Every finding on record at Blue Circle Rehab and Nursing

Based on observation, interview and record review, the facility failed to ensure residents were transferred in a safe manner and in accordance with accepted standards of practice, manufacturer guidelines, and facility policy. This failure was evidenced by improper mechanical lift use, unsafe physical assistance without required transfer devices and inadequate care planned direction for one resident (Residents #17). The facility also failed to maintain mechanical lift equipment in safe working condition for one resident (Resident #63). Facility staff failed to apply a gait-belt around the abdomen of a resident who was unbalanced at the time of transfer (Resident #44). The facility staff failed to remove bug spray in a room that housed two residents (Residents #20 and #62). The sample size was 16. The census was 65. Review of the facility's Mechanical Lift policy, dated 11/18/10, showed: -When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient;-During transfer, with patient suspended in a sling attached to the patient lift, do not roll caster base over objects such as carpet, raised carpet bindings, door frames, or any uneven surfaces or obstacles that would create an imbalance of the patient lift and could cause the patient lift to tip over. Use steering handle on the mast at all times to push or pull the patient's lift. 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/08/26, showed:-Cognitively intact;-The resident has upper and lower body impairment;-Dependent on staff for chair to be and bed to chair transfers;-Diagnoses included diabetes, heart disease, and kidney failure. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident has activities of daily living (ADL) self-care performance issues, related to obesity, limited mobility, and left below the knee amputation (BKA);-Interventions: Offer to assist the resident out of bed approximately 10:30 A.M.as preferred by the resident.-The resident care plan did not address the resident's transfer status or type of equipment to be used during transfers. Observation on 08/24/26 at 10:47 A.M., showed the resident lay in bed. Certified Medication Technician (CMT) D and Certified Nursing Assistant (CNA) C placed the Hoyer (full body mechanical lift) pad under the resident. CNA C applied the loops of the Hoyer pad to the lift. The resident was lifted out of his/her bed. CMT D operated the lift while CNA C guided the resident. The resident was propelled to his/her Broda chair (a specialized chair) out into the hall with the Hoyer lift legs closed. CMT D did not adjust the Hoyer lift legs to the open position during the transfer. During an interview on 08/27/26 at 2:40 P.M., CNA E said the Hoyer lift legs should be open to the widest position when moving a resident. It is to ensure safety for the resident and to provide stability and balance during the transfer. During an interview on 08/28/26 at 2:01 P.M., the Director of Nursing (DON) said she would expect the staff to use the Hoyer lift correctly while transferring residents. That would include ensuring the safety of the resident by having the Hoyer lift legs spread at its widest point while the resident is being propelled. The resident's care plan should reflect that the resident uses a Hoyer lift for transfers. 2. Review of Resident #63's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent assistance with ADLs (requires two employees to assist with personal hygiene, meals, and transfers);-Incontinent of bowel and bladder;-Wheelchair and motorized wheelchair;-Diagnoses: Stroke, kidney disease, seizures (imbalance of electrical pathways), paralyzed one side of the body, and diabetes. Review of the resident's care plan, last updated 09/25/25, showed-Focus: Has an ADL self-care performance deficit related to (r/t) activity intolerance, fatigue, disease process, health status, seizure, diabetes, anemia, stroke, kidney disease, generalized weakness. Requires staff assistance for completion of ADLs. Self-performance varies at times. Assistance for completion of ADLs;-Desired outcome: Will continue to have aspects of care met daily; remaining clean, dry, dressed, groomed and free of odors;-Interventions: Mechanical lift use with assist of two staff. Review of the resident's physician order sheets (POS), dated 09/25/25, showed:-No orders r/t to transfer status. Observation on 08/24/26 at 11:44 A.M., showed CNA H left to obtain a second person for a transfer. At 11:47 A.M., CNA H returned with CNA I. CNA H and CNA I placed a Hoyer pad under the resident. CNA I pressed the remote to lift the resident up out of bed. CNA H guided the resident by the sling. CNA I pressed down the lever to open the legs of the Hoyer. The legs/base of the Hoyer remained at the standard closed position. The resident was suspended in the air, and CNA I had to kick the legs to open/widen the lift to fit around his/her motorized wheelchair. When CNA I lowered the resident into the seat, the Hoyer lift very slowly lowered the resident. During an interview on 08/24/26 at 11:57 A.M., CNA I said the Hoyer lift always stuck when opening the legs. Sometimes times staff had to kick the legs, for them to open/widen. The Hoyer lift always ran this slow, and at times it could cause problems. During an interview on 08/28/26 at 8:37 A.M., the Maintenance Director said maintenance staff did weekly and monthly repairs to the mechanical lifts, but staff did not document these repairs. During an interview on 08/28/26 at 1:37 P.M., Licensed Practical Nurse (LPN) A said he/she heard the Hoyer run slower when not charged. He/She was unaware staff needed to kick the legs open. Staff need to notify the DON or the maintenance department about repairs needed. During an interview on 08/28/26 at 2:01 P.M., the DON said it was a safety hazard for staff to kick open the legs of a mechanical lift while a resident was suspended in the air. The DON expected staff to complete a work ticket, along with the Hoyer lift being taken out of service. During an interview on 08/28/26 at 2:01 P.M., the Administrator said CNAs should place a work order in the maintenance binder. The maintenance department should document and make a comment about what repair was made. The Administrator said this was a safety concern when staff kick the legs of the Hoyer lift open. The Administrator expected staff to complete a work order, along with the Hoyer lift being taken out of service. 3. Review of the facility's Gait Belt policy, undated, showed:-Protocol: Utilize proper body mechanics when performing resident transfers;-Procedure: Identify the resident, explain the procedure, and provide privacy; Review the Kardex (a care plan that shows specific nursing tasks) for the number of staff required for transfer assistance; Transfer the resident using proper body mechanics and document all pertinent observations in the nurses' notes. Review of Resident #44 quarterly MDS, dated [DATE], showed:-Cognitively intact;-Requires supervision or touching assistance; The helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently for lying to siting, sitting to standing, chair to bed and bed to chair transfers;-No rejection in care;-Uses a wheelchair and walker;-Diagnoses included diabetes, depression, paraplegia (partial or complete paralysis of the lower body) and fracture of the musculoskeletal (muscle and bone) system. Review of the resident care plan, in use at the time of survey, showed,-Focus: The resident is at risk for falls related to activity intolerance, disease processes, fatigue, impaired balance and limited mobility;-Interventions: Encourage the resident to be compliant with staff for assistance with transfers.-The resident's care plan did not address the resident's transfer status or equipment that staff is to use during transfers. Review of the resident's medical records showed diagnoses that included injury of the spine, difficulty walking, and muscle weakness. Observation and interview on 08/24/26 at 9:55 A.M., showed the resident lay in bed. The resident requested to get out of bed. CNA C asked the resident, How do you get out of bed? The resident said, I just need a little help. CNA C assisted the resident from supine (flat) to sitting on the edge of the bed by holding the resident's shoulders. The resident had a gait belt located on his/her nightstand next to his/her bed and one on the sink countertop. CNA C removed the gait belt off of the resident's sink countertop and started to apply the gait belt around the resident. The resident said, I'm not using that belt. CNA C said, Okay. CNA placed the gait belt on the resident's bed. CNA C positioned the resident's walker and manual wheelchair next to the resident's bed. The resident pulled on the walker and CNA C assisted the resident by holding the resident under his/her left arm. The resident stood up in a hunched positioned and shuffled to his/her wheelchair and sat down. The resident's gait was unsteady. CNA C did not use a gait belt while assisting the resident. During an interview on 8/27/26 at 2:40 P.M., CNA E said a gait belt should be used anytime the resident required hands on assistance during transfers. If the resident refused the gait belt, the staff member should provide some education and let the DON know the resident refused staff to utilize the gait belt. During an interview on 8/28/26 at 2:01 P.M., the DON said staff are expected to use the gait belt anytime the staff assist with resident transfers. The gait belt was to ensure safety for the resident and the staff. She would expect staff to educate the resident on gait belt use and let her know the resident refused to use a gait belt. The care plan was expected to have the resident's transfer status and if a gait belt is to be used. 4. Review of the facility's Accident and Incidents Protocol policy, revised March 2025, showed:-Protocol: -The facility strives to maintain a safe, clean and comfortable homelike environment to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/ incident);-The facility defines an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome;-The event may be an accident