the facility. The facility census was 53 residents. Review of the facility's policy titled Antimicrobial Stewardship in Senior Living Communities, GA-457 dated 9/23/25 showed:-The facility would establish and maintain as Antimicrobial Stewardship Program (ASP) to ensure optimal use of antimicrobials in the treatment and prevention of infectious diseases.-The ASP would focus its efforts on reviewing appropriateness of antimicrobial regimens for residents within the facility.-All residents with antimicrobials would be screened/reviewed by the Pharmacist.-Residents whom staff deemed high-level targets would get a formal review and, when appropriate, a recommendation would be made to the clinical staff regarding suggested changes in therapy.-ASP recommendations would be communicated to providers responsible for that resident either by direct contact or other forms of passive communication.-ASP members would serve as a resource to clinical staff to assist in providing evidenced-based practice recommendations regarding antimicrobial therapy for residents.1. Review of the facility's antibiotic stewardship program on 1/8/26 at 2:04 P.M. showed the facility did not have an antibiotic stewardship program currently in place.During an interview on 1/8/26 at 2:04 P.M. the facility's Infection Preventionist (IP) said:-He/She had been certified as the facility's IP since October 2025.-He/She was not sure if the facility had an antibiotic stewardship program.-He/She did not have any records from the previous IP to indicate that a program was in place before he/she became the facility's IP.During an interview on 1/9/26 at 10:36 A.M. Licensed Practical Nurse (LPN) B said:-The facility's Medical Director was responsible for overseeing antibiotic usage.-He/She was unsure if the facility had an antibiotic stewardship program or what it entailed.During an interview on 1/9/26 at 10:59 A.M. Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator B said:-He/She was unsure if the facility had an antibiotic stewardship program in place.-The antibiotic stewardship program was important because it helped the facility stay within the recommended guidelines for antibiotic usage.During an interview on 1/9/26 at 11:47 A.M. the Director of Nursing (DON) said:-He/She had only been at the facility for two weeks.-He/She was unaware that the facility did not have an active antibiotic stewardship program.-He/She expected the IP to maintain the antibiotic stewardship program.-The antibiotic stewardship program was important because it ensured the facility was using antibiotics appropriately.

Based on interview and record review, the facility failed to ensure comprehensive care plans were up to date and reflected three sampled residents (Resident #50, #57, and #73) current status out of 14 sampled residents. The facility census was 53 residents.Review of the facility's policy titled Bishop [NAME] Place (BSP) Service/Care Plans dated 10/6/25 showed:-The purpose of the policy was to identify the components of a resident's service/care plan and provide guidance on how the service/care plan should be created and implemented for the resident's daily care routine.-Service/Care plans should incorporate measurable goals, objectives and timetables that lead to the resident's highest obtainable level of independence.-Service/Care plans should be used in developing the resident's daily care routines and would be available to staff personnel who have responsibility for providing care or services to the resident.-The Interdisciplinary Team (IDT) was responsible for the development of an individualized, comprehensive service/care plan.-Each resident's comprehensive service/care plan was designed to:--Incorporate identified problem areas.--Incorporate risk factors associated with identified problems.--Reflect treatment goals and objectives in measurable outcomes.--Identify the professional services that were responsible for each element of care.--Reflect currently recognized standards of practice for problem areas and conditions.--Aid in preventing or reducing declines in the resident's functional status and/or functional levels.--Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. Review of Resident #57's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/24/25 showed:-The resident felt down, depressed, or hopeless two to six days during the look back period.-The resident had an Anxiety Disorder.-The resident had Depression.-The resident had Bipolar Disorder. Review of the resident's admission Record dated 1/6/26 showed:-He/She admitted to the facility with a diagnosis of Major Depressive Disorder (MDD a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild.-During the resident's stay at the facility he/she had been diagnosed with the following:--Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified.--Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. Review of the resident's care plan on 1/7/26 showed:-The resident's care plan indicated that the resident used psychotropic medication (chemical substances, typically prescription drugs, that alter brain chemistry to affect mood, perception, consciousness, and behavior) for his/her Anxiety Disorder and Depression.-The resident did not have a care plan related to his/her diagnosis of Bipolar Disorder.-The resident did not have a care plan specifically related to his/her diagnosis of Anxiety Disorder.-The resident did not have a care plan specifically related to his/her diagnosis of MDD. 2. Review of Resident #73's admission Record showed he/she admitted to the facility on [DATE] with a diagnosis of Aftercare Following Joint Replacement Surgery. Review of the resident's list of MDS's showed he/she did not have an admission MDS completed prior to his/her discharge from the facility on 1/8/26. Review of the resident's care plan on 1/7/26 showed:-The resident was newly admitted to the facility for aftercare related to his/her right knee replacement.-There were no goals in place related to effective pain control management.-There was one intervention in place related to his/her pain control, which was marked yes. 3. During an interview on 1/9/26 at 9:31 A.M. Certified Nursing Assistant (CNA) A said:-The MDS Coordinator was responsible for the completion of care plans.-Care plans should be up to date and reflect the resident's current status.-Care plans should include pain management.-The care plan should indicate the best pain control methods for the resident including pharmacological and non-pharmacological interventions.-Care plans should include mental health diagnoses.-The care plan should indicate the symptoms, medications, and interventions specifically related to each mental health diagnosis. During an interview on 1/9/26 at 10:22 A.M. Licensed Practical Nurse (LPN) B said:-The MDS Coordinator was responsible for completing all care plans.-He/She was unsure if there was anyone specifically responsible for ensuring all care plans were up to date.-All care plans should be up to date and reflect the resident's current status.-Pain management should be included in care plans.-Mental health diagnoses should be included in care plans.-Care plans needed to be up to date because they help to understand the best way to manage each individual resident. During an interview on 1/9/26 at 10:47 A.M. MDS Coordinator B said:-He/She was responsible for baseline and comprehensive care plans.-There was not a designated person to check completion of care plans.-He/She would normally verbalize to management when care plans were updated.-Care plans should be up to date and reflect the resident's current status.-Pain management should have been included in Resident #73's care plan.-Resident #73's care plan should have included all pain management techniques.-All of Resident #57's mental health diagnoses should have been included in his/her care plan.-All medications, interventions, and behaviors for each mental health diagnosis should have been included on Resident #57's care plan. During an interview on 1/9/26 at 11:47 A.M. the Director of Nursing (DON) said:-He/She had only been at the facility for two weeks and had not been able to look at resident care plans by that point in time.-To his/her knowledge the care plans were completed by department.-The MDS Coordinators were responsible for ensuring completion of the care plans.-Care plans needed to be specific to each resident and not generalized.-Pain management should have been included in Resident #73's care plan.-Resident #73's care plan should have included all pain management techniques.-All of Resident #57's mental health diagnoses should have been included in his/her care plan.-All medications, interventions, and behaviors for each mental health diagnosis should have been included on Resident #57's care plan and on the Medication Administration Record (MAR). -Care plans needed to stay up to date so each staff person understood how to care for each resident. 4. Review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included:-Dementia (significant cognitive decline in memory, thinking, judgment, and language severe enough to interfere with daily life) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.-Unspecified depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's quarterly MDS dated [DATE] showed:-The resident was moderately cognitively impaired.-The resident had no inattention, disorganized thinking, or altered level of consciousness (e.g. lethargy or vigilance).-The resident felt down, depressed or hopeless two to six days out of the past 14 days and was rarely socially isolative.-Had no hallucinations (perceptions in the absence of external stimuli) or delusions (firmly held misconception contrary to reality).-Did not have physical or verbal behaviors directed toward others or other behaviors not directed at others (e.g. scratching self, rummaging, or disruptive vocalizations like screaming).-Did not reject cares or wander. Review of the resident's progress notes dated October 2025 showed:-On 10/18/25 at 7:26 P.M. the resident continued on Seroquel for depression. The resident was outside the facility entrance certain his/her family member lived in the apartments across the street. Social services went out to redirect the resident and after a short period of time was able to redirect him/her back into the facility to eat lunch. The Director of Nursing (DON) was made aware.-On 10/23/25 at 7:44 A.M. the resident was agitated and difficult to redirect. He/She was sitting in the hall with a gown on yelling his/her spouse's name, using vulgar language and name calling directed at staff. When staff attempted to assist the resident in getting dressed he/she became more agitated. The resident was assisted to his/her room for calm environment and a room tray was provided for breakfast.-On 10/28/25 at 6:31 P.M. indicated that at approximately 5:00 P.M. the resident was going up and down the hallway yelling out profanities and calling staff names. The resident went up to a Certified Nurse Assistant (CNA) and kicked the back of his/her shoe while his/her back was turned. Review of the resident's progress notes dated November 2025 showed:-On 11/19/25 at 3:55 P.M. the resident refused a shower. Attempts were made several times to get the resident into the shower and the resident continued to refuse.-On 11/19/25 at 5:15 P.M. the resident refused all scheduled medications and all treatments. He/She was observed being agitated, yelling, and cursing repeatedly stating staff was trying to hurt him/her. When staff attempted to perform wound care the resident would not allow anyone to touch him/her and became physically aggressive, kicking and hitting staff. The supervisor was notified and the resident's safety was maintained. Review of the resident's progress notes dated December 2025 showed:-On 12/24/25 at 8:55 A.M. the resident held his/her Senna (medication for constipation) in his/her closed hand and pretended it was taken. When questioned why he/she was still holding the pill the resident said he/she didn't want to take it.-On 12/24/25 a CNA tried to assist the resident to the dining room for dinner. The resident responded shut up bitch.-On 12/29/25 at 8:01 A.M. the resident refused to allow the nurse to take his/her vital signs (measurements of the body's essential functions including temperature, heart rate, breathing rate, and blood pressure). The nurse tried to take vital signs on the resident three times and all attempts were unsuccessful. Review of the resident's Physician Orders dated December 2025 showed:-Monitor for signs and symptoms of adverse reactions related to use of psychotropic medication use and document in nurses' notes starting 2/14/25.-Seroquel (an antipsychotic medication (a psychoactive drug (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) oral tablet 50 milligrams (ml) daily for depression starting 11/30/25.-Sertraline HCI (a serotonin reuptake inhibitor (SSRI) oral tablet 25 mg at bedtime for dementia starting 12/29/25. Note: The order was changed on 1/8/26 to reflect indication for use as depression.-Symptoms related to depression were not identified on the orders. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated December 2025 and January 2026 showed there was no monitoring for symptoms of depression on the MAR or TAR. Review of the resident's Comprehensive Care Plan on 1/8/25 showed:-A care plan for the use of antipsychotic medication for the diagnosis of depression, revised 12/19/25, showed Monitor patterns of target behaviors. The care plan did not show symptoms related to depression that were typical for the resident and any non-pharmacological interventions to address the symptoms.-There was no behavioral care plan. There were no interventions on any individual care plan that identified the resident's behaviors of sometimes refusing medications and cares and verbal and physical behaviors. There was no documentation showing when the resident's various behaviors were most likely to occur and what staff should do when behaviors were exhibited. Observation on 1/5/26 at 10:03 A.M. showed:-When the resident was told good morning the resident asked in a hostile tone of voice what's good about it? -Then the resident yelled out repeatedly I need help and help although staff had been observed in the resident's room just prior to the outbursts and had approached the resident in a calm, quiet, non-confrontive manner. During an interview on 1/8/26 at 2:14 P.M. CNA C said:-It was the first day he/she had worked on the resident's hall, so he/she didn't know the resident's behaviors or usual symptoms of depression.-The care plan should show what the resident did when depressed such as if they tend to isolate themselves or stop going to activities. It should show what staff could do to address any signs of depression. -The behavior care plan should describe the resident's behaviors and when they were most likely to exhibit those behaviors.-The CNAs had electronic access to resident care plans so he/she should be able to look at the resident's care plan to see his/her behaviors, symptoms of depression, and any interventions to address them. -There should be interventions to show what staff should do when the resident displayed certain behaviors or symptoms of depression. -Interventions to calm the resident down or to help with symptoms of depression might be to play a certain type of music he/she liked, assist the resident in calling his/her family, accompany the resident outside, or taking a wheelchair ride or walk down the hall. Staff should be able to look at the resident's care plan to see what they could do that was most likely to help the resident when they had behaviors or symptoms of depression. During an interview on 1/8/26 at 2:20 P.M. CNA D said:-He/She had observed the resident yelling out hello and yelling out in general and calling out for his/her spouse a lot. Sometimes the resident said he/she wanted to get out of this place. -Staff asked the resident what he/she needed if he/she was yelling out. -The CNAs and other nursing staff had access to resident interventions on their electronic care plan. The resident's care plan should show the resident's behaviors and how staff should intervene. -He/She had never seen any symptoms of depression for the resident and didn't know what they were. The care plan should show what the resident tended to do when his/her depression was worse. During an interview on 1/8/26 at 2:27 P.M. CNA E said: -The CNAs had access to the resident care plans. The Behavioral care plan should show interventions when a resident had behaviors.-The Depression care plan should show how staff could tell if the resident was becoming more depressed. It should show what staff were to do to help the resident with their symptoms.-Resident #50's behaviors were verbal outbursts like calling out help and calling for his/her spouse. If staff tried to quiet the resident he/she would still continue to call out for his/her spouse. He/She wasn't sure if there were any interventions to address that. It might be on the resident's care plan. -When the resident started yelling out staff asked him/her how they could help. Sometimes it helped the resident calm down when staff took him/her to his/her room.-He/She had never noticed any symptoms of depression in the resident and didn't know how staff would know if depression symptoms were increasing or what they should do about it. -The resident liked to play the piano and played it pretty well. Maybe that could be an intervention for the resident's behaviors or for symptoms of depression. During an interview on 1/8/26 at 2:44 P.M. MDS Coordinator A said: -If the resident had behaviors the Social Worker would let the MDS Coordinators know or behaviors would be discussed in morning meetings. -The MDS Coordinators were responsible for care planning behaviors. He/She was pretty sure he/she cared planned Resident #50's behaviors.-Resident #50 got agitated from time to time. He/She got verbally loud and accused staff of flirting with his/her spouse.-Every now and then the resident would wander, mainly down the hallway and back. The resident took a daily walk down the hall and staff watch out for him/her. He/She would circle back to the unit. The facility did have a wander guard on the back of the resident's wheelchair for a time, but the resident would take it off. It would likely upset the resident to have it on his/her person. When the resident had gone out of the building in December it was the door close to the nursing desk. He/She was there when the resident left and he/she couldn't redirect the resident. The Social Worker took him/her for a walk and the resident willingly came back with the Social Worker, but he/she wasn't sure what the Social Worker did or said to get the resident to come back.-He/She wasn't aware the resident had ever hit or kicked staff or refused medications. The resident refused some cares and was convinced sometimes that a particular aide was having an affair with his/her spouse.-The CNAs have electronic access to the resident's care plan. When the resident yelled out staff should redirect him/her. That was usually effective for the resident. -He/She thought the direction to monitor for signs and symptoms of depression was on the resident's Depression care plan, but there were no specific symptoms of depression mentioned for the resident. He/She didn't know what symptoms of depression typically looked like for the resident. During an interview on 1/9/26 at 10:50 A.M. Registered Nurse (RN) A said: -Nursing staff received a full day of training and education for working with residents with dementia and behaviors. For the CNAs it was part of their yearly training. Staff were educated to try de-escalation techniques and to walk away for a while.-Resident #50 would call out for his/her spouse, sometimes starting at 7:00 A.M. The spouse would bring their dog which the resident loved. The resident would call staff names and accused one CNA of having an affair with his/her spouse. He/She refused cares and showers and would wander up and down the hall. He/She would hit or kick. Once during a shower he/she called everybody trying to help him/her bitch.-The resident had an increase in physical aggression in December. When the facility did a urinalysis (UA) the resident was diagnosed with a urinary tract infection (UTI). -The CNAs have access to the electronic Cardex which has the resident's interventions. The care plan should have interventions for the resident's behaviors and should mention what his/her target behaviors were.-The resident was started on Sertraline (an antidepressant) in hopes they could gradually reduce the resident's Seroquel.-Symptoms related to depression that were typical for the resident should be on the resident's Depression care plan. -The MDS Coordinator developed the care plan, but he/she wasn't sure who was responsible for auditing their work. During an interview on 1/9/26 at 11:40 A.M. with RN A and the Interim DON, the DON said:-The MDS Coordinators were responsible for resident care plans, with each department providing information for individual care plans. The MDS Coordinator was responsible for ensuring completion of the Comprehensive care plan. -The care plans should be up to date and reflect each resident's status.-Residents with behaviors should have pharmacological interventions as applicable and non-pharmacological interventions.-The care plan should be specific on what staff were to do for the resident and which staff would do it. The care plan should be comprehensive so that everyone knew how to take care of the resident. -There should be symptoms listed for residents who took psychotropic drugs on the resident's MAR where specific symptoms could be identified. Symptoms typical for the resident and target behaviors should be on the Comprehensive care plan.-He/She had only been at the facility a couple of weeks and wasn't sure if anyone had been auditing resident care plans for thoroughness. He/She would be responsible for auditing care plans or assigning that to a designee.