or a situation that could result in an accident. Accidents/incidents may include, but are not limited to, the following: -Resident/ patient to resident/ patient abuse/assault;-Self- inflicted injury; -Injury to resident/ patient during handling;--Should an accident/ incident occur, the facility strives to prevent such an occurrence from happening again;--An accident/ incident can occur anywhere, be discovered by anyone, and happen to anyone. Review of Resident #62's admission MDS, dated [DATE], showed:-Moderately impaired cognition;-Upper extremity: impairment on one side;-Lower extremity: impairment on both sides;-Mobility device: Wheelchair;-Diagnoses included metabolic encephalopathy (chemical imbalance that affects the brain), acute respiratory failure with hypoxia (low oxygen), cognitive communication deficit, dysphagia (difficulty in swallowing) and muscle weakness. Review of Resident #62's care plan, in use during the survey, showed:-Focus: Cognition: The resident has impaired cognitive function/dementia or impaired thought processes r/t Impaired decision making;-Goal: The resident will be able to communicate basic needs on a daily basis through the review date;-Interventions: Cue, reorient and supervise as needed. Review of Resident #62's care plan, in use during the survey, showed no mention of the resident's ability to have bug spray in his/her room. Review of Resident #62's electronic POS dated 08/31/26, showed no order for the resident to have bug spray in his/her room. Review of Resident #20's annual MDS, dated [DATE], showed:-Intact cognition;-Upper extremity: impairment on one side;-Lower extremity: impairment on one side;-Mobility device: Wheelchair;-Supervision or touching assistance only from staff with eating;-Diagnoses included hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), high blood pressure, cognitive communication deficit, dysphagia, muscle weakness, and major depressive disorder. Review of Resident #20's care plan in use during the survey showed:-No mention of the resident's ability to have bug spray in his/her room. Review of Resident #20's POS dated 08/31/26, showed no order for the resident to have bug spray in his/her room. Observations of Resident #62's and Resident #20's shared room showed:-On 08/23/26 at 10:50 A.M., Resident #20 sat in his/her wheelchair in his/her room. Resident #62 was out of the room. A bottle of bug spray sat on Resident #62's bedside table; -On 08/24/26 at 10:47 A.M., Resident #20 lay in his/her bed. Resident #62 was out of the room. A bottle of bug spray sat on the sink counter; -On 08/25/26 at 10:39 A.M. and 12:36 P.M., Residents #20 and #62 were out of the room. A bottle of bug spray sat on the sink counter;-On 08/26/26 at 8:21 A.M., Resident #20 sat in his/her wheelchair inside his/her room. Resident #62 was out of the room. The bottle of bug spray sat on Resident #62's bedside table;-On 08/27/26 at 8:21 A.M., Resident #62 sat in his/her wheelchair inside his/her room. Resident #20 was out of the room. The bottle of bug spray sat on the sink counter;-On 8/28/26 at 6:46 A.M., Residents #20 and #62 were both sleep in their beds in their room. The bottle of bug spray sat on Resident #62's bedside table. During an interview on 08/26/26 at 8:21 A.M., Resident #20 said the bug spray may belong to Resident #62. It was for the flies. There were a lot of flies there. There were many in the dining room probably because the door was open. It's summertime, so there were a lot of flies everywhere. During an interview on 08/27/26 at 8:21 A.M., Resident #62 said the bug spray was his/hers. Sometimes there have been little flies in his/her room. He/She didn't like that, and he/she had food in his/her room; During an observation and interview on 08/28/26 at approximately 7:45 A.M., LPN A said there should not have been bug spray in the residents' room. He/She had not seen the bug spray prior to this. If he/she had seen it, he/she would have removed it because it shouldn't be on the hall. He/She looked in the residents' room at that time and observed the bottle of bug spray. There was a staff person in the room with Resident #62. LPN A said he/she was able to look at the bottle of bug spray and was able to tell it wasn't the facility's bottle. The resident's family member must have brought the bottle in. It still shouldn't have been there. It was a risk. It was chemicals. They couldn't have it in the room. At 7:52 A.M., LPN A said he/she was going to remove the spray. He/She entered the residents' rom and removed the spray at that time. During an interview on 08/28/26 at 2:01 P.M., with the Administrator and the DON, the DON said there should not have been bug spray in the room. It should have been removed. The Administrator said anyone could have gotten ahold of the bug spray. During an interview on 09/02/26 at 10:18 A.M., the Administrator said it's not in the policy to allow bug spray to be kept or used in residents' rooms due to safety regulations, respiratory risks and fire hazard. 31689243168773

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for two residents (Resident # 44 and Resident # 27) and in a common area that residents congregate. The sample size was 16. The census was 65. Review of the facility's Pest reporting and Management policy, undated, showed:-Purpose: to maintain a safe, sanitary, and pest-free environment for residents, staff, and visitors; Early detection and structured communication prevent infestations, minimize health risks, and ensure compliance with state at federal long-term care regulations.-Policy: All facility employees have a duty to report any suspected or confirmed pest activity immediately. Review of the facility's pest log, dated June, July, and August 2026 showed no documentation that files were reported as a problem in the facility. 1. Review of Resident #44's medical record, showed diagnoses included injury of the spine, difficulty walking, and muscle weakness. Observation and interview on 08/23/26 at 8:28 A.M., showed the resident lay in bed. The resident was swatting flies with the fly swatter that were on his/her bedside table. The resident said the flies were everywhere and were just terrible. 2. Review of Resident # 27's medical record, showed diagnoses included bladder cancer, diabetes and stroke. Observation and interview on 08/27/26 at approximately 5:00 P.M., showed the resident sat on the side of his/her bed eating a meal. Three files landed on the resident's food while he/she was eating, and the resident swatted the flies away with his/her hand. The resident said the flies were really bad. 3. Observation on 8/25/26 at 3:50 P.M., showed a sitting area located between the smoking area door and the front entrance of the building contained a couch along one wall and a loveseat along the opposite wall. Approximately seven to eight flies were observed flying around the loveseat, and four to five flies were observed on the couch. A bug zapper mounted above the loveseat was observed unplugged. Multiple residents were sitting in wheelchairs in the sitting area. During an interview on 08/27/26 at 10:30 A.M. Licensed Practical Nurse (LPN) L said, someone would have to be blind not to see how many flies are in the building. LPN L said he/she told the maintenance staff verbally about the flies. 4. During an interview on 08/28/26 at 2:01 P.M., the Administrator said she would expect staff to utilize the pest control log and report the fly problem to the appropriate staff so it would be taken care of. She would expect the bug zapper to be plugged in and always turned on. She would expect the residents to have a pest free environment. 28094113050850

Based on observation, interview and record review, the facility staff failed to treat residents with dignity while assisting one resident while eating (Resident #30) The sample was 16. The census was 65.Review of the facility's Resident Rights and Dignity policy, last reviewed January 2024, showed:-Protocol: The facility will address ethical issues and respect resident rights in providing care; the facility recognizes the resident right to quality of life that supports privacy, confidentiality, dignity, independent expressions, choice, and decision making, consistent with state law ad federal regulation;-Procedure: Treat all residents in a dignified manner. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/11/26, showed;-Severe cognitive impairment;-Requires supervision or touching assistance with eating;-Diagnoses included schizophrenia (a mental condition that distorts reality), Alzheimer's disease, malnutrition (poor nutritional status) and depression. Review of the resident's care plan, in use at the time of survey, showed:Focus: The resident has an activities of daily living (ADL) self care deficit related to Alzheimer's' disease, malnutrition, schizophrenia, limited mobility and activity intolerance;Interventions: The resident likes to sit in his/her chair in the semi-reclined position and often uses his/her fingers to eat; Encourage the resident to sit upright and use utensils; Assist as needed. Observation on 08/24/26 at 8:20 A.M., showed the resident sat in a Broda chair (specialized recliner) with a bed side table positioned across him/her in the main dining room. There were no staff supervising the resident. The resident ate scrambled eggs with his/her hands. The resident coughed while he/she was eating his/her scrambled eggs and drinking apple juice with a straw. At 8:25 A.M., Certified Medication Technician (CMT) D approached the resident and asked him/her what was wrong. The resident did not answer and continued to cough. The CMT informed the resident to Hold on and that he/she needed to get some gloves on. CMT D applied gloves and stood in front of the resident and assisted him/her with eating. At 8:40 A.M. CMT D continued to stand in front of the resident and fed the resident with gloved hands. At 8:46 A.M. CMT D asked the resident if he/she was done eating and removed the resident's breakfast tray. CMT D then removed his/her gloves. CMT D stood in front of the resident while assisting the resident eat during the entire meal service. During an interview on 08/27/26 at 2:40 P.M., Certified Nursing Assistant (CNA) E said staff should sit with the resident at eye level and not wear gloves while assisting the residents to eat. It is a dignity issue. Staff should always show the resident dignity and respect. During an interview on 08/28/26 at 2:01 P.M., the Director of Nursing (DON) said she would expect staff not to stand and wear gloves while assisting the resident to eat. The resident usually fed him/herself, and she wasn't sure why the staff were assisting him/her. All staff were expected to treat residents with dignity and respect. 28094113172487