Based on interview and record review, the facility failed to ensure their facility Criminal Background Investigations policy showed a check of the Nurse Aide (NA) Registry would be completed for all potential facility employees and volunteers; subsequently, three facility employee records (Employees C, D, and E) out of five facility employee records sampled did not have NA Registry background screenings completed prior to hire, potentially affecting any resident at the facility. The facility census was 53 residents.Review of the facility's Criminal Background Investigations, HR-008 policy, revised 2/28/22, showed:-Applicants will complete the Post-Offer Credit Report Act (FCRA) Disclosure and confirm their understanding of the criminal background check requirement. Applicants who do not agree to a post-offer background check will not be allowed to move further in the on-line application process.-A post-offer background check will review any history of felony convictions in the past seven years or pending criminal charges when the third-party vendor e-consent form is completed.-The Human Resources (HR) Department will use a third-party investigative agency to complete criminal background checks on new hires, volunteers, and students according to applicable state laws.-A representative from the HR Department at each Missouri entity will check with the Employee Disqualification List (EDL) from the Missouri Department of Health and Senior Services for each new hire and quarterly for all current employees.-Employees whose name appears on the EDL will not be considered for employment in any patient/resident contact position.--NOTE: The policy failed to show a check of the NA Registry would be completed for all new applicants.Review of 42 Code of Federal Regulations (CFR) 483.012 showed:-The NA Registry documents findings against a Certified Nurse Aide (CNA) of abuse, neglect, or misappropriation of property.-Certified long-term care facilities and the long-term care unit of a hospital are required to check the Registry before allowing a person to work or volunteer.Review on 1/14/26 of the Office of Inspector General (OIG) website showed:-The OIG's List of Excluded Individuals/Entities (LEIE) only contained actions taken by the OIG. -The LEIE does not contain actions taken by other agencies. -The OIG's exclusion authorities do not include the NA Registry.1. Review of Employee E's background checks showed:-He/She was hired as an Activity Coordinator on 1/20/25.-The employee did not have a NA Registry background check.2. Review of Employee C's background checks showed:-He/She was hired as a Licensed Practical Nurse (LPN) on 9/29/25.-The employee did not have a NA Registry background check.3. Review of Employee D's background checks showed:-He/She was hired as a Housekeeper on 10/6/25.-The employee did not have a NA Registry background check.4. During an interview on 1/7/26 at 11:45 A.M. the Candidate Experience Coordinator (CEC) manager said:-The CEC team was responsible for background checks for both the hospital and the Skilled Nursing Facility (SNF).-They did the Family Care Safety Registry (FCSR) background checks which included the Employee Disqualification List (EDL) background check and did criminal background checks prior to hire.-They were not doing the NA Registry checks on all employees.During an interview on 1/9/26 at 10:25 A.M. the Human Resources Business Partner for the facility said:-He/She was responsible for supporting department heads, managers, supervisors, and directors by providing them with information and guidance.-He/She was not involved with doing the background checks. The CEC team did all the employee background checks for the facility.-If someone applied for the position of a CNA the CEC team completed their NA Registry background check prior to hire. The CEC was not doing NA Registry background checks on any other potential applicant.-He/She wasn't sure if anyone audited the CEC team's background checks for employees of the facility, but he/she had not been doing that.During an interview on 1/9/26 at 10:58 A.M. with the Facility President and the Administrator, the Facility President said:-The OIG background screenings were completed prior to hire and monthly thereafter on all facility employees. -It was the facility's opinion that the OIG screenings covered more than the NA Registry background checks.-NA Registry checks were completed for candidates applying for the CNA position and were not being completed on all facility employees.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #58) out of 14 sampled residents had bed assist devices installed in a timely manner, clarified if the resident needed a right side bed assist bar or bilateral bed devices, and failed to ensure the resident's care plan identified specifically the equipment needed to improve the resident's independence with bed mobility and transfers. The facility census was 53 residents.Review of the facility's Bed Rails Policy, revised 12/24/25 showed:-Bed rails will also refer to grab bars, halo bars, assist bars, and safety rails (adjustable metal or rigid plastic bars that attach to a bed). Transfer bars, mobility enhancers, and bed canes are rails used on beds and are intended to 1) reduce the risk of falling from bed, 2) assist the resident in repositioning in bed, and/or 3) assist the resident in transitioning into or out of the bed.-The Interdisciplinary Team will use data collected from individual bed rail assessments and evaluations to assist in care planning.-The facility will complete the following if a bed rail/bed assist device is used:--Assessment of resident for risk of entrapment from bed rails prior to installation.--Therapy will assess the resident.--A physician order will be obtained.--Consents will be obtained from the resident/representative for side rail use.--Individual bed rail assessments and evaluations will be performed upon admission, upon initiation of a bed rail, and at least annually utilizing the bed rail assessment.--Individual bed rail evaluations will include data collection analysis and determination of potential alternatives to use.--When deemed necessary and appropriate the facility will provide education to residents and/or their representative pertaining to the risk and benefits of the use of bed rails/assist bars. 1. Review of Resident #58's admission Record showed the resident readmitted to the facility on [DATE] with diagnoses that included:-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Repeated falls. Review of the resident's Assistance with Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) Care Plan, initiated 12/27/24, showed:-The resident had impaired mobility and general weakness.-The resident would have a positioning device on his/her bed to assist with bed mobility and transfers starting 12/27/24. -NOTE: The care plan did not show that the bed assist bar was no longer needed at any point after 12/27/24 or specify either a right side grab bar or the need for bilateral mobility/transfer devices at any time after 12/27/24.Review of the resident's Fall Risk Evaluation, dated 9/14/25 showed the resident:-Had no falls within the past three months.-Was ambulatory and continent.-Had no gait or balance issues.Review of the resident's Bed Rail Assessment, dated 9/14/25 showed:-The resident was ambulatory.-The resident did not express a desire for a bed rail/bed assist bar.-The resident's interventions included: lower bed to the floor, provide toileting assistance at night, and reminders to use the call light.-Recommendations were for no side rails/bed assist bars as they were not indicated.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/2/25 showed the resident:-Was cognitively intact.-Used a walker and a manual wheelchair for mobility.-Required supervision for toileting hygiene; moving from a seated to a standing position; and chair to chair and toilet transfers. Needed partial to moderate assistance (the helper does less than half the effort) for shower transfers.-Could independently go from a lying position to sitting on the side of his/her bed.-Was occasionally incontinent of urine.-Had no falls since the previous MDS quarterly assessment dated [DATE].-Was taking a diuretic (a medication that makes a person urinate more, helping the kidneys remove excess salt and water to lower blood pressure and reduce fluid buildup).Review of the resident's Physical Therapy Treatment Note, dated 11/17/25 showed the resident would benefit from bed assist rails bilaterally to improve independence with bed mobility and transfers.Review of the resident's Order Summary Report showed a new order dated 12/2/25 for a grab bar to the right side of the bed for mobility and to promote independence per therapy recommendations.Review of the resident's progress notes dated 11/17/25 through 12/2/25 showed no explanation why the Physical Therapy recommendation showed bed assist rails bilaterally and the physician orders showed a grab bar to right side of the bed.Review of the resident's Bed Rail Assessment, dated 12/9/25 showed the resident:-Was non-ambulatory.-Expressed a desire to have side rails/bed assist bar(s).-Had interventions for a lowered bed, assistance with toileting at night, and reminders to use the call light.-A side rail/bed assist bar to the right was indicated to serve as an enabler to promote independence.-Positive and negative aspects of a side rail/bed assist bar were discussed with the resident, family, and/or responsible party.-The assessment did not indicate the exact type of bed assist device the resident needed.Review of the resident's Maintenance Work Order ending in #648 showed:-An order submitted by Social Worker (SW) A for a transfer bar installation to the right side of the resident's bed was created on 12/9/25.-The order was assigned to Maintenance Engineer A on 12/10/25.-The work due date was 12/12/25.Review of the resident's Event Information report, dated 12/15/25 showed:-At 5:55 A.M. staff entered the resident's room and observed the resident in a sitting position on his/her buttocks in the middle of the room. The physician was notified. The Director of Nursing (DON) was notified. The oncoming shift was informed.-The resident was considered at high risk of falls before the fall. -Resident was forgetful before and after the fall. -He/She was alone and resting in bed before the fall.-Resident was toileted at 2:00 A.M.-New interventions for lowered bed and call light visible and within reach.Review of the resident's progress notes, dated 12/15/25, showed installation of a grab bar to the right side of the resident's bed completed on this date. To be assessed for continued need quarterly by the nurse.Review of the resident's Maintenance Work Order ending in #648 showed the transfer bar installation was completed on 12/15/25 at 3:55 P.M.Review of the resident's Order Summary Report showed a new order for the resident's bed to be in the lowest position and a fall mat for safety every night starting 12/20/25.Observation on 1/6/26 at 11:07 A.M. showed:-The resident was lying in bed with his/her eyes open and used the bed assist bar to his/her right while coming to a seated position on the side of his/her bed.-A fall mat was at the right side of the resident's bed and the bed was in a lowered position.-The resident had one bed assist bar on the right side of his/her bed.During an interview on 1/6/26 at 11:08 A.M. the resident said:-He/She had been at the facility for years and always had a bed assist rail on his/her bed, but it was removed some time back. -He/She didn't know why it was removed or when it was removed.-He/She couldn't remember how long it was missing before they installed a bed assist bar, but thought it had been missing for several weeks. -When he/she noticed the bed assist rail missing she didn't think much about it and never voiced any concerns about it being gone. He/She knew before the night he/she fell out of bed the rail had been removed.-He/She wasn't sure the date he/she fell, but thought it was before Christmas. He/She had never fallen out of bed before then.-The night he/she fell a bed rail or bar was not on the bed and there was nothing to grab hold of to try to prevent the fall. He/She thought if a rail or bar had been attached to the bed he/she might have been able to grab it to prevent the fall.-He/She had to go to the bathroom a lot due to being on a diuretic and might have needed staff to take him/her to the toilet the night of the fall, but couldn't remember for sure. -He/She hit his/her head on the bedside table.-He/She was holding his/her call light when he/she fell but couldn't get it to work.-He/She had already gone to sleep before he/she fell and didn't know the approximate time of the fall.-A nurse checked him/her out for injuries and he/she and at least two Certified Nurse Assistants (CNAs) helped him/her up into his/her wheelchair.During an interview on 1/8/15 at 9:50 A.M. Maintenance Engineer A said:-All the residents' beds had been replaced within the past few months. The previous beds all had an upside down U-shaped assist rail. He/She was responsible for maintaining bed assist devices and making sure they were tight and secure. All previous resident beds had the upside down U shape.-When the beds were replaced the company who brought the current beds started installing bed assist bars as soon as the beds were delivered. Someone from the facility told the company they couldn't install assist bars on the beds and the company removed the grab bars they had just installed, so at the time none of the resident beds had a grab assist bar.-After the new beds were delivered the therapists had to check residents out for the need for a bed assist bar. The therapist was supposed to fill out a form and send it to SW A to initiate the work order. They had 24 hours to put a work order in after the therapy evaluation. -He/She typically installed the bed assist bars within 2 or 3 days. Installing the bed assist bars shouldn't take more than four or five days after the therapist evaluates a resident for the need for assist bars.-He/She received a work order after a doctor's order was obtained for a grab bar and installed the grab bar either the day of or day after the resident fell. During an interview on 1/8/26 at 10:30 A.M. SW A said:-The process for a resident to have a bed assist bar started with the Occupational Therapy (OT) or Physical Therapy (PT) evaluation to see if a resident could benefit from it. -The next step was for Therapy to tell the resident's nurse of the bed assist device need. -A Bed Rail Assessment form was then completed by the nurse and the therapist. -Then the nurse puts an order in for the bed assistance device. Once the orders were approved, the nurse would inform him/her the order was approved. -He/She was responsible for getting the consent signed by the resident or their representative. Once the consent was signed he/she would put a work order in for maintenance to install the bed assist bar.-Maintenance usually installed the assist bar within a day or two.-He/She tracked when a work order was completed and made rounds weekly to ensure the device was installed. -Maintenance would send him/her an e-mail when the installation had been completed. -He/She put a work request in for the resident on 12/9/25. It was installed on the 15th. -Maintenance received a lot of bed assist bar requests around that time because of everyone getting a new bed. During an interview on 1/8/25 at 11:10 P.M. OT A said:-None of the residents had bed assist bars when they got new beds starting around November 10, November 11, or November 12. -The bed assist bar evaluation was done by PT on 11/17/25. -The Physical Therapy Assistant (PTA) who evaluated the resident wrote a note recommending bilateral bed assist rails.-When the therapist or therapy assistant determined someone needed a bed assist device he/she would tell the nurse and the nurse notified the doctor. -The next quarter a bed rail assessment would be due, but therapy was not involved in the bed rail assessment because they already had done their evaluation. -The nurse should let the doctor know the same day therapy made their recommendation and should have the order within 24 hours. -Therapy would let Social Services know of the recommendations for a bed assist device.-The nurse would let Social Services know when the order had been approved and Social Services created the maintenance work order for the bed assist device that same day. -Once maintenance knew there was an order for the bed assist device they usually installed it within a few days' time, and sometimes that same day or the next.During an interview on 1/8/2026 at 2:44 P.M. MDS Coordinator A said:-Social Services would e-mail him/her when there was a physician order for a bed assist bar that should be added to the resident's care plan. -The care plan interventions were generic and usually written the same for all residents who had a bed assist bar.-Therapy determined if the bed assist bar should be one or two and the care plan should reflect Therapy staff's recommendation. -Originally, every resident had a positioning device on their bed. When the facility got new beds in November 2025 nobody had a positioning device on their bed. If they wanted one therapy had to determine if they got one. -If a nurse or CNA or other staff person thought a resident could benefit from a bed assistance device they would go to SW A who would let Therapy know of the concern.-The bed assistance device should be installed within two or three days of the therapy recommendation. During an interview on 1/9/2026 at 9:29 A.M. Registered Nurse (RN) A said:-He/She or the charge nurse was notified by either therapy when they did their evaluation or by Social Services of the bed assistance device recommendation. -The nurse would put in the order for the therapy recommendation that same day. Usually the doctor approved the therapy recommendation that day or the next and the nurse notified Social Services as soon as the order was approved.-Social Services created a maintenance work order through an electronic notification that same day. -Maintenance should install the bed assistance device that day or the next. Ideally the whole process should be less than 24 hours. If the resident was assessed for a bed assist bar on a Friday afternoon it might be Monday before the bed assist bar was installed.-If therapy said bilateral bed rails were recommended the order shouldn't say right side only bed assist bars.-The facility got all new beds in November. -All the residents had the upside-down U-shaped bed assist bars on their beds and got a new bed on either 11/10/25 or 11/17/25. The resident got his/her new bed on 11/10/25. Nobody had a grab bar on their new bed until they were assessed by Therapy for the need for one. The previous interim DON said the facility had to assess everyone for a bed assist bar.-Therapy did assessments on everyone with a new bed the week they got their bed.-The resident's Bed Rail Assessment and physician order showed a right side bed assist bar, but it should be consistent with the therapy recommendation which showed bilateral bed assist devices. During an interview on 1/9/25 at 11:40 A.M. with RN A and the DON:-The Social Worker was responsible for doing weekly audits to ensure the bed assist bar installation process was completed.-The MDS Coordinators were responsible for resident care plans which should be specific and comprehensive and reflect the resident's current status and needs. -Bed assist devices should be approved by the physician within 24 hours of the therapy evaluation. -The Social Worker should put in the work order for a bed assist bar the same day the order was approved provided the facility could get the consent of the resident or their responsible party that same day. If they couldn't get ahold of them for a day or two attempts to contact the responsible party should be documented in the resident's progress notes. Once they had the consent a work order should be created.-Maintenance should install the device within 24 hours of receiving the work order. -If a therapy recommendation was made on a Friday the bed assist device should be installed by Monday as long as the facility could get ahold of the resident's responsible party.

Based on interview and record review, the facility failed to accurately document the residents [NAME] Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) for a resident on hospice services by not marking section J item number J1400 for prognosis less than six months to live for one sampled resident (Resident #54) out of 14 sampled residents the facility census was 53 residents.Review of the facility policy titled [NAME] Place (BSP) Minimum Data Set revised 12/2/25 showed:-A Registered Nurse (RN), also known as the MDS Coordinator, would be responsible for conducting and coordinating the development, completion, and submission of the MDS Assessment for each resident.-The individual who completed a portion of the MDS must have certified the accuracy of that portion of the assessment. -The MDS Coordinator or designee would be responsible for ensuring that a resident assessment was submitted to Federal and state MDS database in accordance with current federal and state guidelines. 1. Review of Resident #54's admission Record showed the resident admitted to the facility on [DATE].Review of the resident's Order Summary Report dated 3/19/25 showed the resident had an order to admit to a hospice provider (end of life care) dated 3/19/25.Review of the resident's care plan dated 5/27/25 showed the resident was on hospice services. Review of the resident's quarterly MDS dated [DATE] showed:-Section J1400 was marked no.-Section O was marked yes for hospice care.Review of the resident's quarterly MDS dated [DATE] showed:-Section J1400 was marked no.-Section O was marked yes for hospice care.Review of the resident's significant change MDS dated [DATE] showed:-Section J1400 was marked no.-Section O was marked yes for hospice care.Review of the resident's comprehensive MDS dated [DATE] showed:-Section J1400 was marked no.-Section O was marked yes for hospice care.During an interview on 1/8/26 at 12:29 P.M., MDS Coordinator A said:-The resident was on hospice and received hospice care. -When a resident was on hospice services this was documented in section O.-To qualify for hospice services the resident's life expectancy was six months or less.-He/She did not document in section J1400 because the doctor did not write an order saying the resident had six months or less of life expectancy.-He/She did not realize the Hospice Certification the doctors had to sign every six months would count as enough to mark yes in section J1400.-A significant change MDS would be done when the resident went on hospice. -A significant change MDS was done as soon as it was discovered that one was not done for the resident.During an interview on 1/8/26 at 12:35 P.M., MDS Coordinator B said:-He/She was responsible for the skilled MDS assessments.-The other MDS Coordinator was responsible for the non-skilled long-term residents.-When a resident was on hospice services this was documented in section O.-That to qualify for hospice services the resident's life expectancy was six months or less.-He/She did not document in section J because the doctor did not write an order saying the resident had six months or less of life expectancy.-He/She did not realize the Hospice Certification the doctors had to sign every six months would count as enough to mark section J yes.During an interview at 1/9/26 at 11:47 A.M., the Director of Nursing (DON) said: -He/She had just been at the facility for two weeks. -He/She did not do the anything with the MDS, the MDS Coordinators did that.-The MDS Coordinator RN verified the MDS was correct accurate. -He/She expected that the MDS would be correct and accurate for the resident.

Based on interview and record review, the facility failed to provide catheter care, document catheter care, or refusal of catheter care for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 53 residents. Review of facility policy titled Management of Foley Catheters revised 12/2/2025 showed:-Document the care in the electronic medical record. 1. Review of Resident #33's Admissions Record showed the resident's readmission date of 11/11/25 with the following diagnoses:-Urinary tract infection.-End stage renal disease (ESRD is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant). Review of the resident's Treatment Administration Record (TAR) dated November 2025 showed 13 out of 38 opportunities where catheter care was not documented.Review of the resident's progress notes dated November 2025 showed no documentation where catheter care was refused by the resident. Review of the resident's Order Summary Report dated November 2025 showed an order for catheter care every shift dated 11/12/25.Review of the resident's TAR dated December 2025 showed 20 out of 62 opportunities where catheter care was not documented.Review of the resident's progress notes dated December 2025 showed no documentation where catheter care was refused by the resident. Review of the resident's care plan dated 12/2/25 showed:-Catheter care was to be provided every shift.-The resident refused catheter care at times. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/23/25 showed:-He/She had an indwelling catheter. -He/She had end stage renal disease.-He/She had a urinary tract infection.During an interview on 1/8/26 at 12:48 P.M., Certified Nursing Assistant (CNA) C said the catheter care when on the TAR was performed by the nurse, and he/she would not have done it. During an interview on 1/8/26 at 12:49 P.M., Licensed Practical Nurse (LPN) A said:-Catheter care was charted on the TAR.-When catheter care was charted on the TAR, the initials of the person that charted it and the time was charted would be shown. -When the space was blank on the TAR then catheter care was not done. -When a resident refused cares, it would have been attempted later. -When a resident refused care after several attempts, it was documented as a refusal with a progress note that would have shown that education was given to the resident and what the resident was educated on. -When there were no progress notes of refusals and blank spaces on the TAR then it was an issue. During an interview on 1/8/26 at 12:54 P.M., LPN C said:-The TAR was where catheter care was charted.-When catheter care was charted on the TAR, the initials of the person that charted it and the time would be shown. -When the space was blank on the TAR then it would be assumed that catheter care was not done. -The [NAME] in nursing was if it was not charted the care was not done. -When care was refused by a resident it would have been attempted later. -When care was refused after several attempts it would have been documented as a refusal with a progress note that would have shown that education was given, and what the resident was educated on. -When there were no progress notes of refusals and blank spaces on the TAR then it was a problem. During an interview on 1/9/26 at 11:47 A.M., the Director of Nursing (DON) said:-It was his/her expectation when catheter care that was ordered that it would be performed. -It was his/her expectation that the nurses would have documented the care performed. -If a care was not documented then the care was not done.-It was his/her expectation when a resident refused cares the nurse would chart a progress note with the refusal and the education provided. -It was his/her responsibility or the appointed designee to audit charts to ensure cares were being documented and there were no missed cares, and for any refusal there was a progress note charted. -He/She just started two weeks ago as the DON and had not had time to get things figured out.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident #21) wound care orders were followed during observation of his/her wound care out of 14 sampled residents. The facility census was 53 residents.A policy related to following physician orders was requested and not received prior to exit on 1/9/26.1. Review of Resident #21's admission Record showed the resident readmitted to the facility on [DATE] with a diagnosis of Osteomyelitis (an infection and inflammation of bone tissue).Review of the resident's Order Summary Report dated January 2026 showed:-The resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) Pressure Ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to his/her coccyx (the small bone at the bottom of the spine).-Staff were to cleanse with normal saline, pat dry, cover with mepilex (used for various exuding wounds like pressure ulcers to promote moist healing by absorbing drainage, minimizing pain and trauma on removal, and preventing maceration) border foam dressing, change every other day and as needed for soiling.-NOTE: There was no order for zinc barrier paste (a thick, medicated topical skin protectant containing zinc oxide as a primary active ingredient) to be applied to the resident's coccyx area.Observation on 1/7/26 at 11:35 A.M. of the resident's wound care to his/her coccyx showed:-Licensed Practical Nurse (LPN) B, Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator B, and Registered Nurse (RN) A were all in the room assisting with the resident's wound care.-MDS Coordinator B and LPN B were assisting in the positioning of the resident while RN A was preparing the treatment for the resident.-After RN A cleansed the resident's wound site, RN A instructed LPN B and MDS Coordinator B to apply zinc barrier paste to the resident's coccyx area.-RN A then applied the mepilex border foam on top of the resident's wound bed.During an interview on 1/8/26 at 11:04 A.M. RN A said:-He/She would not have done anything differently related to the resident's coccyx wound dressing.-He/She was unsure why he/she had instructed MDS Coordinator B and LPN B to put the zinc oxide paste to the resident.-He/She initially thought it was a different cream that should have been applied before placing the mepilex dressing but looked up the resident's order and realized that no cream should have been applied to the wound bed at all.-He/She should have followed the wound care instructions as ordered.-It was important for staff to follow wound care orders for wounds to be able to heal properly.During an interview on 1/9/26 at 10:03 A.M. LPN B said:-He/She would not have done anything differently related to the resident's coccyx wound treatment.-He/She thought all of the wound treatments were completed as ordered.-He/She did not realize that the coccyx wound treatment had been done incorrectly.-He/She should not have placed the zinc oxide paste on the resident's coccyx.-It was important for staff to follow wound care orders to ensure wounds were healing appropriately.During an interview on 1/9/26 at 10:32 A.M. MDS Coordinator B said:-He/She had been told by that point in time that he/she and LPN B had applied the zinc oxide paste to the resident's coccyx wound and that was not a part of the treatment order.-He/She should have followed the wound care instructions as ordered.-It was important for staff to follow wound care orders to ensure that the treatments were effective.During an interview on 1/9/26 at 11:47 A.M. the Director of Nursing said:-All wound care treatments needed to be followed as ordered by the physician.-The staff should not have applied the zinc oxide paste to the resident's coccyx wound as that was not a part of the order.-He/She would have expected the staff to have followed the wound care treatment order, as ordered.-It was important for staff to follow wound care orders to promote wound healing and to ensure treatments were effective.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR a requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #57) was reviewed for accuracy and updated after admission to the facility out of 14 sampled residents. The facility census was 53 residents.A policy related to PASRRs was requested and not received prior to exit on 1/9/26.1. Review of Resident #57's PASRR Level One Screening dated 9/1/21 showed:-The screening had been completed by a local hospital prior to the resident's admission to the facility.-The resident did not show any signs or symptoms of a major mental disorder.-The resident had never been diagnosed with a major mental disorder. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/24/25 showed:-The resident felt down, depressed, or hopeless two to six days during the look back period.-The resident had an anxiety disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats).-The resident had Depression.-The resident had bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's admission Record dated 1/6/26 showed:-He/She admitted to the facility with a diagnosis of Major Depressive Disorder (MDD a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild.-During the resident's stay at the facility he/she had been diagnosed with the following:--Bipolar Disorder, Unspecified.--Anxiety Disorder, Unspecified.Review of the resident's care plan dated 1/7/26 showed:-The resident used psychotropic medication (chemical substances that alter brain chemistry, impacting mental processes, moods, emotions, and behaviors) for his/her anxiety disorder and Depression.-The resident did not have a care plan related to his/her diagnosis of bipolar disorder.-The resident did not have a care plan specifically related to his/her diagnosis of anxiety disorder.-The resident did not have a care plan specifically related to his/her diagnosis of MDD.An updated PASRR for the resident was requested and not received prior to exit on 1/9/26.During an interview on 1/9/26 at 10:18 A.M. Licensed Practical Nurse (LPN) B said:-The admissions Coordinator was responsible for ensuring the completion of PASRRs.-He/She assumed that the admissions Coordinator would also be responsible for updating PASRRs when needed.-He/She was not sure about the timeline of PASRRs and when they needed to be updated.During an interview on 1/9/26 at 10:42 A.M. MDS Coordinator B said:-He/She was unsure of the facility's responsibility related to PASRRs.-He/She knew PASRRs needed to be completed prior to the resident's admission to the facility.-The Health Information Specialist would ensure completion of PASRRs upon admission.-The Health Information Specialist would also be responsible for auditing the PASRRs to ensure accuracy.-The Health Information Specialist would let the facility social workers or the admission Coordinator know if a PASRR needed to be updated.-PASRRs needed to be updated for any new diagnoses and any significant changes. -Resident #57's PASRR should have been updated to reflect the resident's current condition.During an interview on 1/9/26 at 11:16 A.M. the Health Information Specialist said:-He/She mainly ensured that there was a physician signature when he/she looked at PASRRs upon admission.-It would not be his/her responsibility to ensure the accuracy of the PASRRs.-It would not be his/her responsibility to see if any PASRRs needed to be redone.-He/She thought that the responsibility would fall under the admission Coordinator or Social Workers.During an interview on 1/9/26 at 11:23 A.M. the admission Coordinator, Social Worker A, and Social Worker B said:-The Health Information Specialist was responsible for ensuring completion of PASRRs upon admission to the facility.-All PASRRs were audited in 2025.-The audit that was completed only verified that PASRRs were in each resident's records and not for accuracy.-There was no one at the facility responsible for ensuring new PASRRs were completed when indicated.-Resident #57 should have had a new PASRR completed to indicate his/her mental health diagnoses.During an interview on 1/9/26 at 11:47 A.M. the Director of Nursing (DON) said:-He/She had only been at the facility for two weeks and was unsure what the facility's protocol was for PASRR completion.-In his/her experience, the facility Social Workers or the MDS Coordinators were responsible for ensuing PASRRs were completed and up to date.-A diagnosis of bipolar disorder would indicate the need for Resident #57's PASRR to have been redone.-He/She would have expected staff to have started the PASRR process within 30 days of the diagnosis.-To his/her knowledge, there was no one at the facility specifically responsible for ensuring the accuracy of PASRRs.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from a significant medication error. On 7/12/24 Resident #1 was administered 5 milliliters (ml) (100 mg (milligrams)/5 ml) oral solution of morphine concentrate (a opiate medicine used to treat moderate to severe pain) instead of the physician ordered 0.5 ml (10 mg) by mouth PRN (as needed) every 6 hours for pain. Narcan (a medicine that can save someone from a prescription Opioid medicine overdose) was ordered by the physician due to the dosage being 10 times the amount ordered and administered. The facility census was 48 residents. The Administrator was notified on 7/24/24 at 2:12 P.M., of an Immediate Jeopardy (IJ) which began on 7/12/24. The IJ was removed on 7/24/24 as confirmed by surveyor onsite verification. Review of the facility's Medication Administration policy, dated 6/29/2023, showed: -Purpose was to administer medications at approximate times as an individual would in their home environment while continuing to comply with physician orders. -The policy was to assure that prescribed medications are administered safely, accurately and in accordance with good nursing practice while accommodating the resident's routines and requests in medication administration. -Procedure: --Physician orders for specific medication administration times shall be followed. --The individual administering the medication must enter their initials into the resident's electronic MAR (medication administrator record) after giving each medication and before administering the next ones. -All reasonable accommodation for resident requests regarding medication administration will be followed by nursing staff. Review of the facility's Safe Medication Administration Practices, Long-term Care policy, dated 5/20/24, showed: -To promote a culture of safety and prevent medication errors, nurse must adhere to the five rights of medication administration. -These rights are to identify the right resident by using at least two resident-specific identifiers, select the right medication, administer the right dose, administer the medication at the right time, and administer the medication by the right route. -Recent literature identifies nine rights of medication administration - which, in addition to the five right, include the right documentation, the right action (or reason for prescribing the medication), the right form, and the right response. -The term medication error refers to a mistake that occurs during the medication administration process. -When a mistake occurs, it's considered an error regardless of whether it harmed a resident. -Federal regulations require that long-term care residents remain free from any significant medication errors. -Implementation: --Avoid distractions and interruptions when preparing and administering medication to prevent medication errors. --Check the resident's medical record to make sure that all required documents, medication information, sensitivities, history and physical examination findings, diagnoses, and laboratory results are present and current. --Confirm the resident's identity using at least two resident identifiers. -Administering high-alert medications: --Identify high-alert medications based on your facility's approved list. --High-alert medications include opioids. --Carefully monitor medication dosing, especially if dosing adjustments are necessary based on narrow therapeutic windows. -Familiarize yourself with all medications that you administer and be aware of potential (adverse drug event) ADEs that might occur. -Know where to obtain resources to confirm potential ADEs if you aren't familiar with the medications in use. 1. Review of the Morphine Sulfate Oral Solution package insert, dated January 2012, showed -Take care to avoid dosing errors due to confusion between different concentrations and between milligram (mg)/and milliliters (ml), which could result in accident overdose and death. -Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction. (5.2) - Controlled substance: Morphine sulfate is a Schedule II controlled substance with an abuse liability similar to other opioids. (5.3) - (Central Nervous System- made up of brain and spinal cord) CNS effects: Additive CNS depressive effects when used in conjunction with alcohol, other opioids, or illicit drugs. (5.4) - Elevation of intracranial pressure: May be markedly exaggerated in the presence of head injury, other intracranial lesions. (5.5) - Hypotensive effect: Increased risk with compromised ability to maintain blood pressure. (5.6) - Special Risk Groups: Use with caution and in reduced dosages in patients with severe renal or hepatic impairment, Addison's disease, hypothyroidism, prostatic hypertrophy, or urethral stricture, elderly, CNS depression, toxic psychosis, acute alcoholism and delirium tremens, may aggravate or induce seizures. (5.9) - Impaired mental/physical abilities: Caution must be used with potentially hazardous activities. (5.10) Review of Resident #1's Face Sheet showed the resident: -Was admitted on [DATE]. -Had diagnoses including dementia and Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). -discharged on 7/13/24. Review of the resident's Discharge Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 7/13/24, showed the resident was severely cognitively impaired. Review of the resident's Medical Status Summary, dated 7/10/24, showed the resident: -Was admitted to hospice services (end of life care) related to dementia. -Was on a pain management program. Review of the Resident's Physician Orders, dated July 2024, showed: -Morphine concentrate 100 mg/5 mL oral solution, give 0.5 mL by mouth (10 mg total dose) as needed (PRN) every (Q) 2 hours PRN for pain, ordered 7/10/24. -Naloxone (Narcan) 4 mg/actuation nasal spray, nasal PRN Q 5 minutes PRN, spray 1 mg each nare for suspected opioid overdose emergency with signs of breathing problems and severe sleepiness or not being able to respond. May repeat in 4 minutes if symptoms recur, ordered 7/10/24. Review of the resident's July 2024 MAR showed: -Morphine concentrate administered on 7/12/24 at 12:16 A.M., 2:12 A.M., 5:12 A.M., 10:09 A.M., 3:43 P.M., no other administration documented for this date. -Naloxone (Narcan) administered on 7/12/24 at 1:10 P.M. Review of the resident's Nurse Notes, dated 7/12/24 at 4:40 P.M., showed: - Assistant Director of Nursing (ADON) administered the resident his/her morphine concentrate for pain. - ADON spoke with Certified Medication Technician (CMT) A related to the dose and amount to pull from the stock. - ADON administered 5 ml of morphine concentrate to the resident. -When the ADON returned to document administration, he/she realized he/she gave the incorrect dose of morphine concentrate. - ADON assessed the resident to have a respiratory rate of 16 with shallow (of little depth) breaths per minute (Normal respirations are 16 to 20 per minute). - ADON notified the Director of Nursing (DON) and the physician. - ADON administered Narcan at 1:10 P.M. nasally into left nare. - ADON assessed the resident's respiratory rate of 18 breaths per minute, regular breathing through mouth at 1:15 PM. - ADON reassessed resident at 1:20 P.M., 1:30 P.M., 1:45 P.M., and 2:00 P.M., showing regular respiratory rate of 18 breaths per minute. -At 4:00 P.M., the resident's spouse requested pain medication and morphine concentrate 0.5 mL was administered without difficulty. Review of the facility Medication Error Report, dated 7/12/24, showed: -Morphine concentrate 100 mg/5 mL oral solution, give 0.5 mL by mouth (10 mg total dose) PRN every 2 hours as needed for pain was ordered for the resident. -ADON administered 5 mL of morphine concentrate. -Medication was double checked with CMT A. -Prior to administration the resident was restless and complained to his/her spouse of pain. -When ADON returned to document the dose given, he/she noticed on the narcotic sheet the dose previously given was 0.5 mL. - ADON spoke with the DON, spouse, and physician. -The physician asked how the resident was doing and requested Narcan be given. -The resident's respiratory rate was 16 breaths per minute and shallow prior to Narcan administration. -Narcan was administered at 1:10 P.M., nasally. -The ADON stayed with the resident for 15 minutes monitoring his/her respiratory status and pain. -The resident had an increase in respiratory rate and depth after the administration of Narcan. During an interview on 7/23/24 at 2:21 P.M., CMT A said: -If a narcotic needs to be given, a nurse will come to the hall and administer the narcotic. -CMTs are not allowed to administer narcotics in long-term/skilled care. -He/she was unaware of how the ADON was notified that the resident needed his/her morphine. -The ADON asked CMT A about the dosage of the morphine concentrate. -CMT A observed the ADON pull up the morphine concentrate in a syringe and was going to put the morphine in a medication cup. -He/She told the ADON the resident would not get the medication correctly if administered from a medication cup. -He/she tried to tell the ADON the amount pulled for administration was the wrong dose by saying, I don't think that is right. -The ADON kept reading the orders on the box for the morphine concentrate. -When the ADON returned to CMT A's cart to sign out the morphine concentrate, the ADON realized he/she had given the wrong amount. -The ADON administered Narcan to the resident as a result of giving too much morphine concentrate. During an interview on 7/23/24 at 2:50 P.M., the ADON said: -Narcotics cannot be given by CMTs. -He/she recalled the medication error regarding the resident on 7/12/24. -He/she was not sure who asked him/her to give the resident his/her morphine concentrate. -He/She asked CMT A where the morphine concentrate was located. -CMT A showed him/her where the medication was in the locked narcotic drawer. -CMT A was standing with him/her as he/she pulled out the medication to be administered. -He/she misread the administration amount and pulled up more than the ordered dose. -He/she put the morphine concentrate in a medication cup and administered the medication to the resident. -When he/she returned to sign out the medication and he/she noticed he/she was signing out more than everyone else had previously. -He/she informed the DON of the error and together they contacted the physician. -He/she has given narcotics on the floor about three times since he/she started in April 2024. -He/she verified the morphine concentrate 5 mL (100 mg) was given at 12:50 P.M. followed by Narcan administered at 1:10 P.M. -He/she was aware of the appropriate medication practices and he/she needed to follow them. -He/she did not verify the appropriate dose to be administered. -He/she should have looked at the label on the bottle, checked the MAR, and the order if needed. -The administration of 100 mg of morphine concentrate instead of the ordered amount of 10 mg of morphine was a preventable event. -He/she felt if CMT A had not been side by side with him/her at the time he/she was pulling up the medication, he/she would of went to another licensed nurse to verify the dose instead of CMT A. During an interview on 7/23/24 at 3:52 P.M., the DON said: -CMTs are not allowed to administer narcotics of any kind, they are supposed to get a nurse to come to the hall to administer any and all narcotics. -On 7/12/24 there was hospice staff with the resident and requested that he/she be given morphine concentrate for pain. -Hospice nurses do not administer medications in the facility. -The ADON said he/she would give the medication. -The hospice staff were not present at the time the ADON administered the morphine concentrate 100 mg. -The ADON notified him/her immediately upon discovering morphine concentrate was administered at 100 mg instead of 10 mg as ordered. -Together they contacted the physician, who ordered Narcan be given. -There was not a policy in place to have liquid morphine be verified by another licensed nurse. -The medication error was preventable. -He/she expected safe medication administration practices for all nurses. During an interview on 7/24/24 at 8:02 A.M., the Physician said: -He/She was aware of the medication error on 7/12/24 involving the resident. -He/She ordered morphine concentrate 0.5 mg (10 mg) every two hours as needed for pain consistent with hospice/palliative care. -Agreed with the dose of 5 mL (100 mg) was a significant medication error. -Due to the dose being 10 times the amount ordered, he/she felt Narcan was an appropriate pathway. -Although no clinical harm was done, it doesn't negate the fact an error was made. -There are checks and balances in place to minimize the risk of this kind of medication error. During an interview on 7/24/24 at 2:09 PM the Administrator said: -He/she was aware of the medication error on 7/12/24. -He/she expected staff to follow procedure as the procedures are in place to protect the resident. -Although the medication was significant, he/she wants to cultivate a positive culture for reporting to rectify errors if/when they occur and contact the doctor immediately. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00239368