Based on observation, interview and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADLs) and ensure residents maintained personal hygiene for three of 16 sampled residents. Residents #57 and #7 were observed being left soiled for extended period and Resident #1 was observed with soiled fingernails and not receiving assistance with meals. The census was 65. Review of the facility's Personal Care Needs policy, revised date 1/2024, showed:-Protocol: The facility will provide the needed support when the resident performs their ADLs. The interdisciplinary plan of care will address the individual needs and preferences of the residents. Personal care in ADL support will be provided according to the resident care plan. Personal care and support include but is not limited to the following:--Assistance with meals;--Grooming/dressing;--Peri care;--Nail care;--Toileting;-Procedure:--Complete interdisciplinary admission/observations in the Electronic Health Record (EHR) and identify the individual needs and/or preferences of the resident;--Develop and implement individualized interventions; document on individual resident care plan;--Communicate interventions to the staff and provide training as needed;--Observe compliance with individualized interventions during daily rounds and monitor resident outcomes;--Unless otherwise identified by the resident Plan of Care (POC) or preference, when assisting/feeding a resident with meals staff should be seated in a chair and not standing over the resident;--Document in the progress notes if an exception to the established plan of care occurs i.e.: refusals. 1. Review of Resident #57's care plan, revision dated 02/26/25, showed:-Focus: The resident has an ADL self-care deficit related to (r/t) activity intolerance, confusion, disease process, fatigue (exhaustion), hemiplegia (one side unable to move), impaired balance, limited mobility, stroke, dysphagia (immobility to swallow). Requires staff assistance for completion of ADLs. Self-performance varies at times; -Desired outcome: Will continue to have aspects of care met daily; remaining, clean, dry, dressed, groomed and free of odors;-Interventions: Staff to assist with completion of ADLs on a daily basis; ensure needs are met daily;-Focus: The resident refuses/is resistive to care in the following manner/area(s): refuses ADL care/assistance, refuses grooming assistance, appears disheveled/odorous, refuses medication, refuses oral care, refuses safety interventions, refuses to change clothing regularly, refuses treatment, refuses/resists incontinence care, to wear shoes;-Desired outcome: The resident will cooperate with care;-Interventions: Attempt to determine preferred times for ADLs, preferred time for bathing/showering, changing clothing, etc. Alter schedule to accommodate residents' preferred time, if possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed time if residents are resistive with ADLs, reassure resident, leave and return later and try again;-Focus: Risk for Impaired Skin Integrity: malnutrition, dryness, bruises easily, history of skin tear d/t fragile skin condition, abnormal labs, decreased circulation/oxygenation, vitamin deficiency, mood/behavior status, at risk for malnutrition, incontinence risk.;-Desired outcome: risks associated with skin integrity will be minimized;-Interventions: Monitor skin for changes and report adverse findings to medical doctor for follow-up and treatment. Review of the resident's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/01/26, showed:-admission date: 11/25/22;-Severely impaired cognition;-Dependent on staff for assistance with ADLs;-Incontinent of bowel and bladder;-Diagnoses included stroke, dementia. Observation on 08/24/26 at 8:45 A.M., showed the resident lay in bed in his/her room. The resident had a strong smell of urine. Certified Nursing Assistant (CNA) G rolled the resident towards CNA F to apply a new brief. The resident's brief was saturated with a strong smell, along with a brown ring on the linen pad. CNA G discarded the soiled linen and applied a clean brief. During an interview on 8/24/26 at 8:45 A.M., CNA F said he/she went to change the resident because he/she had not been cleaned up. The brown ring could happen if the urine was already dark and/or several hours had passed without the resident being changed. During an interview on 08/24/2026 at 08:45 A.M., CNA G said the dark ring on the linen could have been from the wound drainage on the left hip, or urine that had dried. During an interview on 08/28/2026 at 2:01 P.M., the Director of Nursing (DON) said a brown ring on the linen could have meant the resident was left wet for an extended amount of time or the resident had discolored urine. 2. Review of Resident #7's care plan, revision dated 01/29/24, showed-Focus: Resident has incontinence related to confusion, disease process, and history of urinary tract infection;-Goal: Risks of complications associated with incontinence episodes will be minimized through review date;-Interventions: Check and change as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Review of the resident's quarterly MDS, dated [DATE], showed:-admission date: 01/25/24;-Intact cognition;-Substantial/maximal assistance (helper does more than half the effort) with all ADLs including toileting hygiene;-Incontinent of bowel and bladder;-Diagnoses included: Lumbar spinal stenosis (lower back pain), congestive heart failure, venous insufficiency (swelling in legs or ankles). Observation on 08/25/2026 at 09:22 A.M., showed the resident sat at a table in his/her wheelchair and drank coffee in the dining room. At 10:15 A.M., the resident remained seated at the same table in his/her wheelchair. At 12:20 P.M., the resident remained seated at the same table in his/her wheelchair. A puddle of liquid was observed on the floor beneath the wheelchair. The puddle had a rounded area beneath the wheelchair and extended in a narrow trail along the length of the wheelchair. During an observation and interview on 08/25/26 at 12:20 P.M., the resident had a strong urine order. The resident said the liquid on the floor was from him/her urinating and he/she needed to be changed. Observation on 08/25/2026 at 1:35 P.M., showed the resident remained seated at the same table while volunteers provided church service. The puddle beneath the wheelchair was still present and the narrow trail that extended along the length of the wheelchair had dried. At 3:43 P.M., the resident pushed himself/herself out of the dining room toward his/her room. At 4:14 P.M., the resident remained in the same clothes from 9:22 A.M. observation. During an interview on 08/26/25 at 11:45 A.M., CNA J said residents that were bed bound should be checked every two hours. The residents in wheelchairs that push themselves around would generally tell the staff when they needed assistance with incontinent care. During an interview on 08/28/2026 at 1:37 P.M., Licenses Practical Nurse (LPN) A said facility staff should conduct rounds every 2 hours and as needed for repositioning residents, along with perineal care. During an interview on 08/28/2026 at 2:00 P.M., the DON said residents should be checked every 2 hours for incontinent episodes and for repositioning. 3. Review of Resident #1's significant change MDS, dated [DATE], showed:-admission date: 05/13/22;-Severe cognitive impairment;-Substantial/maximal assistance (helper does more than half the effort) with all ADLs including the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident;-Incontinent of bowel and bladder;-Diagnoses: coronary artery disease, diabetes, non-Alzheimer's dementia, moderate protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease (COPD). Review of the resident's care plan, in use during the survey, showed:-Focus: Resident at risk moderate protein calorie malnutrition and incontinence risk;-Goal: Risks associated with skin integrity will be minimized through review date;-Interventions: Encourage good hydration and nutrition-Focus: The Resident refuses/is resistive to ADL care/assistance;-Goal: The resident will cooperate with care through next review date;-Interventions: If refusing to eat/dining assistance: Empower the residents by allowing choices in mealtime, menu selection, dining location. If resident resistive with ADLs, reassure resident, leave and return later and try again. Observation on 08/23/26 at 8:17 A.M., showed the resident lay in bed with a bedside table positioned across from him/her. The breakfast tray contained scrambled eggs, two slices of bacon, one slice of toast, one unopened four-ounce juice container, one unopened eight-ounce milk container, and one unopened 16.9-ounce container of soda. The resident was observed attempting to drink the soda while the lid remained on the container. Resident's fingernails were jagged with dark matter underneath. No staff were observed in the hallway or in the immediate area during the observation. Observation and interview on 08/24/26 at 8:50 A.M., showed the resident lay in bed with a bedside table positioned across from him/her. The breakfast tray contained a large portion of scrambled eggs and a bowl filled to the brim with cereal and milk. The cereal appeared to be fully saturated and was consistent with the cereal having been sitting in the milk and untouched. A juice container was unopened with a small puncture hole in the middle, and a straw laid across the container. When asked whether he/she had finished eating, the resident said, he/she had not eaten