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #2 and #3) were free from medication errors, out of 10 sampled residents. On 3/25/24 Resident #2 was given the wrong medication when the Certified Medication Technician (CMT) handed the medication to Licensed Practical Nurse (LPN) A, who then administered the medication to the wrong resident, and on 4/4/24 Resident #3 was given his/her medication twice. A family member had given the medication to the resident and it was not signed out on the Medication Administration Record (MAR). When the resident returned to the facility the medication was given to the resident for the second time. The facility census was 48 residents. Review of the facility's Medication Administration policy, dated 6/29/2023, showed: -Purpose was to administer medications at approximate times as an individual would in their home environment while continuing to comply with physician orders. -The policy was to assure that prescribed medications are administered safely, accurately and in accordance with good nursing practice while accommodating the resident's routines and requests in medication administration. -Procedure: --Physician orders for specific medication administration times shall be followed. --The individual administering the medication must enter their initials into the resident's electronic MAR after giving each medication and before administering the next ones. -All reasonable accommodation for resident requests regarding medication administration will be followed by nursing staff. Review of the facility's Safe Medication Administration Practices, Long-term Care policy, dated 5/20/24, showed: -To promote a culture of safety and prevent medication errors, nurse must adhere to the five rights of medication administration. -These rights are to identify the right resident by using at least two resident-specific identifiers, select the right medication, administer the right dose, administer the medication at the right time, and administer the medication by the right route. -Recent literature identifies nine rights of medication administration - which, in addition to the five right, include the right documentation, the right action (or reason for prescribing the medication), the right form, and the right response. -The term medication error refers to a mistake that occurs during the medication administration process. -When a mistake occurs, it's considered an error regardless of whether it harmed a resident. -Federal regulations require that long-term care residents remain free from any significant medication errors. -A medication error that doesn't cause resident harm is referred to as a potential adverse drug event (ADE) because the actions of the resident or clinician averted the error before it affected the resident. -A potential ADE is also referred to as a near miss or close call. -Implementation: --Avoid distractions and interruptions when preparing and administering medication to prevent medication errors. --Check the resident's medical record to make sure that all required documents, medication information, sensitivities, history and physical examination findings, diagnoses, and laboratory results are present and current. --Confirm the resident's identity using at least two resident identifiers. -Administering high-alert medications: --Identify high-alert medications based on your facility's approved list. --High-alert medications include opioids. --Carefully monitor medication dosing, especially if dosing adjustments are necessary based on narrow therapeutic windows. -Familiarize yourself with all medications that you administer and be aware of potential ADEs that might occur. -Know where to obtain resources to confirm potential ADEs if you aren't familiar with the medications in use. 1. Review of Resident #2's Face Sheet showed the resident was admitted on [DATE] with diagnoses including cystitis (infection of the urinary bladder) and neuromuscular dysfunction of the bladder. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/30/24, showed the resident was cognitively intact. Review of the facility Medication Error Report, dated 4/4/24, showed: -The resident was given the medication Rifaximin (an antibiotic used to treat irritable bowel syndrome) that he/she did not have an order for. -LPN A assisted with medication pass. -As the CMT was pulling the medication, he/she said the name of a different resident. -LPN A took the medication to the resident named. -Once administered, it was realized the resident was not ordered the medication. -LPN A assessed the resident and monitored the resident. -No adverse reaction was noted. Review of the resident's Physician Orders for April 2024 showed: -No orders for Rifaximin. Review of the resident's MAR for April 2024 showed no orders or administration of Rifaximin. During interview on 7/31/24 at 1:53 P.M. LPN A said: -He/she was helping CMT B on another hall pass medications. -While CMT B was preparing the medication to be administered, he/she said another resident's name. -CMT B handed the medication to LPN A to administer. -He/she administered the medication to the resident. -CMT B asked if the medication had been given, LPN A confirmed the medication was given. -CMT B realized the medication was administered to the wrong resident. -The resident was assessed and monitored and had no negative effects. -The resident was made aware of the error and the physician had been notified. -LPN A discussed ways to prevent further errors like this from happening with CMT B. -LPN A confirmed the medication, Rifaximin, was given to the resident and the resident did not have an order for the medication. During an interview on 7/31/24 at 2:15 P.M., CMT B said: -LPN A was helping him/her with passing medications. -He/she felt LPN A misheard the resident's name. -The resident received medication ordered for another resident. -The resident did not have any adverse effects as a result of the error. -He/She and LPN A discussed ways to prevent errors like that happening again. During an interview on 7/23/24 at 4:28 P.M., the resident said: -He/she did not recall the medication error in which he/she received the wrong medication on 4/4/24. -He/She felt he/she didn't recall the incident because nothing happened as a result. During an interview on 7/24/24 at 8:02 A.M., the Physician said: -He/she was aware of the error in which the resident received medication he/she was not ordered. -He/she confirmed there were no negative effects as a result of the medication error. During an interview on 7/24/24 at 2:09 P.M. the Administrator said: -He/she knew about the resident receiving the wrong medication on 4/4/24. -The resident did not have any negative effects as a result. 2. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE] with diagnoses including paralysis of the left side of the body after a stroke. Review of the resident's Quarterly MDS, dated [DATE] showed the resident was mildly cognitively impaired. Review of the resident's Physician Orders for March 2024 showed: -Baclofen (a drug used to treat muscle spasms) 20 mg, take one tablet oral three times a day (TID) every day for muscle spasms. -Acetaminophen (a drug for pain) 325 mg, take two tablets oral TID every day for pain management. -Tizanidine (a drug for hypertension) 2 mg by mouth TID every day. -Gabapentin 300 mg by mouth every eight hours every day, take one tablet TID daily. *Note: facility liberilized medication pass times were 7:00 A.M. to 10:00 A.M., 11:00 A.M. to 2:00 P.M., and 4:00 P.M. to 7:00 P.M. Review of the resident's MAR for March 2024 showed all medications documented as given on 3/25/24 at all three medication passes. Review of the resident's Nurse Notes, dated 3/25/24 at 4:03 P.M., showed: -The resident had taken his/her 2:00 P.M. medications twice (medications not signed off when given to the family member to administer). -Resident returned early to his/her room. -When the resident was questioned about his/her 2:00 P.M. scheduled medications, the resident could not recall if he/she received the medications. -The medications administered again were Tizanidine 2 mg tablet, Gabapentin 300 mg, and Acetaminophen 325 mg tablet two tablets. -The resident was evaluated by the physician in house and determined the resident did not have any negative side effects to be alarmed about. Review of the facility Medication Error Report dated 3/25/24 showed: -Resident was given his/her 2:00 P.M. medications twice because the scheduled medications were given to the family member without signing the medications off in the MAR. -The nurse realized the medications had not been signed off and the resident did not recall if the medications were given. -The following medications were given twice Acetaminophen 325 mg two tablets, Gabapentin 300 mg, and Tizanidine 2 mg. -The resident was evaluated by the provider in house who reported the resident was stable and the double dose did not have any negative side effects. During an interview on 7/23/24 at 4:22 P.M. the resident said: -He/she did get his/her medications twice on 3/25/24. -He/she did not have any negative reactions as a result of taking his/her medications twice. -He/she had been with his/her family member. -When he/she left with his/her family member, staff would send his/her medications with his/her family member. -His/her family member had given him/her the medication while he/she was out. -Upon returning the staff administered the medications to him/her again. During an interview on 7/23/24 at 4:25 P.M. the resident's family member said: -When he/she took the resident out of the facility, the staff would give him/her the medications to give to the resident. -On 3/25/24 the staff had given him/her the medication to be given on or about 2:00 P.M. -He/she gave the resident the medications about 2 P.M. -When they returned to the facility the staff administered the scheduled medications for the second time. -They reported to him/her the medications were not signed off as given which prompted them to give the resident the medications again. -The resident did not have any negative effects. During an interview on 7/24/24 at 8:02 A.M. the Physician said: -He/she was aware of the resident receiving a double dose of his/her 2:00 P.M. medications on 3/25/24. -The resident did not have any adverse effects as a result of the medication error.

Based on observation and interview, the facility failed to keep the walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary food preparation equipment; to change the deep fryer oil in a timely manner; and to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination), in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 53 residents with a licensed capacity for 57 residents at the time of the survey. 1. Observation on 1/31/24 between 9:07 A.M. and 11:30 A.M. during the initial kitchen inspection showed the following: -There were plastic strips, a bread clip, and a pen under the racks in the walk-in freezer. -The walk-in freezer had no thermometer inside. -The oil in the deep fryer was so dark the bottom basket resting rack was not visible. -The manual can opener had an unknown residue on its blade. -The light blue, red, and yellow cutting boards were excessively scored to the point of plastic bits flaking off. -The microwave had splatters on the inside roof. -The toaster had a multitude of crumbs in the bottom and the crumb trays were missing. During an interview on 1/31/24 between 9:21 A.M. and 10:09 A.M. the Dietary Manager (DM) said the following: -He/She did not see a thermometer in the walk-in freezer and would put one in there directly. -They used the deep fryer on a daily basis. Observation on 2/1/24 at 9:53 A.M. during the follow-up kitchen inspection showed the following: -The deep fryer oil was so dark the bottom rack was not visible. -The manual can opener had the same unknown residue on its blade. -The light blue, red, and yellow cutting boards were excessively scored. -The microwave had splatters on the inside roof. -The toaster had a multitude of crumbs inside and was missing its crumb trays. During an interview on 2/1/24 at 2:23 P.M. the DM said the following: -The cooks were responsible for cleaning the walk-ins' floors before, during, and after the morning and evening shifts. -Food preparation items were cleaned after every use and they were used daily. -Damaged food preparation items were reported to them by their dietary staff, they were discarded, and new ones reordered. -He/She would expect food to be free of foreign substances. -The deep fryer's oil was tested daily and they used its filtering system after lunch and at night to keep it clean, then it was changed twice a week by the cooks.

Based on observation, interview and record review, the facility failed to properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for one sampled resident (Resident #47) out of five residents sampled for TB screening. The facility also failed to implement infection control practices by not following infection control protocols during wound care for one sampled resident (Resident #355); to ensure the Foley catheter (a tube passed into the bladder to drain urine) tubing was not touching the floor and the drainage bag was properly placed in a clean dignity/privacy bag (a bag to place a Foley catheter drainage bag into to keep out of view) for one sampled resident (Resident #30); and to follow the standard of practice for wound care and infection control practice for one sampled resident (Resident #2) out of 15 sampled residents. The facility census was 53 residents. 1. Review of the facility's policy titled Tuberculosis, Residents Screening and Handling of for dated 2024 showed any resident without documented negative Tuberculin Skin Test (TST), Blood Assay for Mycobacterium TB (BAMT-blood tests to screen for TB) or chest x-ray within the previous 12 months received a baseline (two-step) TST upon admission. Review of Resident #47's entry tracking record showed the resident admitted to the facility on [DATE]. Review of the resident's Admission Tuberculin Testing Record showed: -The resident's first-step TST was administered on 12/29/23 and read on 1/1/24. -No second-step TST was administered. During an interview on 2/6/24 at 10:32 A.M., Registered Nurse (RN) B said: -The nurses did the first TST upon admission and read it two days later. -They had a sheet for TST documentation and it went in a folder. -They looked in the folder and the second TST was supposed to be done within seven to 21 days. During an interview on 2/6/24 at 12:35 P.M., the Director of Nursing (DON) said: -The admitting nurse was to administer the residents' first TST. -They had a book that the form went in and there was a calendar in the book to track when the first-step TSTs should be read and when the second-step TST should be administered and read. -The first TST was read 48-72 hours after administration. -Once the first TST was read, the forms were put in the book for 10 days later to administer the second-step TST and read it 48-72 hours after administration. -When the nurses arrived for their shift, they were supposed to open the book and see if any TSTs needed to be administered or read that day. 42955 2. Review of the facility's Hand Hygiene, IPC-001 Policy, last revised 3/1/22, showed: -The purpose of the policy was to provide a guideline to prevent the dissemination of disease through the contact means of transmission. -Hand hygiene was the single most important means of preventing the spread of disease. -All employees complied with hand hygiene guidelines and procedures. -All employees performed hand hygiene with either soap and water or alcohol-based hand rub for routine decontamination of hands. -Routine indications for hand hygiene included: --Before and after direct contact with patients. --After removing gloves. --When moving from a contaminated body site to a clean body site during patient care. -Gloves were to be worn when there was contact with blood or other potentially infectious materials, mucous membranes and nonintact skin. -Perform hand hygiene after glove removal. Review of Resident #355's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -An encounter for surgical aftercare following surgery on the skin and subcutaneous (beneath, or under, all the layers of the skin) tissue. -Necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death). Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) entries showed the resident had not been admitted to the facility long enough to complete the admission MDS. Review of the resident's physician orders, dated 1/29/24, showed: -Clean wound with Vashe (a wound cleanser solution), pat dry. -Paint tissue surrounding the wound with no sting skin barrier and allow to dry. -Fill undermining (significant erosion underneath the outwardly visible wound resulting in more extensive damage beneath the skin surface) with Prisma Collagen (biodegradable gel). -Fill remaining wound bed with black foam. -Cover with drape and cut a quarter size hole in drape and place pad. -Manage three times a week and as needed. -Wound care nurse to assess and treat as indicated. Review of the resident's baseline care plan (necessary healthcare information to properly care for the resident immediately upon admission), dated 1/30/24, showed the resident had a wound on the front of his/her neck. Observation on 2/2/24 at 9:37 A.M. of wound care performed by RN A, showed: -He/She poured Vashe into a cup. -He/She sanitized hands. -He/She reported he/she had previously cleaned the bedside table and was waiting for it to dry. -He/She put wound care supplies on cleaned table without a barrier. -He/She put clean gloves on. -He/She adjusted the resident's bed. -He/She removed gloves. -He/She did not use hand sanitizer or wash hands. -Some of the pre-packaged gauze pads fell off table on to the floor. -He/She picked them up and put them in the trash. -He/She used the wall mounted hand sanitizer and left the room to get more gauze. -He/she returned to the room and used the wall mounted hand sanitizer upon re-entering the room then applied gloves. -He/She cleaned the pair of scissors, removed gloves, and applied new gloves. -He/She did not use hand sanitizer or wash hands prior to putting on clean gloves. -He/She removed the resident's C-Collar (a neck brace used to prevent rotation of the head) which was visibly soiled from food stains and other unidentifiable debris. -He/She removed the gloves and put on new gloves without using hand sanitizer or washing hands. -He/She removed the soiled adhesive covering which covered the wound and threw it away with the tubing that was attached to the wound and connected to tubing going to the wound vac (a type of therapy to help wounds heal). -He/She removed one glove from the box and wrapped it around the end of tubing which connected the wound vac to the tubing from the wound. -He/She removed the gloves and applied new gloves without using hand sanitizer or washing hands. -He/She used a disposable measuring tape and measured the wound. -He/She removed the glove on his/her right hand and opened a new gauze packet. -He/She wrote the wound measurements on the gauze package. -He/She applied a new glove to the right hand without using hand sanitizer or washing hands. -He/She used a cotton swab to measure all areas of the wound, including the right, left, top and bottom sides of the wound. -He/She used the same cotton swab to probe all sides of the wound measuring for tunneling. -He/She used the same disposable measuring tape for each measurement of the wound. -He/She removed the right glove. -He/She wrote measurements on a gauze pad package and removed other glove then put on two new gloves without using hand sanitizer or washing hands. -He/She placed clean supplies, including cleaned scissors on the residents abdomen. -The resident was wearing a soiled hospital gown. -He/She placed gauze on wound. -He/She removed gloves and applied new gloves without using hand sanitizer or washing hands. -He/She cleaned around the wound, removed gloves, and sanitized hands as he/she left the room. -He/She returned to the room, sanitized hands, applied new gloves and used scissors to cut new foam. -He/She did not sanitize scissors between use. -He/She cut the new foam with the same scissors. -He/She removed gloves and applied new gloves without using hand sanitizer or washing hands to tuck collagen into tunneling in the wound. -He/She removed gloves, applied new gloves without using hand sanitizer or washing hands. -He/She applied the adhesive seal to resident's skin. -He/She removed gloves, applied new gloves without using hand sanitizer or washing hands. -He/She applied the new foam. -He/She removed gloves, applied new gloves without using hand sanitizer or washing hands. -He/She removed new tubing from package and applied to resident over the foam and covered with adhesive tape. -He/She used the soiled scissors to cut the new adhesive covering. -He/She connected the new tubing from the wound to the tubing connected to wound vac without sanitizing the tube pieces where they connected. -He/She removed gloves and turned wound vac back on. -He/She described a substance in the tubing as a pink sanguineous (containing blood) material, approximately 10-20 cubic centimeters (cc), not actually measurable. During an interview on 2/5/24 at 12:01 P.M., RN A said: -He/She had worked at the facility since October 2023. -He/She sanitized scissors in between patients. -He/She had two pairs of scissors and cleaned them once he/she was done doing cares with the resident. -He/She defined a clean procedure as working from a surface that was sanitized then he/she opened packages and kept all supplies on the sanitized table or surface. -Unless he/she put a drape over the surface then it would not be considered clean. -He/She sanitized his/her hands when he/she entered and exited each resident's room. -He/She did not normally sanitize while in the room and between glove changes. -He/She sanitized his/her hands if he/she came in contact or close contact to a colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall) for example. -He/She did not think changing the cotton swab between measuring and tunneling the wound was necessary since the normal flora (the microorganisms that exist on or within the human body) of the body and the flora of the wound was the same. -He/She confirmed he/she did not wipe the ends of the tubing with alcohol wipes but used a glove to protect and contain the end of the tube. -He/She did not wear a mask during the wound care as the bacteria was contained in the wound and it was not air borne. During an interview on 2/6/24 at 12:34 P.M., the DON said: -Staff were expected to sanitize or wash their hands before entering the resident's room. -Staff were expected to wash their hands anytime they are touching any piece of equipment. -Staff were expected to wash hands or sanitize before and after measuring a wound during wound care. -Staff were expected to wash hands or sanitize each time they changed gloves during cares. -Staff were expected to remove gloves and wash hands after touching soiled items and before putting on new gloves. -Staff were expected to wash or sanitize hands before leaving the resident's room. -Scissors should be cleaned before and after each use. -Wound care required a clean field with a sterile barrier placed on a bed side table. -He/She did not consider residents hospital gowns to be clean or sterile area. -During wound care clean supplies should remain on the table, dirty supplies should not be on the clean or sanitized area. -An actual barrier was a paper placed on a clean table top that was bleach wiped. -He/She expected nurses to use a new swab with each measurement during wound care to keep from cross contaminating. -Nurses should have used a clean swab and clean/new disposable ruler between measurements. -Both ends of the tubes attached to the wound and to the wound vac should be cleaned with alcohol wipes prior to reattaching. 37576 3. Review of the facility's Management of Foley Catheters undated Policy showed: -Do not place the drainage bag any place where it will become contaminated. --i.e., on the floor. Review of Resident #30's Face Sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (an infection in any part of the urinary system). -Acute kidney failure (the kidneys are no longer able to filter waste from the blood). -Retention of urine (difficulty urinating and completely emptying the bladder). During an interview on 1/31/24 at 11:55 A.M., the resident's family member said: -He/She had concerns about the resident's Foley catheter bag and the cover it was in. -It was under the resident's wheelchair when he/she was up. -The cloth bag did not cover the urine bag completely. -The cloth bag dragged on the floor, and it appeared dirty. -He/She felt the cover bag should be changed more often and washed. Observation on 1/31/24 at 11:55 A.M., showed: -The resident was sitting in his/her wheelchair in the dining room/common area. -The Foley catheter bag was partially in a cloth dignity bag attached under the resident's wheelchair. -The cloth dignity bag was lying on the floor and appeared to be dirty. -Part of the catheter tubing was touching the floor. Observation on 2/1/24 at 11:00 A.M., showed: -The resident was sitting in his/her wheelchair in the dining room/common area. -The Foley catheter bag was partially in a cloth dignity bag attached under the resident's wheelchair. -The cloth dignity bag was lying on the floor and appeared to be dirty. -Part of the catheter tubing was touching the floor. During an interview on 2/5/24 at 12:49 P.M., Certified Nursing Assistant (CNA) H said: -The Foley catheter bag should be fully in a dignity bag at all times. -The Foley catheter bag and/or dignity bag should not be on the floor at any time. -The Foley catheter tubing should not be touching the floor at any time. During an interview on 2/6/24 at 9:37 A.M., RN B said: -Foley catheter bags were kept in dignity bags. -When a resident was up in a wheelchair the dignity bag with the catheter bag in it should be attached to the back of the chair or under the chair. -The catheter bag and/or dignity bag and tubing should not be on the floor at any time. -The cloth dignity bags were washable and should be changed weekly or when dirty. During an interview on 2/6/24 at 12:34 P.M., the DON said: -When a resident with a Foley catheter was up in a wheelchair it should be hooked to the wheelchair lower than the resident's bladder. -The cloth dignity covers should get changed a couple of times a week. -The cloth dignity covers were laundered with the resident's laundry and reused as long as the resident was using the cover. -The catheter bag, the tubing or the cover should never be touching the floor. 39469 4a. Review of the facility's policy, Skin Care - Wound Care, dated 2/6/24 showed: -Ordered or recommended wound care would have been provided by the facility staff while properly following all standards of practice for wound care and infection control practices. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the right upper back, Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Review of the resident's Admission MDS dated [DATE] showed: -His/Her Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating he/she was cognitively intact. -He/She had a Stage III pressure ulcer. Review of the resident's February 2024 Physician's Order Sheet (POS) showed the following order: -Clean the wound with Vashe (a liquid wound cleanser), then pat dry. -Apply Santyl (ointment used to remove damaged tissue from chronic skin ulcers), nickel thick, to wound bed for enzymatic debridement (a chemical debridement that softens unhealthy tissue). -Cover with a plain contact layer, telfa (a non sticking wound dressing) and medipore (a type of tape made from a soft cloth) tape. -Change daily. Observation on 1/31/24 at 11:25 A.M. with RN/Wound Care Nurse (WCN) A showed: -He/She cleansed his/her hands then applied a pair of gloves. -He/She did not clean the top of the dresser or place a clean barrier before laying down the dressings. -He/She removed the soiled dressing. -He/She did not change gloves or cleanse his/her hands. -He/She cleaned the pressure ulcer. -He/She did not change gloves or cleanse his/her hands. -He/She put on the new dressing. -He/She then discarded his/her gloves and cleansed his/her hands. During an interview on 1/31/24 at 11:40 A.M. RN/WCN A said: -He/She did not forget to do anything. -He/She would not have done anything differently. -He/She did wound care on the resident daily. During an interview on 2/2/24 at 7:30 A.M. Licensed Practical Nurse (LPN) B said: -Staff should always cleanse their hands when gloves were changed. -If staff were doing wound care they should clean the top of the surface with a bleach wipe or put down a barrier such as a paper towel to put the dressings on. During an interview on 2/6/24 at 10:00 A.M. the Assistant Director of Nursing (ADON) said: -During wound care the equipment or supplies should be on a clean field or a table that had been bleach wiped or a barrier should have been put on the table. -Hand hygiene should have been done before and after each glove change. -Hand hygiene should have been done after cleaning the equipment such as the blood pressure machine. -The Clinical Education Specialist does frequent education with the staff concerning hand hygiene. During an interview on 2/6/24 at 12:30 P.M. the DON said: -When doing cares he/she would have expected the staff to wash their hands before and after cares. -He/She would have expected staff to wash their hands after each glove change. 4b. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hypertension (high blood pressure). -Acute pain related to trauma. Review of the resident's Admission MDS dated [DATE] showed: -His/Her Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating he/she was cognitively intact. -He/She had fractures (broken bones) with multiple trauma. -He/She had Hypertension. -He/She was on scheduled pain medications. Review of the resident's POS dated February 2024 showed the following orders: -Metoprolol Tartrate (medication used to treat high blood pressure) 25 milligram (mg) tablet, take 1/2 of a tablet twice a day for hypertension. -Lidocaine (a pain medication used to ease pain by numbing the nerves) 4% topical (on the skin) patch, apply one patch topically to area of pain every A.M. and remove patches every H.S. (night) for pain management. Observation of medication pass on 2/2/24 at 7:17 A.M. with LPN B showed: -He/She took the resident's blood pressure on a portable blood pressure machine. -The resident's blood pressure was 128/63 within limits of administering Metropolol. -He/She took a pair of scissors out of his/her pocket to cut open the package containing the Lidocaine patch without cleaning the scissors first. -He/She stuck the scissors back in his/her pocket without cleaning them. -He/She administered the Metropolol to the resident. -He/She cleaned the blood pressure machine without gloves on. -He/She did not cleanse his/her hands after cleaning the blood pressure machine. During an interview 2/6/24 at 11:10 A.M. Certified Medication Technician (CMT) C said: -Staff should always clean their scissors before and after using them. -If staff cleaned a blood pressure machine gloves should be worn. -Staff should always wash or sanitize their hands after removing gloves. During an interview on 2/6/24 at 12:30 P.M. the DON said if staff took a pair of scissors out of their pocket he/she would expect them to clean the scissors before and after using them.