yet. When asked about the food on the tray, the resident said, no one had brought him/her anything yet and he/she was hungry. Observation on 08/24/26 at 8:53 A.M., showed CNA M entered the resident's room and from the hallway, could be heard asking the resident whether he/she was still eating. The resident was heard responding that he/she had not eaten yet. CNA M was heard telling resident the food was in front of him/her. The resident was then heard mumbling incoherently. CNA M was heard asking resident if he/she was going to eat anything else, and the resident continued to mumble. At 8:54 A.M., CNA M exited the resident's room with the breakfast tray. During an interview on 08/25/26 at 1:30 A.M., Certified Medication Technician (CMT) K said the resident needed to be assisted with feeding but at times resisted so staff had to prompt him/her to eat. CMT K said there were two CMTs scheduled daily. During the facility's mealtimes, one CMT would be assigned to assist residents in the dining room and the other CMT was assigned to pass out room trays. The CMT assigned to the room trays was responsible for checking the residents body positioning, dentures were in place, all beverages opened, and correct diet order was given. CMT K said there was no list on who required assistance with set-up, prompted to eat, or fed. The CMTs use nursing judgement on what type of assistance the residents received. Observation on 08/26/26 at 8:10 A.M., showed the resident lay in bed at a 45-degree angle. The breakfast tray contained two pancakes with syrup, two slices of bacon, and a bowl of cereal, an opened eight-ounce container of milk, and an opened four-ounce container of juice. The resident was observed eating the pancake with his/her fingers with difficulty while syrup dripped down the front of his/her chest. At 8:20 A.M., the resident was observed holding the end of the spoon between the thumb and index finger, with the spoon hanging vertically. The resident was unable to position the spoon horizontally or angle it sufficiently to scoop the cereal and bring it to the mouth. The spoon remained in a vertical position and dangled from the resident's grasp. Resident was observed setting the spoon down and attempting to eat the dry cereal with his/her fingers. The resident reached into the cereal bowl and attempted to pick up individual pieces of cereal using the thumb and index finger while the middle, ring, and little fingers remained extended and straight. The resident made several attempts before successfully picking up one piece of cereal. Observation on 08/26/26 at 1:08 P.M., showed the resident was served lunch in the main dining at a table. Multiple staff members were in the dining room. The resident had baked chicken with bones, broccoli, pasta, and a banana for dessert. The resident began eating and using the banana as a spoon. The resident then began to eat pasta and the baked chicken that was on his/her plate with his/her hands. The resident had approximately one-half inch fingernails and were jagged with dark matter underneath. The resident finished eating the chicken and pasta with his/her hands and began to eat the banana with the skin on it. Another resident sitting at the resident's table assisted the resident to peel his/her banana. No staff member assisted the resident with his/her meal during the entire meal service. During an interview on 08/25/26 at 11:49 A.M., the Restorative C.N.A (RCNA) said he/she was responsible to obtain resident's weights, provide nail care and assist residents with feeding who required to be fed that received a room tray. RCNA said when he/she worked as a restorative aid, he/she was often pulled to the floor to work as a CNA. RCNA said it was all CNAs responsibility to ensure the residents on their assignment had clean nails and received the assistance they needed if the resident ate in their room. During an interview on 08/26/25 at 11:45 A.M., CNA J said the CMTs were responsible for hall trays and assisting residents who required assistance or needed to be fed. During an interview on 08/28/2026 at 1:37 P.M., LPN A said the resident needed help with prompting and setup and was aware the resident was not being assisted. LPN A said staff tried to encourage the resident to eat in the dining room, but the resident often refused. The staff still needed to make sure the resident was assisted when he/she ate in his/her room. During an interview on 08/28/2026 at 2:00 P.M., the Administrator said residents who required assistance with feeding should have the assistance they needed to prompt proper nutrition. The Administrator said not providing this support could result in the residents' decline through weight loss and poor nutrition. 2809411

Based on observation, interview and record review, the facility failed to label insulin pens per facility policy for nine of 10 insulin pens in use for residents at the facility. The census was 69.Review of the facility's Insulin Labeling and Storage policy, dated [DATE], showed:-All insulins will be stored in the refrigerator on delivery until opened for usage;-New insulins removed from the reiterator needs to be dated and include the resident's name. This includes both bottles or pens;-Insulins are only good for 28 days after opening. Observation and interview on [DATE] at 10:07 A.M., showed Licensed Practical Nurse (LPN) B identified the medication cart that contained the insulin pens in use for all residents. Observation at this time showed 10 insulin pens in the top drawer. A sticker was placed on all pens with a space for the date opened and the date expired. There were two insulin aspart (rapid acting insulin), two insulin degludec (ultra long-lasting insulin), three Lantus (long-acting insulin), and two Humalog (short acting insulin) pens with no date opened and no expiration date identified. LPN B said all insulin pens should be labeled when removed from the refrigerator and labeled with their expiration date. He/She would not know when these pens were opened or placed on the cart. Insulin pens are good for 28 days after opened. During an interview on [DATE] at 12:00 P.M., with the administrator and Director of Nursing, they said they would expect staff to follow the facility's Insulin Labeling and Storage pen policy. 2707967

Based on observation, interview and record review, the facility failed to ensure each resident was provided adequate assistance to prevent accidents for one resident who required the use of a Hoyer lift (full body mechanical lift) when staff transferred the resident with the use of a gait belt (Resident #3). The sample was 7. The census was 69.Review of the facility's Gait Belt Transfer policy, dated October 2023, showed:-Review Kardex for number of staff transfer assistance needed;-Fasten the gait belt securely around the resident's waist with the buckle at the side;-Position one hand under the buckle;-Position the other hand under the belt;-Transfer the resident using proper body mechanics. Review of Resident #3's medical record, showed:-Diagnoses included hemiparesis and hemiplegia (weakness and/or paralysis on one side of the body) following a stroke on right dominate side;-A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/8/25, showed sever cognitive impairment. Functional limited range of motion to one side, lower extremity. Partial assistance required for chair to bed transfer;-A care plan, in use at the time of the survey, showed:--Focus: The resident has an activity of daily living self-care performance deficit related to right hemiparesis. Interventions: Mechanical lift use with assist x 2;--Focus: at risk for falls related to poor balance, unsteady gait, stroke with right hemiplegia, dementia with impulsivity, and impaired decision making. Interventions: Use Hoyer lift with assist x 2 for transfers. During an interview on 1/15/26 at 7:55 A.M., Certified Nursing Assistant (CNA) C said the resident is on his/her assignment and requires a Hoyer lift to transfer. He/She will need help to get him/her up. Observation on 1/15/26 at 8:49 A.M., showed CNA A and Licensed Practical Nurse (LPN) B entered the resident's room to complete a skin assessment. The resident sat in his/her wheelchair. One staff member stood on each side of the resident. CNA A placed a gait belt around the resident's waste. Staff assisted the resident to stand up by placing one arm under the resident's armpit and one hand that held the gait belt. The resident's knees remained bent, and he/she stood on his/her toes. Staff appeared to strain to hold the resident up in a hunched position. The resident started to yell put me down, put me down, I'm slipping. Staff set the resident back down into his/her wheelchair. Staff positioned the resident's wheelchair parallel to the bed then again assisted the resident to stand with the use of the gait belt. Staff stood on either side of the resident, placed one arm under the resident's armpit, and one hand that held the gait belt. As staff lifted the resident, his/her left foot remained on the ground and twisted as his/her right foot lifted into the air. Staff swung the resident to the side and placed the resident into bed. During an interview on 1/15/26 at 11:06 A.M., LPN B said there were stickers outside the resident room doors to indicate transfer status of residents. The resident's transfer status is also listed in the staffing book. Review of the staffing book, located at the nurse's station, showed the resident identified as a Hoyer Lift. The binder indicated a pink indicator should be used for his transfer status. Observation on 1/15/26 at 11:10 A.M., showed no pink sticker on the resident's name plate outside his/her Review of the resident's Kardex, located at the nurse's station, showed transfers: Dependent. During an interview on 1/15/26 at 12:00 P.M., with the Administrator and Director of Nursing, they said staff know a resident's transfer status by using the Kardex and it is also listed in the staffing book. The colored stickers on the name plate are used to match the color listed in the staffing book. If there is no sticker on the name plate, staff should check the staffing book or Kardex. They can also ask the charge nurse, therapy, or management. When transferring with a gait belt, the resident should be able to bear weight and have enough balance to stand with standby assist. The staff should follow the care as directed in the care plan and the staffing binder. If a resident's care plan and staffing binder indicates a resident is a Hoyer transfer, it is not acceptable to use a gait belt. 2707967