Based on observation, interview, and record review, the facility failed to ensure resident's oxygen tubing was stored in a bag and dated when staff had changed out the tubing for two sampled residents, (Resident #8 and Resident #304), and to ensure a resident's Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while sleeping) machine had distilled water for the reservoir, and to ensure the resident's CPAP mask was cleaned daily for one sampled resident (Resident #305) and the CPAP mask was stored appropriately in a bag when not in use for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Policy Oxygen Therapy for Adults in Long Term Care Setting, dated 8/4/22 showed: -Oxygen therapy medically prescribed for residents would have been administered according to health and safety guidelines and delivered either by Oxygen mask, nasal cannula, or nasal catheter. -A nasal cannula is tube-like and placed into the resident's nose and held in place by an elastic band placed around the resident's head. -Ensure Oxygen tubing is not dragging or touching the floor. -Store all cannulas, Oxygen tubing, and nebulizer (a device that turns liquid medication into a mist) masks in a plastic bag when not in use. -Disposable nasal cannulas (tubing with prongs that insert into a resident's nose to deliver oxygen), nebulizer masks and tubing will be changed weekly on the night shift and plastic storage bag will be changed and dated weekly on the night shift. -Prevent all Oxygen tubing from dragging or touching the floor by using a bag or container to store excess tubing. -Check the mask, tank, humidifying jar to be sure the equipment is in good working order. -Ensure there is clean water in the humidifying jar. -Periodically re-check the water level in the humidifying jar. The Policy for the CPAP machine was requested and not provided. 1. Review of Resident #8's face sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic (persisting for a long time or constantly recurring) Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) with acute (sudden onset) lower respiratory infection. -Chronic Respiratory Failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide) with Hypoxia (low oxygen levels in the body tissues). -Dependence on supplemental Oxygen. Review of the resident's Care Plan dated 9/15/23 showed: -He/she required staff assistance with Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) secondary to acute respiratory failure. -He/She used Oxygen at 2 Liters (L-measurement for the flow of Oxygen received from an Oxygen delivery device) per nasal cannula. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 12/6/23 showed he/she was on Oxygen therapy. Observation on 1/31/24 1:51 P.M., showed: -An Oxygen concentrator (a medical device that separates nitrogen from the air around a person so they can breathe up to 95% pure oxygen) in the resident's room. -The Oxygen tubing was laying across the top of the concentrator. -The Oxygen tubing with nasal cannula was not in a storage bag. -There was no storage bag attached to the concentrator. Observation on 2/1/24 9:30 A.M., showed: -An Oxygen concentrator in the resident's room. -The Oxygen tubing with nasal cannula was laying across the top of the concentrator. -The Oxygen tubing with nasal cannula was not in a storage bag. -There was no storage bag attached to the concentrator. Observation on 2/5/24 9:46 A.M., showed: -The resident was using Oxygen per nasal cannula from the concentrator. -There was no storage bag attached to the concentrator for tubing storage when not in use. During an interview on 2/5/24 12:53 P.M., Certified Nursing Assistant (CNA) H said: -Oxygen tubing not in use should be in a dated labeled bag. -Oxygen tubing should not be laying on a concentrator or other surface when not in use. Observation on 2/6/24 9:32 A.M., showed: -The resident was using Oxygen per nasal cannula from the concentrator. -There was no storage bag attached to the concentrator for tubing storage when not in use. During an interview on 2/6/24 9:35 A.M., Registered Nurse (RN) B said: -A resident's Oxygen tubing should be in a storage bag labeled and dated when not in use. -The bag should be changed every week and dated. -The tubing should not be hanging anywhere without being bagged when not is use. 39469 2. Review of Resident #304's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of COPD. Review of the resident's Admission MDS dated [DATE] showed: -The resident's Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating he/she was moderately cognitively impaired. -He/She had COPD. -He/She was on Oxygen therapy. Review of the resident's care plan dated 1/26/24 showed: -A head to toe assessment was to have been completed within 24 hours of admission. -Staff was to review admission orders with the resident. -There was no documentation of Oxygen use on the care plan. Review of the resident's Physician Order Sheet (POS) dated February 2024 showed the following orders: -Staff was to check the Oxygen level every shift and as needed (PRN) for respiratory signs and symptoms. -If the Oxygen level was below 94% nursing was to refer to PRN Oxygen order. -Staff was to administer Oxygen at 2 to 4 liters PRN for oxygen levels below 94%, dated 1/25/24. Observation on 1/31/24 at 11:45 A.M. showed: -The resident did not have his/her Oxygen on his/her face. -The resident's Oxygen tubing was hanging on the bed rail, running. -There was no Oxygen bag in the resident's room to store the tubing in when not in use. Observation on 2/1/24 at 9:27 A.M. showed: -The resident's Oxygen tubing was wound around the bed rail, not in a bag, not in use, running. -The resident's second Oxygen tubing was wound around the Oxygen tank on the back of the residents wheelchair that he/she was sitting in, not in a bag. During an interview on 2/2/24 at 6:30 A.M. CNA K said: -Oxygen tubing when not in use should be in a bag. -The nurses were responsible to have changed out the Oxygen tubing, weekly. -The date the tubing was changed should have been written on the bag or on the tubing. Observation on 2/5/24 at 3:00 P.M. showed: -The resident's Oxygen tubing was wound around the bed rail, not in a bag, not in use. -The resident's Oxygen tubing was wound around the Oxygen tank on the back of the resident's wheelchair that he/she was sitting in, not in use. During an interview on 2/5/24 at 3:10 P.M. Licensed Practical Nurse (LPN) B said: -The CNA's were supposed to change out the Oxygen tubing weekly. -The CNA's should have dated the Oxygen tubing when it was changed. -If Oxygen was not in use the tubing should have been stored in a plastic bag. 3. Review of Resident #305's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Obstructive Sleep Apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident's POS dated February 2024 showed the following orders: -The resident had Obstructive Sleep Apnea. -Staff was to assist the resident in the application of his/her CPAP nightly, dated 1/26/24. -Staff was to clean the resident's CPAP mask cushion with soap and water on a daily basis, allow to dry. Dated 1/26/24. Review of the resident's care plan dated 1/26/24 showed: -Nursing was to complete a head to toe assessment within 24 hours of admission. -Nursing was to review admission orders with the physician. Review of the resident's Admission MDS dated [DATE] showed: -The resident's BIMS score was 12 out of 15 indicating he/she was moderately cognitively impaired. -The resident had pulmonary (lung) disease. -Under special treatments and programs, CPAP was not checked. Observation on 2/1/24 at 10:20 A.M. showed: -The resident's CPAP mask was sitting on the dresser not in a bag. -There was no water in the water reservoir in the CPAP machine. -There was no distilled water in his/her room. Observation on 2/2/24 at 6:20 A.M. showed: -The resident's CPAP mask was sitting on the dresser not in a bag. -There was no distilled water in his/her room or in the water reservoir in the CPAP machine. During an interview on 2/2/24 at 6:20 A.M. the resident said: -They had not given him/her distilled water for his/her CPAP machine. -Staff had not cleaned his/her CPAP mask. During an interview on 2/2/24 at 6:30 A.M. CNA K said: -If a resident had a CPAP machine the mask should be in a bag when not in use. -The CPAP mask should be washed daily by the CNA's. -Nursing should have provided distilled water for the resident's CPAP. -He/she did not know the resident had a CPAP machine. -He/she had not cleaned the mask. -There was no distilled water in the resident's CPAP reservoir. During an interview on 2/2/24 at 7:37 A.M. LPN A said: -He/She did knot know the resident had a CPAP machine. -The CPAP mask should have been cleaned by night shift CNA after they woke up in the morning. -The nurse should have ensured the resident had distilled water for his/her CPAP machine. -The distilled water was locked up in a supply room and the nursing staff had the key. Observation on 2/5/24 at 2:20 P.M. of the resident showed: -The resident's CPAP mask was sitting on the dresser, not in a bag. -The resident's CPAP mask was tan around the edge. -There was no water in the reservoir of the CPAP machine. During an interview on 2/5/24 at 2:20 P.M. the resident said: -The staff had not cleaned the CPAP mask. -The staff had not brought him/her any distilled water for the CPAP machine. During an interview on 2/6/24 at 10:00 A.M. the Assistant Director of Nursing (ADON) said: -Oxygen tubing should have been changed out weekly on Sunday nights by the nursing staff. -The Oxygen tubing or the bag the Oxygen tubing was stored in should have had the date written on it when it was changed. -Oxygen tubing should have been stored in a bag when not in use. -The mask to a CPAP machine should have been cleaned daily by the CNA's. -If the CPAP machine had a reservoir for water then the staff should have ensured there was distilled water. -The nurse should have provided distilled water for the resident's CPAP machine. 49185 4. Review of Resident #12's Face Sheet showed a diagnosis of Obstructive Sleep Apnea. Review of the resident's POS dated 9/2/21 showed an order for a CPAP on at home settings at night. Review of the resident's POS dated 1/4/23 showed to wash CPAP mask and hose out with soap and water and leave it out to air dry on the bedside table every Monday. Review of the resident's annual MDS dated [DATE] showed: -The resident was cognitively intact. -CPAP was not marked. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -CPAP was not marked. Review of the resident's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated January 2024 showed: -Wash CPAP mask and hose out with soap and water and leave it out to air dry on the bedside table every Monday. -CPAP on at home settings at night. Observation on 1/31/24 at 9:29 A.M., of the resident's room showed: -The CPAP machine was on the bedside table. -The CPAP mask was on the bedside table. -The CPAP mask was not in a bag. Observation on 1/31/24 at 1:31 P.M., of the resident's room showed: -The CPAP machine was on the bedside table. -The CPAP mask was on the bedside table. -The CPAP mask was not in a bag. During an interview on 1/31/24 at 1:31 P.M., the resident said: -He/She was able to set up, put on the mask, and turn on the CPAP machine by himself/herself. -He/She had a gallon jug of distilled water to use in the CPAP humidifier. Review of the resident's electronic MAR and TAR dated February 2024 showed: -Wash CPAP mask and hose out with soap and water and leave it out to air dry on the bedside table every Monday. -CPAP on at home settings at night. Observation on 2/1/24 at 10:38 A.M. of the resident's room showed: -The CPAP machine was on the bedside table. -The CPAP mask was on the bedside table. -The CPAP mask was not in a bag. During an interview on 2/1/24 at 10:38 A.M., the resident said: -He/She used the CPAP every night. -He/She filled the reservoir with distilled water, put the CPAP mask on, turned the CPAP machine on at night, and turned it off in the morning. -Staff did not need to help him/her. -In the morning, he/she laid the CPAP mask on the bedside table. -Staff never gave him/her a bag to keep the mask in. Observation on 2/2/24 at 6:26 A.M., of the resident showed: -The resident was lying in bed in the dark. -The resident was wearing the CPAP mask. -The CPAP machine was audible. Observation on 2/2/24 at 9:54 A.M., of the resident's room showed: -The CPAP machine was on the bedside table. -The CPAP mask was on the floor between the bedside table and the bed. -The CPAP mask was not in a bag. During an interview on 2/2/24 at 12:17 P.M., CNA D said: -When not in use, the CPAP mask should be in a bag. -The staff should put the CPAP mask in a plastic bag if the resident did not. -When the plastic bag was not there, staff got a new one. -At nighttime the empty bag was put in the resident's bedside table drawer. -When he/she found a CPAP mask on the floor, he/she cleaned it, and told the nurse. Observation on 2/2/24 at 12:21 P.M., of the resident's room showed: -The CPAP machine was on the bedside table. -The CPAP face mask was still on the floor between the bedside table and the bed. -The CPAP mask was not in a bag. Observation on 2/2/24 at 12:23 P.M., of the resident's room showed: -CNA D brought a new bag for the CPAP mask. -He/She picked the CPAP mask up off the floor. -He/She placed the CPAP mask in the bag and laid it on the bedside table. During an interview on 2/2/24 at 12:36 P.M., the ADON said staff should make sure the CPAP mask was in a bag when not in use. During an interview on 2/5/24 at 9:59 A.M., the MDS Coordinator said staff should make sure the CPAP mask was in a bag when not in use. 5. During an interview on 2/6/24 12:34 P.M., the Director of Nursing (DON) said: -Oxygen tubing should not be hung on the concentrator without being in a bag when not in use. -Oxygen tubing should be in a plastic bag when not in use. -The plastic bag for the tubing should not touch the floor. -The plastic bag for the tubing should be dated and changed weekly. -The nurses were responsible to ensure the physician's orders were carried out. -The staff were expected to change out the Oxygen tubing on Sunday nights and should have ensured the date was written on the bag or the tubing itself. -Nursing staff was responsible to take care of a resident's CPAP machine. -Staff should have cleaned the CPAP mask daily. -Nursing staff should have ensured there was distilled water for the CPAP machine. -If a resident used Oxygen or a CPAP machine it should have been on their care plan. -The expectation was the CPAP mask should be in a bag when not in use.

Based on observation, interview, and record review, the facility failed to ensure three of the four medication carts were locked when the nursing staff was not within direct line of sight of the medication cart. The facility census was 53 residents. Review of the facility's policy, Storage of Medications, dated as retrieved on 2/6/24 showed: -The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing drugs and biologicals (a therapeutic substance, such as a vaccine or drug) should have been locked when not in use. -Carts used to transport such items should not have been left unattended if open or otherwise potentially available to others. 1. Observation on 1/31/24 at 11:25 A.M. with Registered Nurse (RN)/Wound Care Nurse (WCN) showed: -He/She went into a resident's room to do wound care. -He/She left the treatment cart in the hallway unlocked, while he/she was in the room for 20 minutes. -Two residents passed within two feet of the unlocked treatment cart while the nurse was in the resident's room doing wound care with his/her back to the door. -The treatment cart had residents' medications prescribed by the physician in it. -There were five tubes of Santyl (medication used to remove damaged tissue from chronic skin ulcers) in the treatment cart prescribed by the physician. -There were three tubes of Zinc Oxide (medication used to treat skin irritations) in the treatment cart, prescribed by the physician. During an interview on 1/31/24 at 12:00 P.M. RN/WCN said: -He/She should have locked the treatment cart while in the room doing wound care with a resident. -There were residents who were confused and wandered who could have opened the treatment cart. 2. Observation on 2/2/24 at 7:17 A.M. during medication pass with Licensed Practical Nurse (LPN) B showed: -He/She went into a resident's room to check his/her blood sugar level. -The accu check machine (device used to check a patient's blood sugar level) did not work. -He/She came out to the medication cart, unlocked it to see if there were batteries to replace the ones in the accu check machine. -There were no batteries in the medication cart. -He/She walked down to the end of the hallway to obtain a different accu check machine. -He/She left the medication cart unlocked for three minutes. -Two residents walked by the unlocked medication cart within two feet of the cart. 3. Observation on 2/2/24 at 8:50 A.M. of the medication cart on B Hall showed: -Certified Medication Technician (CMT) B left the medication cart unlocked in the hallway, while he/she went into the dining room to give a resident his/her medication. -CMT B's back was to the cart for two minutes. -One resident walked by within two feet of the unlocked medication cart. 4. During an interview on 2/6/24 at 10:00 A.M. the Assistant Director of Nursing said: -The medication carts should have been locked if the Nurse or CMT were not within direct observation of the cart. -The Clinical Education Specialist had done frequent education with the staff about keeping the medication carts locked when not in front of the cart. During an interview on 2/6/24 at 11:00 A.M. LPN B said the medication cart should have been kept locked if staff were not in front of the cart. During an interview on 2/6/24 at 11:10 A.M. CMT C said: -Medication carts should have been locked if staff were not in front of the medication cart, using it. -The facility had provided a lot of education on keeping the medication carts locked. During an interview on 2/6/24 at 12/30 P.M. the Director of Nursing said: -He/She expected the staff to ensure the medication carts were locked if they were not in front of the cart using it. -The staff has had education on locking the medication carts.

Based on interview and record review, the facility failed to disperse remaining resident trust account funds and to convey within 30 days of death, a final accounting of the resident trust fund account to the individual or probate jurisdiction administering the resident's estate in accordance with state law after the residents expired for three sampled residents (Residents #106, #107, and #108) out of three expired residents sampled for disbursement of funds. The facility census was 53 residents. Review of the facility's policy titled Management of Residents' Funds dated 2024 showed: -A representative of the business office would review the resident's records upon notification of a resident's death. -If the resident had any funds being held by the facility, the funds should be transferred to the resident's representative, the state or probate jurisdiction administering the resident's estate. Review of the Personal Funds Account Balance Report form dated [DATE] showed: -Nursing facilities were required to submit a written account of the remaining personal funds for any deceased resident who received aid, care, assistance or services paid by the Department of Social Services which includes all of the resident's remaining funds held by the nursing home. -Within 60 days from the date of the resident's death, send the completed form and a copy of the complete accounting of the resident's personal funds account to the Missouri HealthNet Division Third Party Liability Unit. 1. Review of the facility's resident trust fund account, showed the following: -Resident #106 expired on [DATE]. $400.57 remained in the trust account and the facility had not disbursed those funds after the resident expired. The resident was on Medicaid. -Resident #107 expired on [DATE]. $164.17 remained in the trust account and the facility had not disbursed those funds after the resident expired. It did not include the resident's payment source. -Resident #108 expired on [DATE]. $100.00 remained in the trust account and the facility had not disbursed those funds after the resident expired. The resident was on Medicaid. During an interview on [DATE] at 10:22 A.M., the Accounting Specialist said: -They still have the money of the three sampled residents with credit who have expired. -The money was not issued back to the family or Medicaid. -The money in Resident #107's account had been held for a long time and they couldn't find anybody to return money to. -Residents #106 and #108 were on Medicaid. -He/She did not think Resident #107 was on Medicaid and he/she didn't know if there was family to send it to. -They were supposed to send Medicaid money back to Medicaid. During an interview on [DATE] at 9:09 A.M. the Administrator said: -The personal finance account paperwork had not been filed for any of the sampled residents. -He/She would have to find out who was responsible for completing the paperwork and returning funds after the death of a resident. During an interview on [DATE] at 2:13 P.M., the Administrator said the accounting specialist was responsible for completing the forms and returning the residents' money.

Based on interview and record review, the facility failed to complete the Pneumococcal Immunization Informed Consent form correctly before having the resident and nurse sign it; and failed to re-offer the immunization for one sampled resident (Resident #8) out of five residents sampled for immunizations. The facility census was 53 residents. Requested a policy for Pneumococcal Immunization and received an updated Consent for Vaccine form. 1. Review of Resident #8's face sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic (persisting for a long time or constantly recurring) Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) with acute (sudden onset) lower respiratory infection. -Chronic Respiratory Failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide). -Dependence on supplemental oxygen. Review of the resident's Pneumococcal Immunization Informed Consent form dated 1/6/2013 showed: -Areas for consent to receive, refused because already received with a blank line for a date, or other reason. -None of the three areas were filled out on the form. -The form was signed by the resident and by a staff member and each dated on 8/25/18. During an interview on 2/5/24 at 11:18 A.M., the Director of Nursing (DON) said: -The resident had refused the Pneumococcal immunization. -The nurse had not checked the refused box due to the refusal box showed refused because already received and had a date line and the resident had not previously received the vaccine and did not want it. During an interview on 2/5/24 at 12:41 P.M., the resident said: -He/She may have refused the pneumonia vaccine back then, that was six years ago. -He/She would like to receive the pneumonia vaccine now if able to receive it. During an interview on 2/6/24 at 12:34 P.M., DON said: -The Pneumococcal Immunization Informed Consent form should have been filled out completely when the resident and the nurse each signed the form in 2018. -The form should not have been signed by the resident or the nurse before being completely filed out. -The pneumonia vaccine was offered to residents when they were admitted and given with the resident's consent or consent of their family representative. -The pneumonia vaccine was not offered to residents yearly.

Based on interview and record review, the facility failed to obtain a complete Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I Screening for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Behavior Assessment and Monitoring Policy dated 3/13/23 showed: -The interdisciplinary team will utilize information from the PASRR process as well as complete a comprehensive assessment of the resident needs, strengths, goals, life history and preference using the Resident Assessment Instrument (RAI) process specified by Centers for Medicare and Medicaid Services (CMS). -The Preadmission and PASRR Process: identifying potential mood and behavioral changes, support and care plan interventions is part of the assessment process as well as coordination of care. It is the policy of the facility to screen all potential admissions on an individualized basis for behavioral health needs. -Social Services will complete a Social Services Initial Assessment which includes PASRR Level II Completion (as applicable). 1. Review of Resident #12's PASRR Level I Screening dated 9/1/21 showed: -The PASRR Level I form was completed by a local hospital. -Question #4 in Section B was blank. -- Has the person had serious problems in level(s) of functioning in the last six months? -Question #5 in Section B was blank. --Has the person received intensive psychiatric treatment in the past two years? -The resident did not sign the form. -NOTE: As a result of questions #4 and #5 being left blank the determination of completing a Level II screening could not be made. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 12/7/23 showed the resident: -Was cognitively intact. -Had a diagnosis of Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest and could interfere with daily life). During an interview on 2/5/24 at 12:53 P.M., the Director of Nursing (DON) said: -He/She thought the preadmission PASRR Level I Screening was reviewed by the Admission Coordinator. -None of the floor nursing staff review the PASRR forms. During an interview on 2/5/24 at 1:00 P.M., the Admission Coordinator said: -The Social Worker at the hospital was supposed to completely fill out the PASRR Level I form, then have the hospital physician sign it. -The resident was admitted before he/she was the Admission Coordinator. -The previous Admission Coordinator should have checked the form before admitting the resident. -There was not a more recent Level I Screening. -Questions #4 and #5 in Section B were not answered. -Question #5 was the question that could have triggered a PASRR level II questionnaire. -He/she did not know if a PASRR Level II should or should not have been done based on the form. -Knowing the resident's history, he/she believed the resident did not need a PASRR Level II. During an interview on 2/6/24 at 12:46 P.M., the DON said: -When a PASRR Level I form was received, it should have been filled out completely. -The resident was admitted before the current Admission Coordinator started. -The incomplete PASRR Level I received for the resident fell through the cracks. -It should have been reviewed by the previous Admission Coordinator. -If questions #4 and #5 were not filled out, they could not determine if they could properly take care of the resident. -It should be complete. -The facility was now using online PASRR forms. -He/She did not know how often the residents were reassessed. -They should be reassessed periodically to ensure that the facility was still able to provide the proper care.

Based on observation, interview, and record review, the facility failed to ensure a physician ordered special mattress was in place to minimize a Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) for one sampled resident (Resident #2) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy, Skin Care - Wound Care), dated 2/6/24 showed: -The Wound Care Team and/or the primary nurses were responsible for providing care for the patient with a skin wound. -Ordered or recommended wound care would have been provided by facility staff while properly following all standards of practice for wound care. -Staff was to have implemented Individualized Plan of Care. -Staff was to have implemented measures to manage tissue load to minimize pressure, friction and shear. -Staff was to have provided ordered and recommended wound care in accordance with accepted wound and infection control standards of practice. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer to his/her right upper back, Stage III. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 12/11/23 showed: -His/Her Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating he/she was cognitively intact. -He/She had a Stage III pressure ulcer. -He/She should have had a pressure reducing device for his/her bed. Review of the resident's Care Plan dated 12/11/23 showed the resident was to have a Low Air Loss (LAL - a mattress designed to distribute the patient's body wight over a broad surface area and help prevent skin breakdown) mattress to assist with wound healing. Observation on 1/31/24 at 11:25 A.M. with Registered Nurse (RN)/Wound Care Nurse (WCN) A showed: -The resident had a Stage III pressure ulcer on the right side of his/her lower back. -The pressure ulcer was a quarter size, Stage III with 100% white slough (a layer of dead skin). -There was no LAL mattress on the resident's bed. During an interview on 1/31/24 at 11:35 A.M. RN/WCN A said: -He/She did wound treatment on the resident daily. -The resident had a Stage III pressure ulcer. -The resident mostly laid on his/her back. -They encouraged the resident to lay or his/her side or to get up into the wheelchair. -When the staff encouraged the resident to lay on his/her side it should have been documented in the nurses' notes. -He/She did not think staff charted when the resident was encouraged to lay on his/her side was charted. -The resident's care plan should have indicated that he/she had a pressure ulcer. -The resident should have had a LAL mattress. -It should have been documented he/she had a LAL which he/she had in the other room. -He/She had changed rooms about two weeks ago and the LAL mattress should have been on his/ her bed but it was not. -All of the residents' beds can function as a LAL the motor only needed to be applied to the bed. -There was no documentation on the resident's care plan of having a pressure ulcer or what staff should be doing with him/her such as getting him/her off of his/her back. -The Certified Nursing Assistants (CNA)s had assignment sheets that told them what to do with the resident, a LAL mattress should have been listed on the assignment sheet. -The Charge Nurse was responsible to ensure Physician's orders were followed through. -The Wound Nurse would have been responsible to ensure there were precautions and procedures in place to help the pressure ulcer to heal. -Somehow the LAL mattress order was missed. During an interview on 1/31/24 at 11:45 A.M. the resident said: -He/She had a LAL mattress in his/her other room before he/she was moved. -He/She did not know why he/she did not have one on this bed. -He/She did not get up out of bed very often any more as it was too hard for him/her. During an interview on 2/1/24 at 10:30 A.M. CNA F said: -He/She got an assignment sheet at the beginning of the shift that showed what they were supposed to do with the residents. -He/She did not know anything about the resident having a sore on his/her back or what was to have been done with it. -He/She did not know if the resident should have had a LAL mattress. -He/She did not have an assignment sheet for today. During an interview on 2/1/24 at 10:45 A.M. the Assistant Director of Nursing (ADON) said: -The wound should have been care planned. -The care plan should have told the staff what to do for the pressure ulcer. -The resident should have had a LAL mattress. -The order for the LAL mattress was missed. -The Wound Care Nurse should have ensured the resident had a LAL mattress on his/her bed especially if he/she was doing wound care daily. -The LAL mattress should have been on the CNA's assignment sheet. -The LAL mattress was not on the CNA's assignment sheet. Review of the resident's CNA's assignment sheet dated 2/1/24 showed: -Skin area was blank. -Assistive devices was blank. -No documentation of a LAL mattress. Review of the resident's February 2024 Physician's Order Sheet (POS) showed the following order: -Wound care nurse to assess and treat as indicated, dated 12/14/23. -LAL mattress, dated 2/1/24. During an interview on 2/2/24 at 7:45 A.M. CNA J said: -The resident did not have a LAL mattress listed on his/her assignment sheet. - The LAL mattress should have been on the assignment sheet if the Physician had ordered it. -He/She had worked with the resident and did not think he/she had a LAL mattress on his/her bed before today. During an interview on 2/2/24 at 8:00 A.M. Licensed Practical Nurse (LPN) B said: -The resident had a pressure ulcer. -The resident had been in a different room a couple of weeks ago and had a LAL mattress there. -The resident went to the hospital and when he/she came back he/she went to a different room. - The resident had a physician's order for a LAL mattress and for some reason it was not put on his/her bed when he/she was moved to a different room before today. -The resident did not get out of bed much and needed the LAL mattress to help the pressure ulcer. -The Charge Nurse should have ensured all orders were completed. During an interview on 2/5/24 at 2:00 P.M. RN/WCN A said: -The resident had a Stage III pressure ulcer. -He/She did wound treatments on the resident. -He/She did not notice there was no LAL mattress on the residents bed and should have seen that. -The resident was in the hospital for a while and when he/she came back he/she was in a different room. -The resident refused to get out of bed and should have had a LAL mattress on his/her bed but somehow that was missed. -The Charge nurse should have caught the LAL mattress order. During an interview on 2/5/24 at 2:20 P.M. the ADON said: -The resident was in the hospital from 11/7/23 to 11/28/23 and returned on 12/4/23. -When he/she came back from the hospital he/she was put into a different room. -Staff missed putting the LAL mattress on his/her bed to help with wound care. -The Charge Nurse should have ensured the order was carried over. During an interview on 2/6/24 at 12:30 P.M. the Director of Nursing (DON) said: -If a resident had a Stage III pressure ulcer and would not get out of bed, he/she would have expected a LAL mattress on their bed. -All of the beds could have been LAL mattress beds all the staff needed to do was to put the motor and attach it to the bed. -The Nurses were responsible to ensure the Physician's orders had been carried out. -The LAL mattress order should have been care planned.

Based on observation, interview and record review, the facility failed to ensure a pain patch was not left on the resident's breakfast tray for one sampled resident (Resident #105) and to ensure a nursing staff member did not leave medications in the resident's room for the resident to self-administer without a nursing staff member present for one sampled resident (Resident #19) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy titled Self-Administration of Medication dated as revised 3/8/21 showed instructions to assess residents to determine if they were capable of self-administering over-the-counter medications. 1. Review of Resident #105's care plan dated 1/24/24 showed the resident experienced pain. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/30/24 showed the following staff assessment of the resident: -Cognitively intact. -Experienced occasional pain with a pain level of eight out of ten being the worst pain level he/she experienced. Review of the resident's medical record showed no self-administration of medication assessment. Observation and interview on 1/31/24 at 9:52 A.M. showed: -The resident was lying in bed in his/her room. -A white patch without any packaging was sitting directly on the resident's breakfast tray. -The patch had writing in black marker on the side that was facing down on the tray that was difficult to read but appeared to be the date (1/31) and staff initials. -The patch was approximately one inch away from the resident's breakfast plate which still had food on it. -The resident said the nurse put some kind of cream on his/her feet and the nurse told the resident he/she was leaving the patch on the resident's tray because he/she needed to wait a little while after applying the cream before applying the pain patch. Observation and interview on 1/31/24 at 1:07 P.M. showed: -Part of a white patch could be seen on the top of the resident's right foot with the resident's sock partially covering the patch. -The resident said the nursing staff put the pain pads on his/her feet. Review of the resident's Medication Administration Record (MAR) dated January 2024 showed: -A physician's order for Capsaicin 0.025% topical cream (used to help relieve a certain type of pain known as neuralgia (shooting or burning pain in the nerves), apply topically twice a day in the morning and at bedtime every day for muscle and/or joint pain and it was administered in the morning on 1/31/24. -A physician's order for Lidocaine 4% topical patch, apply two patches topically twice daily every day to painful feet and they were administered in the morning on 1/31/24. During an interview on 2/2/24 at 8:20 A.M., Licensed Practical Nurse (LPN) C said: -He/She left an unopened Lidocaine pain patch on a resident's bedside table during the morning medication pass and stepped out in the hall to the medication cart. -He/She knew not to leave any type of medication in a resident's room without being in there and he/she should have taken it out with him/her until ready to apply it. During an interview on 2/6/24 at 12:35 P.M., the Director of Nursing (DON) said he/she would not expect the nurse to leave a pain patch out on a resident's tray unattended. 2. Review of Resident #19's admission MDS dated [DATE] showed the staff assessed the resident as moderately cognitively impaired. Review of the resident's medical record showed no self-administration of medication assessment. Observation on 1/31/24 at 12:28 P.M. showed: -The nurse was not in the resident's room. -The resident was observed holding a pill cup to his/her mouth and swallowing two medications out of the cup. -The medications included one pink, oblong pill and one white, oblong pill. Review of the resident's MAR dated January 2024 showed: -The resident was given nine medications the morning of 1/31/24. -The resident was given two 500 mg tablets of Acetaminophen (pain medication) at 12:21 P.M. on 1/31/24. During an interview on 2/6/24 at 11:00 A.M., LPN B said: -Nursing staff should not leave medications at the bedside. -Nursing staff needed to watch the resident to ensure the resident took the medications and did not choke. During an interview on 2/6/24 at 12:35 P.M., the DON said: -He/She would not expect a resident's medication to be left in the resident's room. -He/She would expect the nursing staff to watch the resident take their medication.

Based on interview and record review, the facility failed to notify the resident's physician of a change of condition, failed to notify the physician or respond to a resident's elevated blood glucose, and failed to continue to assess or monitor the resident's elevated blood glucose for one sampled resident (Resident #1). During shift change at 7:00 A.M., the resident was found clammy, lethargic, with a blood glucose (the amount of sugar in the blood) of 577 (milligrams per deciliter-mg/dl). A repeat blood glucose was 571 mg/dl. The resident continued to have a change in mental status and was discharged to home at 3:05 P.M. The resident's family member took the resident to the hospital where he/she was admitted to the Medical Intensive Care Unit (MICU) related to his/her elevated blood glucose and was in Diabetic Ketoacidosis (DKA-a serious diabetes complication where the body produces excess blood acids or ketones and occurs when there is not enough insulin in the blood), out of four sampled residents. The facility census was 41 residents. The Administrator was notified on 6/3/21 at 4:45 P.M., of an Immediate Jeopardy (IJ) which began on 5/15/21. The IJ was removed on 6/4/21 as confirmed by surveyor onsite verification. Record review of the facility's policy for Nursing Care of the Resident with Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a complete lack of insulin secretion in the pancreas or a resistance to insulin), revised February 2010, showed: -The purpose of the policy was to assist the resident in controlling his/her diabetes. -The policy was also used to assist staff in recognizing, managing and documenting the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)], (high blood sugar) included symptoms such as lethargy (a lack of energy). -Symptoms of DKA included lethargy, dehydration, weakness, decreased awareness, loss of consciousness, or coma. -If any of these conditions existed, the facility staff member was to notify the physician. -The physician was to have ordered the frequency of glucose monitoring for each individual resident. -Residents whose blood sugar was poorly controlled may have required more frequent blood glucose monitoring. -The reference range for normal blood sugars were 90-130 mg/dl before meals and less than 180 mg/dl after meals. -[CONDITION(S)] was considered anything above target reference ranges. -Documentation should have included taking the resident's vital signs as ordered, assessing the resident's level or consciousness, assessment of motor weakness, and blood sugar results/laboratory study results. 1. Record review of Resident #1's hospital laboratory report, dated 4/15/21, showed the resident's Creatinine (a laboratory indication of how the kidneys are functioning with normal ranges being between 0.84-1.21 mg/dl) was 0.94. Record review of the resident's facility Face Sheet showed the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] (cancer of the largest part of the large intestine which is a long tube-like organ in the stomach used to remove water and some nutrients and electrolytes from partially digested food). -Gastrointestinal hemorrhage (bleeding into the stomach). -Type II diabetes mellitus with diabetic [CONDITION(S)] (a complex disorder of carbohydrate, fat and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Type II diabetes mellitus with macular [CONDITION(S)] (a complication resulting from diabetes when there is a build-up of fluid in the center of the retina of the eye causing visual distortion). -Type II diabetes with diabetic [CONDITION(S)] (damage to the nerves resulting in sensory loss in the extremities). -[CONDITION(S)] disease (a neurological disease). -Bi-polar disorder (a mental disorder signified by episodes of severe depression lows to manic highs). Record review of the resident's Physician's Order Sheet (POS), dated 4/23/21, showed: -The resident was taking Glypizide (an oral antidiabetic medication) 10 milligrams (mgs) two times per day to control his/her diabetes. -There was no order present to perform any blood glucose monitoring in the resident's POS. Record review of the resident's Physician's Progress Note, dated 4/25/21, showed: -The resident had been admitted to the facility after a stay in another skilled facility followed by a hospital stay. -He/She was being admitted to the facility for rehabilitation. -He/She had [CONDITION(S)] and diabetes. -The physician's plan was to continue the previous treatment plan and monitor the resident's blood sugars. -The resident was to be a full code. -The resident was to be discharged from the facility when he/she was ready. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 4/30/21, showed the resident: -Was cognitively intact. -Required limited assistance of one staff member for bed mobility, transferring, locomotion (movement or the ability to move from one place to another) on and off the unit, personal hygiene and bathing. -Required extensive assistance of one staff member for toileting, dressing, walking in his/her room and the hallway. -Required supervision and set up by one facility staff member for eating. -Had diabetes mellitus. Record review of the resident's Nursing Care Plan for diabetes, dated 5/5/21, showed: -Accuchecks (measuring the amount of sugar in the blood using a glucometer) per physician's orders. -Encourage adequate hydration and nutrition. -Monitor labs per physician's orders. -No labs were ordered or completed. Record review of the resident's nurse's notes, dated 5/4/21 at 7:48 A.M., showed: -The resident was transferred to the toilet at 7:20 A.M. -After having a formed bowel movement, instead of the resident being able to pull himself/herself up with the grab bars, the resident began to lose his/her balance, appearing dazed, required the Certified Nursing Assistant (CNA) to assist the resident up from the toilet. -The CNA noticed the resident's lips were blue and he/she appeared very pale in color. -The CNA yelled for assistance to get the resident into his/her wheelchair. -Several other staff members came into the room and after a few minutes, the resident began to respond to verbal commands again. -His/Her vital signs were all normal. -The resident had come around completely by 7:25 A.M., and was noted to have been incontinent of another bowel movement. -The incident was reported to the physician who gave no new orders. -No blood sugars were completed. Record review of the resident's diabetes nursing care plan, dated 5/5/21, showed: -The resident's blood sugar was to remain within a normal range. -The facility staff was the check the resident's blood sugar levels per the physician's order. Note: There was no physician's order to check the resident's blood sugars. -The facility dietician was to evaluate the resident and make recommendations upon admission, quarterly and as needed. -The facility staff was to provide the resident's medications as ordered. -The facility staff was to encourage hydration and nutrition. -The facility staff was to provide a low concentrated sweets diet, monitor and document amounts consumed. Record review of the facility CNA A's investigation interview conducted by the Director Of Nursing (DON), dated 5/17/21 at 10:42 A.M., showed: -One the morning on 5/15/21 at 6:45 A.M., CNA A was walking past Resident #1's room and saw the resident slumped over in his/her chair. -CNA A went in and felt the resident, discovering he/she was clammy. -CNA A reported the incident to LPN A and LPN B, who were receiving report at the nurse's station. -The nurses went to the resident's room and he/she was still slumped over in his/her chair. -LPN B said the resident acted this way all the time due to his/her [CONDITION(S)] disease. -The nurses took the resident's vital signs and his/her blood sugar. -CNA A thought he/she heard the nurses say the resident's blood sugar was in the 500's. -Later in the day when the resident was being discharged from the facility, CNA A went outside to make sure the resident did not accidentally take the facility wheelchair home with him/her. -When CNA A went outside, he/she saw LPN A trying to hold on to the resident while trying to get him/her into the vehicle which was a truck. Record review of the facility's investigation interview with Licensed Practical Nurse (LPN) B and conducted by the DON on 5/17/21 at 10:08 A.M., showed: -On 5/15/21 at 6:45 A.M., CNA A came down the hall to inform the nurses the resident was clammy. -LPN B followed CNA A to the resident's room. -LPN B told the facility staff the resident was always confused and shaky because of his/her [CONDITION(S)] disease. -Registered Nurse (RN) A tried to get a blood sugar, but was not able to because the resident's fingers were calloused. -LPN B completed a finger stick and was able to obtain enough blood to find that the resident's blood sugar was 577 mg/dl. -LPN B did not think that blood sugar reading was correct, so he/she obtained another finger stick and got a blood sugar reading of 571 mg/dl. -LPN B did not think the machine was working correctly, because he/she had trouble with it earlier in the night shift. -The resident had been fine during the night. -The DON asked LPN B why he/she did not notify the physician, LPN B said he/she did not know the resident was diabetic. -LPN B also stated he/she was ready to leave for the day as he/she had already given report and his/her shift was over. Record review of the facility's investigation interview with LPN A conducted by the DON on 5/17/21 at 10:25 A.M., showed: -On 5/15/21 at 6:45 A.M., LPN A was in the midst of shift report when CNA A came to him/her stating that Resident #1 was slumped in his/her chair. -LPN A, RN A, CNA A and LPN B all went to the resident's room to check on the resident. -LPN B took the resident's blood sugar reading and said it was 500 something. -LPN B said the reading could not be right, because the resident had nothing to eat or drink during the night. -LPN A began backing out of the resident's room as everyone was gathered around the resident and he/she could not focus. -Everything started hitting him/her all at once and LPN A did not know what to do at that point. -He/She then went back in the resident's room after the other nurses had left and found the resident sitting up and talking without difficulty, but the resident was still clammy. -By the time LPN went back to assess the resident again, around 3:00 P.M., he/she was told the resident was being discharged and the resident's family was outside waiting. -LPN A said he/she should have followed his/her gut instinct and reassessed the resident, but he/she did not. -At 3:00 P.M., LPN A said the resident was happy and showed no signs of distress when he/she was escorting the resident to the car for discharge. -At around 5:00 P.M., LPN A got a phone call from the hospital regarding the care the resident had received. -LPN A told the hospital nurse the resident's blood sugar had been in the 500 mg/dl range. -When the DON asked LPN A why he/she did not notify the physician when the resident's blood sugar was in the 500 mg/dl range, LPN A stated he/she did not know why he/she had not notified the physician. -LPN A stated he/she did not know a lot about the resident, but wished he/she had followed his/her gut instinct. Record review of the facility's investigation interview with RN A conducted by the DON on 5/17/21 at 10:20 A.M., showed: -On the morning on 5/15/21 at 6:45 A.M., CNA A came to RN A to tell him/her the resident was clammy. -RN A asked if they needed to take the resident's blood sugar. -RN A went to the resident's room along with CNA A, LPN A and LPN B. -RN A heard LPN B say the resident normally acted that way. -RN A attempted to get a blood sugar, but could not get any blood. LPN B was able to get blood and the resident's blood sugar read 577 mg/dl. -RN A did not think that reading could have been correct, so they did another blood sugar and got 571 mg/dl. -RN A said he/she did not notify the physician, because he/she was not responsible for that resident as he/she had a different group of residents. -RN A thought LPN A would have called the physician since the resident was his/her responsibility. Record review of the facility's investigation written statement from the DON dated 5/17/21 at 11:08 A.M., showed: -On the afternoon of 5/15/21, he/she was notified by the concierge of Resident #1's family member coming to the facility to pick up the resident to be discharged home. -The DON notified LPN A the resident was being discharged and the DON was getting the resident's paperwork together. -At 3:00 P.M., the DON took the paperwork to the resident's family member for a signature of the discharge summary as the family member was the resident's Durable Power of Attorney (DPOA-the person designated to made decisions for another person when they are not physically or mentally able). -Around 5:00 P.M., LPN A approached the DON stating he/she had gotten a call from the hospital stating the resident had been admitted to the hospital with diabetic ketoacidosis. -The DON asked LPN A why he/she had not informed the DON about the resident's blood sugars prior to allowing the resident to be dismissed. -LPN A stated the resident was having trouble standing, so the family member stated that he/she was going to take the resident directly to the hospital. -At that point, CNA A came to the nurse's station where the discussion was taking place and stated that he/she had told them the resident had been clammy and did not look good that morning. -At 6:30 P.M., the DON got a phone call from the resident's family member who informed him/her the resident had been taken to the ICU because he/she had DKA. -The resident had an indwelling catheter (a tube inserted into the bladder used to drain the urine) placed because he/she was going into acute [CONDITION(S)] (the inability of the kidneys to excrete waste, concentrate urine and preserve electrolytes). -The family member informed the DON that he/she had been told by someone from the facility the resident's blood sugar reading had been 539 mg/dl. -The DON told the family member the facility would not have discharged the resident with a blood sugar that was so high. -The family member then asked the DON what the resident's blood sugars had been and upon looking the blood sugar readings up in the computer, none were found to have been documented. -The DON then went to LPN A to ask what the resident's blood sugar had been, to which he/she replied it was 539 mg/dl. -The DON then asked LPN A why he/she had not informed the DON of the situation as the DON could have taken care of the situation and not discharged the resident. -LPN A stated he/she did not know the resident and was really busy and did not get a chance to see the resident again during the shift until he/she was told by the DON the resident was being discharged . -The DON and house supervisor then spoke with LPN A to educate him/her on physician notification of resident changes in condition to which LPN A verbalized understanding. -On the evening of 5/16/21 the DON received information that the resident's blood sugar had actually been 571 mg/dl. Record review of the resident's facility nurse's notes, dated 5/15/21 at 3:47 P.M., showed: -The resident's oxygen saturation (the measurement of the amount of oxygen in the blood) was 99% on room air. -Note: This was the only facility documentation for 5/15/21 and the resident had already been dismissed from the facility when the nurse's note was written. Record review of the resident's hospital physician's progress note, dated 5/15/21 at 3:15 P.M., showed: -The resident was placed on a continuous Insulin drip at 2 mg per hour and intravenous (administered within the vein)(IV) fluids due to the resident presenting in the ED with a blood sugar per blood draw of 655 mg/dl. Record review of the hospital physician's Progress Note, dated 5/15/21 at 8:08 P.M., showed: -The resident had presented to the hospital Emergency Department (ED) in DKA. -The resident's family member reported to the ED physician that the resident was usually alert and oriented. -The family member stated he/she picked the resident up from the skilled facility where the resident had been staying and the facility staff reported to the family member the resident had been clammy, disoriented/lethargic all day, but was dismissed from the facility anyway. -Due to the concern by the resident's family member regarding his/her condition, the family member brought the resident directly to the hospital. -The resident's blood sugar was tested in the ED and showed to be 562 mg/dl. -The resident was admitted to the MICU. -The resident showed blood sugars below 200 mg/dl once the resident had been on the insulin drip at two units per hour. -The resident also showed an acceleration in his/her renal disease (a compromise in the kidney's ability to filter out waste appropriately) showing a Creatinine of 8.4 which had previously been 0.9. Record review of the hospital physician's progress note, dated 5/16/21, showed: -The resident's Creatinine had increased to 9.0. -He/She required hemodialysis (a process of cleansing the blood by passing it through a special machine-necessary when the kidneys are not able to filter the blood). During an interview on 6/2/21 at 4:08 P.M., CNA B said: -He/She worked as a CNA and a Restorative Aide and had frequently worked with the resident. -On 5/13/21, he/she cared for the resident. -That morning, the resident was able to assist with getting dressed, walked with a walker and stand by assistance to the bathroom, and pulled himself/herself up from the toilet. -Later in the day on 5/13/21, CNA B assisted the resident to the bathroom and he/she was much weaker. -The resident was no longer able to pull himself/herself up from the toilet and he/she had very little energy. He/She mentioned his/her concern to the charge nurse that day (he/she could not recall which charge nurse), but there did not seem to be a concern on the part of the nurse. -He/She had cared for the resident on the day the resident arrived at the facility and said that he/she observed the resident ambulating without any assistance to the bathroom and at that time reminded the resident he/she needed to call for help as he/she was at risk for falling. During an interview on 6/3/21 at 11:00 A.M., CNA A said: -He/She used to work the night shift and was very familiar with the resident. -The resident had previously been walking to the bathroom and getting in and out of bed by himself/herself even though he/she should have obtained assistance. -On the morning of 5/15/21, he/she was coming onto the unit and he/she observed the resident leaning out of his/her chair. -He/She went in to the resident's room, and noticed the resident was clammy, sweaty, pale in color, and just did not look right. -He/She had been a CNA for over [AGE] years and he/she knew when a resident had something wrong. -CNA A went straight to the nurse's station to report the resident's issues. -The nurses accompanied CNA A to the resident's rooms the nurses could assess the resident. -RN A took over the vital signs and the resident's blood sugar was over 500 mg/dl. -The resident appeared to be somewhat different throughout the day, not eating well and unable to stand himself/herself up in the bathroom. -The resident's family member called and he/she spoke with the family member telling him/her that the resident was not looking very well. -The resident's family member said he/she was taking the resident to the doctor to get on some [CONDITION(S)] mediation, and that was likely what was wrong. -He/She assisted in getting the wheelchair back into the facility when the resident was dismissed later in the afternoon. -He/she noticed LPN A having difficulty getting the resident into the vehicle so he/she assisted and asked the resident's family to assist also. -At that time, CNA A mentioned to the family member that he/she still did not think the resident looked right. -LPN A did not say much to the family member except for explaining the resident's discharge medications. During an interview on 6/1/21 at 12:45 P.M., LPN A said: -He/She was not very familiar with Resident #1. -He/She had only seen him/her two to three times before 5/15/21. -On 5/15/21 at 6:45 A.M., he/she was getting report when CNA A came to him/her stating the resident was slumped in his/her chair and was not responding to him/her. -RN A, CNA A and LPN B, all went to the resident's room to check on the resident while LPN A obtained a blood pressure cuff and glucometer. -The glucometer showed error and it took two to three times to get the glucometer to work correctly. -LPN B took the resident's blood sugar reading and said it was 500 something and they did not think the glucometer was working correctly. -LPN A was concerned the resident's blood pressure was low. -He/She did not know the resident was diabetic. -RN A and LPN B just blew off the blood sugar and low blood pressure. -RN A did not call the physician and LPN A thought he/she was going to make the call. -The resident seemed okay later in the day, but then when he/she was attempting to put the resident into the car to go home he/she had issues getting him/her into the car and LPN A wondered if he/she had missed something with the resident. -Later in the day, LPN A got a phone call from the hospital stating the resident was in the ICU with diabetic ketoacidosis. -5/15/21 was LPN A's first day taking care of this resident. -When he/she found out the resident was going home, the DON had arrived and did the resident's discharge paperwork while LPN A gathered his/her belongings. -Later on 5/15/21, CNA A said he/she had been concerned about the resident and thought something was not right with him/her. During an interview on 6/1/21 at 2:10 P.M., LPN B said: -He/She had given report to LPN A when CNA A said the resident was clammy and losing his/her balance. -The resident had [CONDITION(S)] disease and LPN B always saw the resident that way. -He/She went to the resident's room and assisted in obtaining the resident's blood sugar. -The resident's blood sugar was 500 something so he/she repeated the blood sugar and it was 521 mg/dl. -The resident was then alert and acting normally. -He/She took care of the resident many times and he/she did not see any difference than how the resident usually was during the night shift. -He/She did not feel the blood sugar was correct and since he/she had already given report, he/she expected the day shift, LPN A to notify the physician. During an interview on 6/1/21 at 2:55 P.M., the DON said: -The resident's family member had a sports utility vehicle when he/she picked the resident up to go home. -The DON believed they had problems getting the resident into the vehicle because it was high off the ground and the resident was in a wheelchair. -He/She gave the discharge paperwork to the family member and the resident did not appear lethargic. During an interview on 6/2/21 at 10:25 A.M., RN A said: -On the morning on 5/15/21, he/she came out of report and CNA A came to RN A to tell him/her that Resident #1 was having a [CONDITION(S)]. -It took several times to get the resident's blood sugar due to callusing and he/she thought it read around 275 mg/dl, but in fact it was 571 mg/dl. -The facility staff took the blood sugar again and it was 500 something. -RN A and LPN A had divided up the residents earlier and RN A was not in charge of Resident #1. -RN A said he/she did not notify the physician, because he/she was not responsible for that resident as he/she had a different group of residents. -RN A thought that LPN A would have called the physician since that resident was his/her responsibility. -RN A did not see the resident the rest of the day. -He/She heard LPN B say when they were in the resident's room the resident always acted like this as he/she had [CONDITION(S)] disease, so RN A did not really think anything of it. -If he/she had been in charge of the resident, he/she would have immediately notified the physician, DON, and resident's family. -If he/she had a question as to whether the glucometer was working properly, he/she would have checked to see if the machine had been correctly calibrated and if he/she still had a question, he/she would have obtained a different glucometer. -He/She was not aware the resident had diabetes as he/she was not familiar with the resident. During an interview on 6/2/21 at 10:55 A.M., the DON said: -If he/she had been notified of the incident with the resident on 5/15/21, he/she would have immediately notified the physician. -LPN A should have called the physician, family, and DON to report the change in condition. -He/She would have expected LPN A to closely monitor the resident through the day and that the resident not have been discharged from the facility. During an interview on 6/3/21 at 11:36 A.M., the resident's family member said: -He/She confirmed it was his/her assessment that the resident needed to go to the hospital. -The resident could not stand up and he/she usually could. -It took three people helping and the resident still could not stand up when attempting to get him/her into the vehicle. -One of the CNAs said take the resident to the hospital. -The resident's color did not look right. -The resident's voice was weak and very faint which was not like his/her usual voice. -When the resident was asked if he/she was feeling alright or ok, the resident produced a whisper of yeah. -The resident's coloring was pale. -The nurse (LPN A) did not say much to the family member other than to provide the resident's discharge paperwork and speak about his/her medications. -Once the resident was gotten into the vehicle, the family member took the resident straight to the hospital. During an interview on 6/1/21 at 2:45 P.M., the resident's physician said: -He/She knew the whole unfortunate story regarding the resident. -He/She was not on call that day, but he/she knew the Nurse Practitioner (NP) had not gotten a call regarding the resident's high blood sugar. -He/She would have expected the facility nurse to notify him/her of the high blood sugar. -He/She did not know why they did not notify the NP. -The last he/she knew, the resident was still in the hospital ICU. During an interview on 6/2/21 at 9:05 A.M., hospital medical intensive care unit (MICU) nurse manager said: -The resident was currently getting [CONDITION(S)] while remaining in the MICU. -The resident had been getting an insulin drip until very recently. -The resident was currently at a [CONDITION(S)] treatment, but was not able to answer questions well anyway due to the severity of his/her condition. During an interview on 6/2/21 at 11:30 A.M., the resident's physician said: -Had he/she been notified of the resident's high blood sugar level, he would have attempted to treat the resident there with insulin, close monitoring, and lab work. -If the resident continued to be symptomatic, he/she would have sent the resident to the hospital after getting the approval of the resident's family. -He/She did not order blood glucose monitoring for the resident in the facility and that was an oversight on his/her part. -He/She would have never sent the resident home as the resident was not stable medically. During an interview on 6/2/21 at 2:40 P.M., the MDS Coordinator said: -He/She had completed the resident's MDS and Nursing Care Plans: -He/She knew the resident was diabetic from his/her history that was sent to the facility from the previous facility and hospital records. -He/She created the diabetes care plan because the resident's medical history indicated it was necessary. During an interview on 6/2/21 at 3:15 P.M., the DON said: -He/She thought the facility staff was so focused on the resident's [CONDITION(S)] Disease, that they did not think about the resident's diabetes. -He/She would have expected that the staff know the resident was diabetic and acted accordingly by calling the physician when the resident's blood sugar was discovered to be so elevated. During an interview on 6/2/21 at 4:43 P.M., hospital RN B said: -The resident arrived to the hospital requiring two nursing staff to dead lift him from his/her wheelchair. -When he/she asked the family member how the resident had gotten into the car, the family member said he (the family member) was strong. -The resident was somnolent (sleepy or drowsy) and somewhat confused. -The resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -At the facility the resident was on an oral anti-diabetic medication. -The facility was not checking the blood sugars as reported by the LPN A as there was no physician's order. -The facility nurse said they had done a random blood sugar check on 5/15/21 and the meter read greater than 500. -Hospital RN B said he/she had talked to a few people at the facility and they decided the monitor was broken and sent the resident home, even though the resident was having more episodes of spacing off and the facility were attributing it to new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility staff reported to hospital RN B that the resident normally would get up with a standby assist of one staff member. -Hospital RN B said that the blood sugars were not addressed at all, the resident's change in condition was not addressed, nor was the resident's change in level of consciousness. -The resident's family member was not instructed to take the resident to the hospital. -LPN A when notified, was surprised the resident's family member took the resident to the ED. -The resident having gone from needing staff assistance of one person to needed staff assistance of two to three people was a reason to call an ambulance. -A person having a blood sugar greater than 500 mg/dl was a reason to call an ambulance. -The resident ended up on [CONDITION(S)] and treated with an insulin drip in the MICU and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] -When the resident originally discharged to the facility he/she had a Creatinine of 0.9 which was normal. -The resident was unable to verbalize that he/she knew his/her name or knew where he/she was. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation to a D level at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. 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. MO 377