Based on observation, interview and record review, the facility failed to ensure Certified Medication Technician (CMT) D provided nutritional supplements as ordered to Residents #6, #15, #14, and #10. In addition, the facility failed to ensure Resident #10 received whole milk at meals as ordered. The facility identified 23 residents as receiving nutritional supplements. Four of those residents were sampled and problems were identified with all four. The census was 70.Review of the facility Weight Protocol last reviewed on 10/2025, showed:-Purpose: To provide a permanent, accessible record of residents' weights;-Procedure:-Monthly weights will be completed by the 15th of the month. Weights will be given to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to input into the electronic medical record (EMR) within 5 business days;-The weights are reviewed weekly amongst IDT (interdisciplinary team);-Monthly weights will be reviewed by the RD (Registered Dietician) during their monthly visit and will make recommendations to the physician, documents in the EMR and reviews and updates the resident's POC (plan of care) as indicated;-The RD assesses each resident with a significant weight change (following Minimum Data Set (MDS) criteria 5% in 30 days, 7.5% in 90 days and 10% in 180 days) and makes recommendations to physicians and updates the residents plan of care as needed;-The RD will also review and assess all weight changes which reflect an insidious change in weight as determined by the RD.Review of the facility CMT job description revised on 1/20/22, showed:-Mission Statement: The facility is here to create a home where residents, employees, and community form relationships that individuality, personal integrity, and service to each other;-Job Responsibilities (include): Assist with providing activities of daily living such as; feeding, grooming, and resident care. Perform all other work duties as assigned that is in scope of practice. 1. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/25, and located in the EMR, showed:-admission date of 6/19/25;-Hearing and vision adequate;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Supervision or touching assistance required for eating;-Diagnoses of anemia (a lack of healthy red blood cells), renal (kidney) insufficiency, malnutrition (protein or calorie) and depression;-Height: 5'9;-Weight: 115 pounds (lbs.);-One Stage 2 pressure ulcer (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous). May also present as an intact or open/ruptured blister.). Review of the resident's weights and vitals summary, showed:-6/19/25 at 2:40 P.M.: 114.8 lbs. Review of the resident's care plan, located in the EMR, showed:-6/22/25, Focus: Risk for Impaired Skin Integrity: severe protein calorie malnutrition. Goal: Risks of complications related to skin status will be minimized. Interventions: Encourage good hydration and nutrition. Diet per RD recommendation and physician's order;-6/22/25, Focus: Activities of daily living (ADL)/Mobility deficits. Goal: Will continue to have aspects of care met daily. Interventions: Assist with meals;.-7/8/25, Focus: Nutritional Status: Underweight with skin breakdown and diagnosis of protein calorie malnutrition. Goal: Maintain healthy body weight to promote weight gain and wound healing. Interventions: Continue current liberalized diet order. Monitor changes in weight. Assess nutrition status quarterly and with significant changes in weight. Review of the resident's weights and vitals summary, showed:-8/7/25 at 12:09 P.M.: 112.2 lbs. Review of the resident's care plan, showed:-9/11/25, Focus: Actual alteration in skin integrity: Coccyx (a small triangular bone at the base of the spinal column ). Goal: The resident will have no complications related to skin injury. Interventions: Administer/provide supplemental nutrition as ordered. Dietician to consult as necessary (PRN) related to wounds. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Review of the resident's quarterly MDS, dated [DATE], showed:-Hearing and vision adequate;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Partial/moderate assistance required for eating;-Diagnosis of malnutrition;-Weight of 106 lbs.;-Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months: Yes, not on physician prescribed weight-loss regiment;-Weight gain of 55 or more in the last month or gain of 10% or more in the last 6 months: Yes, on physician-prescribed weight gain regimen;-One stage 2 pressure ulcer. Review of the resident's weights and vitals summary, showed:-10/2/25 at 1:06 P.M.: 102.6 lbs. Review of the resident's nutrition/dietary note, dated, dated 10/15/25 at 5:09 P.M., showed:-Supplement: Ensure (dietary supplement (BID), Med Pass (dietary supplement) 2.0 90 milliliter (ml) three times a day (TID);-Skin: Stage 2 pressure ulcer to coccyx;-Weight: 106 lbs. -Weight Change: 2 lb. weight gain 1 month, 7 lb. weight loss 3 months;-Noted Ensure added, would discontinue. Review of the resident's census report (a report that showed the original admission date, discharge date s to the hospital and readmission dates), showed:-discharged (to hospital): 10/24/25;-readmission: [DATE]. Review of the resident's physician's order sheet (POS), showed:-11/1/25: Regular diet;-11/1/25: Ensure with meals for supplement. Review of the resident's Medication Administration Record (MAR, where CMTs, Licensed Practical Nurses (LPNS) and Registered Nurses (RNs) initial a medication/ordered supplement has been administered. If a medication/ordered supplement cannot be administered as ordered, the CMT/LPN/RN should document why it was not administered.), dated 11/1/25 through 11/30/25, showed:-11/2/25: Ensure with meals for supplement at 7:00 A.M., 12:00 P.M. and 4:00 P.M. Observation on 11/3/25 at 6:23 A.M., showed the resident lay in bed. One carton of Ensure that was warm to touch and almost empty sat on his/her bed table. During an interview, the resident said the Ensure was from yesterday, but he/she was not sure what time it was brought in. He/She did not know how often or at what time he/she should receive Ensure. He/She liked Ensure and drinks it when provided. Observation on 11/3/25, showed:-At 7:57 A.M, the resident's breakfast tray sat on a small hall cart ready for delivery to the resident. Review of the dietary menu slip on the tray showed Regular Diet/Breakfast. No information about Ensure was on the menu slip. The breakfast tray contained one carton of 2% milk, two containers of apple juice, one doughnut, scrambled eggs and one bowl of cereal. No Ensure was on the breakfast tray;-At 8:19 A.M., a staff member entered the resident's room (on the 500 Hall) with the breakfast tray and began feeding the resident;-At 8:43 A.M. the resident's tray was removed from the room. The resident ate nearly 100% of his/her breakfast and drank 100% of his/her milk and apple juice. No Ensure was noted in the resident's room after the breakfast tray had been removed. Observation of the CMT medication carts (the facility had two CMT medication carts) on 11/3/25, showed:-8:37 A.M.: Medication cart on 400 Hall. No Ensure was observed on the medication cart;-8:45 A.M.: Medication cart on 100 Hall. CMT C and CMT E passed medications. No Ensure was observed on the medication cart;-12:00 P.M.: Medication cart on 300 Hall. No Ensure was observed on the medication cart; -12:02 P.M. Medication cart on the 100 Hall. CMT C and CMT E passed medications. No Ensure was observed on the medication cart;-12:05 P.M. Med Cart on 200 Hall. No Ensure was observed on the medication cart. Observation on 11/3/25 at 12:57 P.M., showed the resident lay in bed. A staff member sat next to the resident, feeding the resident lunch. The dietary menu slip showed no information about Ensure and no Ensure was noted on the lunch tray. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed Ensure had been administered as ordered on 11/4/25 at 7:00 A.M.Observation on 11/4/25 at 9:49 A.M., showed CMT D passed medications on the 500 Hall. No Ensure was observed on the medication cart. At 9:53 A.M., the resident lay dressed in bed with his/her eyes closed. His/Her breakfast tray sat on a counter in the room next to the entrance door. The resident ate 0% of his/her biscuits/gravy and cereal. His/Her carton of 2% milk had been peeled back but not opened. There was no Ensure on the breakfast tray, or in his/her room. At 9:56 A.M., a staff membered entered the room and removed the breakfast tray out of the room. Observation on 11/4/25 at 10:00 A.M., showed CMT E passed medications to residents on the 300 Hall. No Ensure was observed on the medication cart. The CMT said he/she started passing medications this morning at 7:00 A.M. He/She was assigned to the 200 Hall, 300 Hall and odd numbered rooms on the 400 Hall. Observation on 11/4/25 at 10:05 A.M., showed CMT D was on the 400 Hall with the medication cart. No Ensure was observed on the medication cart. The CMT said he/she was passing medications to residents on the 100 Hall, even numbered rooms on the 400 Hall, 500 Hall today. Review of the resident's weights and vitals summary, showed:-11/4/25 a t 11:22 A.M.: 107.8 lbs. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed he/she administered Ensure as ordered on 11/4/25 at 12:00 P.M. Observation on 11/4/25 at 1:05 P.M., showed the resident lay in bed as Certified Nursing Assistant (CNA) B sat in the room, feeding the resident lunch. The resident's tray had spaghetti, garlic bread, broccoli, two puddings and one orange drink. No Ensure was noted on the tray. At 1:19 P.M., the CNA exited the room and said the resident ate 50% of the spaghetti, 0% of the pudding, garlic bread and broccoli. He/She drank all of his/her orange drink and an extra glass of water. He/She did not give the resident Ensure and no one came in the room while he/she fed the resident and gave the resident Ensure. Observation of the resident's room at that time showed no Ensure in the room. Observation on 11/5/25 at 7:10 A.M., showed CMT C and CMT E stood at the medication cart on the 300 Hall. No Ensure was observed on the medication cart. Observation on 11/5/25 at 7:14 A.M., showed CMT D stood at the medication cart on the 100 Hall. No Ensure was observed on the cart. During the observation, the CMT moved the medication cart from the 100 Hall to the 500 Hall. Observation on 11/5/25 At 7:36 A.M., showed the resident lay in bed. No Ensure was noted in the room. Observation on 11/5/25 at 8:20 A.M., showed the resident's breakfast tray sat on a small cart near the nurse's station. The tray had one carton of 2% milk, one bowl of cereal, two pancakes and four pieces of bacon. At 8:30 A.M., CMT C took the resident's breakfast into the resident's room where the resident lay in bed. He/She left the room and returned with apple juice. CAN B entered the room and told CMT C he/she would feed the resident. CMT C exited the room. Observation on 11/5/25 at 9:11 A.M., showed CMT D's medication cart sat outside the resident's room on the 500 Hall. No Ensure was observed on the medication cart. At 9:14 A.M., the CMT returned to the medication cart and pushed the medication cart to 400 Hall. During an interview on 11/5/25 at 10:38 A.M., CMT D said he/she finished his/her morning med pass. He/She worked the day shift (6:30 A.M.-2:30 P.M.) yesterday and today and was assigned to pass medications on the 100 Hall, part of the 400 Hall and the 500 Hall. He/She did not have Ensure to give the resident yesterday or today because there was none stocked in the medication room. He/She told the Central Supply Clerk he/she was out of Ensure yesterday. He/She should not have initialed the Ensure had been administered yesterday, 11/4/25. He/She should have made a note the Ensure was not administered with an explanation. During an interview on 11/5/25 at 11:45 A.M., the Central Supply Clerk said CMTs are responsible to pass nutritional supplements, including Ensure. CMT D never said anything to him/her about being out of Ensure yesterday or today. The facility is not out of Ensure. She stocks the CMT medication room weekly. They have plenty of Ensure stocked in the medication room at all times. Observation of the CMT medication room with the Central Supply Clerk at that time, showed containers of Ensure in the refrigerator. Observation of a carton of Ensure showed one single serving was 237 mls (approximately 8 ounces) and contained 250 calories. During an interview on 11/6/25 at 11:30 A.M., the Administrator said they reweighed the resident on 11/5/25, and he/she weighed 103.6 lbs. This represents an 11.2 lb. or 9.75% weight loss since admission and a three-month significant weight loss of 8.6 lbs. or 7.66% weight loss since 8/7/2025. 2. Review of Resident #15's significant change in status MDS, dated [DATE], showed:-Moderately impaired cognition;-Setup or clean-up assistance required for eating;-Diagnoses of anemia, anxiety and depression;-Height 5'3;-Weight: 144 lbs.;-Loss of 5% or more in the last month or loss of 10% or more in the last 6 months: Yes, not on physician-prescribed weight-loss regimen;-Hospice. Review of the resident's care plan, showed:-9/19/25, Focus: The resident has impaired cognitive function/dementia or impaired thought processes. Goal: Will be able to communicate basic needs daily. Interventions: Administer medications as ordered. Ask yes/no questions when necessary;-9/22/25, Focus: Nutritional status. Overweight with weight loss and diagnosis of depression. Goal: Maintain healthy body weight. Interventions: Monitor changes in weight. Assess nutrition status quarterly and with significant changes in weight. Provide supplemental calories. Review of the resident's POS, showed:-10/18/25: Med Pass 2.0, 60 ml BID;-Regular diet. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed:-10/18/25: Med Pass 2.0 two times a day at A.M. med pass and P.M. med pass. Review of the resident's nutrition/dietary note dated, 10/31/25 at 3:43 P.M., showed:-Weight 141 lbs.;-Weight Change: 3 lb. loss in one month, 23 lb. loss in three months and 12 lb. loss in six months;-Supplemental calories recently changed to Med Pass 2.0 60 ml BID. Wounds noted to right heel, right lateral ankle, and left heel. Would continue supplements and monitor. Observation on 11/3/25 at 8:02 A.M., showed the resident lay in bed in his/her room on the 100 Hall, as staff entered the room and set-up the resident's breakfast tray. The resident had one small bowl of cream of wheat, one doughnut, scrambled eggs, one carton of 2% milk and one apple juice. No Med Pass 2.0 was observed on the breakfast tray. Observation on 11/4/25 at 9:49 A.M., showed CMT D passed medications on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. Observation on 11/4/25 at 10:05 A.M., CMT D passed medications on the 400 Hall. No Med Pass 2.0 was observed on the medication cart. The CMT said he/she was assigned to pass medications on the 100 Hall, the even numbered rooms on the 400 Hall, and the 500 Hall today. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed the Med Pass 2.0 had been administered on 11/4/25 during the A.M. med pass. Observation on 11/4/25 at 12:50 P.M., showed the resident lay in bed. Staff took the resident's lunch tray that had spaghetti, garlic bread, broccoli, pudding and an orange drink. No Med Pass 2.0 was observed on the lunch tray. Observation on 11/5/25 at 7:14 A.M., showed CMT D stood at the medication cart on the 100 Hall. No Med Pass 2.0 was observed on the cart. Observation on 11/5/25 at 9:11 A.M., showed CMT D's medication cart sat on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. At 9:14 A.M., CMT D returned to the medication cart and pushed the medication cart to the 400 Hall. Review of the resident's weight obtained by the facility on 11/6/25, showed a weight of 141.4 lbs. 3. Review of Resident #14's quarterly MDS, dated [DATE], and located in the EMR, showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Severe cognitive impairment;-Dependent for eating;-Diagnoses of anemia, renal insufficiency, stroke, malnutrition and depression;-Height: 4'11;-Weight 76 lbs. Review of the resident's care plan, showed:-1/23/20, Focus: Impaired cognitive function/dementia and impaired thought processes. Goal: Will maintain current level of cognitive function. Interventions: Communicate with the resident/family/caregivers regarding resident's capabilities and needs;-1/23/20, Focus: ADL self-care performance deficit related to moderate intellectual disabilities. Goal: Will continue to have aspects of care met. Interventions: Staff to assist with completion of ADLs on a daily basis, ensure needs are met daily;-12/21/23, Focus: Nutritional Status, underweight with diagnosis of dysphagia (difficulty swallowing) and protein-calorie malnutrition. Interventions: Continue current mechanically altered diet order. Monitor changes in weight. Provide supplemental calories. Assess nutrition status quarterly and with significant changes in weight. Review of the resident's nutrition/dietary note, dated 9/25/25 at 11:46 A.M., showed:-Mechanical soft diet (soft foods, ground meats), whole milk at meals, pudding at lunch and dinner;-Supplements: Med Pass 2.0, 120 ml TID;-Weight (9/16/25) 74 lbs.;-Weight Change: 7 lbs. one month, 10 lbs. three months, 10 lbs. six months;-Would continue diet order and supplements and monitor. Review of the resident's POS, showed:-11/27/24: Med Pass 2.0 three times a day for supplement. Give 120 ml TID;-11/27/24: Regular diet, mechanical soft texture. Whole milk at meals/pudding at lunch and dinner. Review of the resident's MAR, showed:-11/27/24: Med Pass 2.0 three times a day at 8:00 A.M., 4:00 P.M., and 9:00 P.M. Observation on 11/3/25 at 7:58 A.M., showed the resident sat at a feeding assistance table in the dining room with staff feeding the resident. Observation on the resident's breakfast menu slip that sat next to the breakfast plate, showed whole milk at breakfast/lunch/dinner. The resident had one carton of 2% milk served with breakfast. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed the resident received Med Pass 2.0 on 11/4/25 at 8:00 A.M. Observation on 11/4/25 at 9:49 A.M., showed CMT D passed medications on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. Observation on 11/4/25 at 10:05 A.M., CMT D passed medications on the 400 Hall. No Med Pass 2.0 was observed on the medication cart. The CMT said he/she was assigned to pass medications on the 100 Hall (where Resident #14 resides), the even numbered rooms on the 400 Hall, and the 500 Hall today. Observation on 11/4/25 at 12:56 P.M., showed the resident sat at a feeding assistance table in the dining room as staff fed the resident lunch. The resident received one carton of whole milk with lunch. Observation on 11/5/25 at 7:14 A.M., showed CMT D stood at the medication cart on the 100 Hall. No Med Pass 2.0 was observed on the cart. Observation on 11/5/25 at 7:47 A.M., showed the resident sat at a feeding assistance table in the dining room with staff feeding the resident. The resident was served one carton of 2% milk, one carton of apple juice, one bowl of cereal, ground sausage and pancakes. No Med Pass 2.0 was observed being given to the resident during breakfast. Observation on 11/5/25 at 9:11 A.M., showed CMT D's medication cart sat on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. At 9:14 A.M., CMT D returned to the medication cart and pushed the medication cart to the 400 Hall. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed the resident received Med Pass 2.0 on 11/5/25 at 8:00 A.M. Observation on 11/6/25 at 8:40 A.M., showed the resident sat at the feeding assistance table in the dining room. The resident's breakfast menu slip sat next to his/her plate. The facility Wound Nurse was feeding the resident at this time. She opened one carton of 2% milk and added it to the resident's cereal. When asked if the resident should receive 2% milk, the Wound Nurse looked at the menu slip and said no, the resident should receive whole milk. She did not read the menu slip prior to feeding the resident, but she should have and let the kitchen know the resident needed whole milk. During an interview on 11/6/25 at 8:48 A.M., the Dietary Manager said the facility currently did not have any single cartons of whole milk. They only had whole milk in the gallon jugs. It is the responsibility of her dietary staff to read the menu slips and make sure the resident received the whole milk. If the dietary staff doesn't serve what is on the menu slip, then nursing should be reading the menu slip as well and let dietary know if the menu slip does not match what was served. Observation of a gallon of whole milk showed a serving size (one cup or 240 mls) contained 150 calories. Observation on one carton/one serving per carton (240 ml) of 2% milk contained 120 calories. During an interview on 11/6/25 at 9:11 A.M., the Administrator said she expected both the dietary and nursing department to read the menu slips. If a discrepancy is noted, she expected the nursing department to notify the dietary department. Review of the resident's weight obtained by the facility on 11/6/25, showed a weight of 79.6 lbs. 4. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Makes Self Understood: Sometimes understood;-Ability To Understand Others: Sometimes understands;-Severe cognitive impairment;-Dependent upon staff for eating;-Diagnoses of diabetes mellitus (low/high blood sugar), aphasia (impairment in a person's ability to comprehend or formulate language), and stroke;-Height: 5'4;-Weight: 93 lbs.;-Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months: Yes, not on a physician-prescribed weight-loss regiment. Review of the resident's care plan, showed:-4/25/22, Rocus: Impaired cognitive function/dementia or impaired thought processes related to stroke. Goal: Will be able to communicate basic needs on a daily basis. Interventions: Ask yes/no questions in order to determine the resident's needs;-4/25/22, Focus: ADL self-care performance deficit related to stroke. Goal: Will continue to have aspects of care met daily. Interventions: Staff to assist with completion of ADLs on a daily basis, ensure needs are met;-1/4/24, Focus: Nutritional Status. Underweight with potential for weight loss. Interventions: Assess nutrition status quarterly and with significant changes in weight. Monitor changes in weight. Provide supplemental calories. Review of the resident's nutrition/dietary note, dated 9/17/25 at 4:43 P.M., showed:-Diet Order: Puree;-Supplement: Med Pass 2.0 60 ml TID;-Weight: 93 lbs.;-Weight Change: 7 lb. weight loss in one month, 4 lb. loss in three months, and 8 lb. gain in six months. Review of the resident's POS, showed:-11/1/24: Regular puree diet;-8/22/25: Med Pass 2.0 three times a day. Give 60 ml TID. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed:-8/22/25: Med Pas 2.0 60 ml, three times day at 8:00 A.M., 4:00 P.M., and 9:00 P.M.;-11/4/25 at 8:00 A.M.: CMT D initiated the Med Pass 2.0 had been administered as ordered. Observation on 11/4/25 at 9:49 A.M., showed CMT D passed medications on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. Observation on 11/4/25 at 10:05 A.M., CMT D passed medications on the 400 Hall. No Med Pass 2.0 was observed on the medication cart. The CMT said he/she was assigned to pass medications on the 100 Hall (where Resident #10 resides), the even numbered rooms on the 400 Hall, and the 500 Hall today. Observation on 11/5/25 at 7:14 A.M., showed CMT D stood at the medication cart on the 100 Hall. No Med Pass 2.0 was observed on the cart. Observation on 11/5/25 at 7:47 A.M., showed the resident sat in the dining room at a feeding assistance table. Staff were feeding the resident at that time. The resident received a puree diet with one carton of 2% milk, and one carton of apple juice. No Med Pass 2.0 was observed during the breakfast meal. Review of the resident's MAR, dated 11/1/25 through 11/30/25, showed CMT D initialed the Med Pass 2.0 had been administered as ordered on 11/5/25 at 8:00 A.M. Observation on 11/5/25 at 9:11 A.M., showed CMT D's medication cart sat on the 500 Hall. No Med Pass 2.0 was observed on the medication cart. At 9:14 A.M., CMT D returned to the medication cart and pushed the medication cart to the 400 Hall. Review of the resident's weight obtained by the facility on 11/6/25, showed a weight of 101 lbs. 5. During an interview on 11/5/25 at 10:38 A.M., CMT D said he/she worked the day shift (6:30 A.M.-2:30 P.M.) yesterday and today and was assigned to the 100 Hall, part of the 400 Hall and the 500 Hall. He/She did not have Med Pass 2.0 to give the residents yesterday because it was out of stock. He/She told the Central Supply Clerk yesterday. Today, as soon as he/she got to work, he/she got a container of Med Pass 2.0 and gave it to four residents prior to passing his/her medications and prior to the surveyor arriving. The residents he/she gave the Med Pass 2.0 to included Resident #15, Resident #14 and Resident #10. He/She ran out of the Med Pass 2.0 and was not able to give any of the other residents the Med Pass 2.0 He/She should not have initialed the Ensure had been administered yesterday, 11/4/25. 6. During an interview on 11/5/25 at 11:45 A.M., the Central Supply Clerk said CMTs are responsible to pass nutritional supplements, including Ensure. CMT D never said anything to him/her about being out of Med Pass 2.0 yesterday. The facility was not out of Med Pass 2.0 yesterday or today. She stocks the CMT medication room weekly. They have plenty of Med Pass 2.0 on hand. Observation of the CMT medication room at that time with the Central Supply Clerk showed several containers of Med Pass 2.0. 7. During an interview on 11/5/25 11:57 A.M., the Administrator said CMTs are responsible to administer the Med Pass 2.0 as ordered. 8. During an interview on 11/5/25 at 1:20 P.M., the facility's Medical Director said he expected the facility to follow their policies. He expected residents with nutritional supplement orders to receive the supplements as ordered. 9. During an interview on 11/6/25 at 9:11 A.M., the Administrator said CMT D clocked in to work at 6:36 A.M. on 11/5/25. She reviewed the video footage with the surveyor that showed the CMT arrived at the nurse's station at 6:36 A.M. on 11/5/25 and began to clean and stock his/her medication cart. From 6:36 A.M. until 6:50 A.M. when the surveyor arrived, the CMT never had Med Pass 2.0 on his/her medication cart and never left the nurse's station with Med Pass 2.0. 2658022

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they used expired Covid tests to test employees and residents for Covid-19. The facility failed to check with the manufacturer to see if the expiration date waiver was extended. The waiver was not extended. The census was 72. Review of the facility's Response to Covid-19 protocol, last reviewed ,d+[DATE], showed Covid-19 testing: Covid-19 testing will be conducted in accordance with current Centers for Medicare and Medicaid Services (CMS) and Department of Health and Senior Services (DHSS) requirements, utilizing Point of Care and polymerase chain reaction (PCR) testing as appropriate. During interview on [DATE] at approximately 11:00 A.M., the Assistant Director of Nursing said the facility had one case of Covid-19 due to an employee testing positive. The facility began testing staff and residents. The last test was done today to see if the Covid-19 precautions could be removed. The facility completed the testing and the facility did not currently have any Covid-19 in the facility. Observation and interview on [DATE] at approximately 8:40 A.M., showed the 200 and 300 hall nurse medication cart had 7 boxes of Access Bio Covid-19 Antigen tests with a lot number of CP23B69. The expiration date showed [DATE]. Licensed Practical Nurse (LPN) B verified the expiration date and said he/she would throw these away. LPN B removed them from the cart and took them to the Director of Nursing's (DON) office. Observation and interview on [DATE] at approximately 8:45 A.M., showed the 100, 400, and 500 hall nurse medication cart had 8 boxes of Access Bio Covid-19 Antigen tests with a lot number of CP23B69. The expiration date showed [DATE]. LPN C verified the expiration date. LPN C removed them from the cart and said he/she would take them to the DON's office. Observation and interview on [DATE] at approximately 9:00 A.M., showed the boxes of expired tests sat on the Nurse Manager's desk. The DON said those are the tests the facility used on [DATE] to test employees for Covid-19. She said they have a waiver for the tests, allowing them to be used past the expiration date. The waiver extends the expiration date by 6 months so the tests would not be considered expired. She will provide the waiver. Review of the Access Bio, Inc.: CareStart COVID-19 Antigen Home Test and On/go Antigen Self-Test 15-month to 21-month self-life extension, granted by the Food and Drug Administration (FDA) on February 1, 2023, showed the last numbers for the waiver as CP23A25, CP23A26, CP23A27 with the extended expiration date [DATE] from [DATE]. During an interview on [DATE] at 10:02 A.M., the Quality Control (QC) Lab Manager from Access Bio responded to an email to clarify the expiration dates for this control number and the waiver. The QC Lab Manager wrote, Thank you for reaching out regarding the expiration date for the COVID-19 Antigen Home Test. Starting with the B lots, the product was printed with an extended shelf life of 21 months. Therefore, the lot you have-CP23B69 - has the expiration date of [DATE]. Since this date has already passed, please discard the product from the mentioned lot. Additionally, there is no further extension of expiration beyond this 21-month period. During an interview on [DATE] at 12:03 P.M., the Administrator and DON said the facility should have checked with the manufacturer regarding expiration dates to see if the waiver had expired prior to using the Covid tests.

Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing meals, for one of two meal services observed. The sample was 19. The census was 72. Observation on 12/9/24 at 8:54 A.M., of the lunch meal service prep, showed [NAME] H removed steak patties from a box and place them on the skillet top. After the steaks were cooked, [NAME] H placed the steak patties into a tin and placed the tin on the steam cart for meal service. Review on 12/10/24 at 8:20 A.M., of the Swiss steak recipe, showed: -Ingredients: beef cutlets, salt, black pepper, vegetable oil, onions, celery, and diced tomatoes; -Method of preparation: season cutlets with salt and pepper. [NAME] in hot oil. Place on baking pans. Saute onions and celery in same fat. Place over meat. Pour tomatoes over cutlets. Cover baking pan with foil. Bake for 2 to 2 1/2 hours. Observation on 12/9/24 at 9:17 A.M., of the lunch meal service prep, showed [NAME] H placed three slices of bread into the blender with three, 1 cup scoops of stewed tomatoes to prepare the pureed stewed tomatoes. [NAME] H said he/she was making three portions of the stewed tomatoes. [NAME] H did not use a recipe and no recipes were observed in the food preparation area. Review on 12/10/24 at 8:20 A.M., of the recipe for pureed stewed tomatoes, showed a half slice of bread and half cup of stewed tomatoes should be placed in the blender for each portion of pureed stewed tomatoes being made. Observation on 12/9/24 at 9:21 A.M., showed [NAME] H place three cooked steak patties into a blender with three slices of bread. [NAME] H then poured an unmeasured amount of steak base into the blender. [NAME] H did not use a recipe for pureed Swiss steak. Review on 12/10/24 at 8:20 A.M., of the recipe for pureed Swiss steak, showed a half slice of bread and 1 steak patty should be placed into the blender for each portion of pureed Swiss steak being made. During an interview on 12/9/24 at 9:40 A.M., [NAME] H said he/she was not following any recipes. He/She looked at the menu and from there decided how to cook the food. The Swiss steaks are preseasoned so he/she is only cooking them and nothing else will be done with them. On 12/11/24 at 9:50 A.M., [NAME] H said cooks should use a recipe when cooking but that each cook should be able to deviate from the recipe to add their own flavor. It is not important for cooks to know where recipes are because cooks need to learn how to cook on their own. During an interview on 12/10/24 at 8:37 A.M., [NAME] I said he/she did not know where to find the recipes for the meals most of the time and just cooks what he/she knows. He/She will look at the directions on the packages of the food to try and determine how to cook it. On 12/11/24 at 9:48 A.M., [NAME] I said he/she expected cooks to follow recipes when preparing food for the residents. This is important to know what diet each resident eats. He/She expected cooks to know where to find the recipes. During an interview on 12/11/24 at 12:38 P.M., the Administrator said cooks should be using recipes when preparing meals. She expected the cooks to know where the recipes are and how to use them.

Based on interview and record review, the facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for 12 of 12 months. The facility also failed to reconcile the resident trust at the end of the month for two months. The census was 72. Review of the facility's undated resident rights policy, showed: -Right regarding financial affairs: Manage his or her financial affairs; -Information about available services and the charges for each service; -Personal funds or more than $100 ($50 for residents whose care is funded by Medicaid) deposited by the facility in a separate interest-bearing account, and financial statements quarterly or upon request; -Not be charged for services covered by Medicaid or Medicaid. Review of the facility's resident trust, showed: -January 2024, reconciled on 1/1/24, with a balance of $29,370.97. The statement only included the Resident Fund Management Service (RFMS) statement. No documentation of the bank statement or end of month reconciliation; -February 2024, reconciled on 2/1/24, with a balance of $40,157.89. The statement only included the RFMS statement. No documentation of bank statement or end of month reconciliation; -March 2024, reconciled on 3/31/24, with a balance of $39,841.32. The statement only included the RFMS statement. No documentation of bank statement; -April 2024, reconciled on 4/30/24, with a balance of $35,781.65. The statement only included the RFMS statement. No documentation of bank statement; -May 2024, reconciled on 5/31/24, with a balance of $35,679.65. The statement only included RFMS statement. No documentation of bank statement; -June 2024, reconciled on 6/30/24, with a balance of $39,297.08. The statement only included RFMS statement. No documentation of bank statement; -July 2024, reconciled on 7/31/24, with a balance of $42,258.11. No documentation of bank statement; -August 2024, reconciled on 8/31/24, with a balance of $45,090.51. No documentation of bank statement; -September 2024, reconciled on 9/30/24, with a balance of $35,480.35. No documentation of bank statement; -October 2024, reconciled on 10/31/24, with a balance of $38,643.42. No documentation of bank statement; -November 2024, reconciled on 11/30/24, with a balance of $44,686.35. No documentation of bank statement. During an interview on 12/10/24 at 1:35 P.M., the Business Office Manager (BOM) said she had some training, but the previous BOM passed away. She was only told to print the RFMS and reconciliation. She does not receive the bank statements, but corporate may have them. During an interview on 12/11/24 at 12:00 P.M., the administrator said she would expect the resident trust to be reconciled accurately and timely with the bank statements.

Based on observation, interview and record review, the facility failed to provide residents a safe, clean, comfortable, and homelike environment. The facility failed to launder dirty linen, leaving residents' rooms malodorous (Resident #38 and #24). Two residents with air conditioner units had gaps, allowing air to leak (Residents #23 and #37). One resident had broken or missing tile in the room (Resident #21). One resident had broken base boards and window blinds (Resident #13). The facility failed to ensure resident furniture was repaired for one resident with broken drawers (Resident #1). In addition, one resident had an active leak underneath the air conditioner unit (Resident #65). The sample size was 19. The census was 72. Review of the facility's Cleaning of Resident Rooms policy, dated July 2024, showed: -The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms and identify potential pest control concerns; -General guidelines: -Housekeeping surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; -Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled; -Walls, blinds, and window curtain in resident areas will be cleaned when these surfaces are visibly contaminated or soiled; -Resident room cleaning: -Gather supplies as needed; -Prepare disinfectant according to manufacturer's recommendations; -Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solution; -Change mop water at least every three rooms, or as necessary; -Change cleaning cloths when they become soiled. Wash cleaning cloths daily and allow cloths to dry before reuse; -Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Review of the facility's undated Nursing Home Resident Rights, showed: -Right to a dignified existence: A homelike environment, and use of personal belongings; -Right to self-determination: Reasonable accommodation of needs and preferences. 1. Review of Resident #38's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/30/24, showed: -Diagnoses included vascular dementia and major depressive disorder; -Severe cognitive impairment. Observation on 12/5/24 at 11:32 A.M., showed the resident asleep in his/her bed. The resident's bed had only a fitted sheet which the resident was using to cover himself/herself. The resident's fitted sheet had various brown stains. A large liquid yellow stain was on the lower portion of the fitted sheet. A strong odor of urine permeated from the resident. Observations on 12/6/24, of the resident's bed linen, showed: -At 8:54 A.M., the resident in his/her room seated in his/her wheelchair and ate breakfast. The resident's bedding had been stripped from the bed and was inside a plastic bag on top of the resident's bare mattress. A strong feces odor permeated from the plastic bag which could be smelled in the hallway; -At 9:00 A.M., Certified Nursing Assistant (CNA) E walked into the room and propelled the resident out of the room to go to an activity; -At 9:06 A.M., Licensed Practical Nurse (LPN) C walked into the resident's room and back out of the room; -At 9:18 A.M., the Assistant Director of Nursing (ADON) walked past the resident's room; -At. 9:28 A.M., the dirty linen remained on the resident's bed; -At 9:41 A.M., the feces odor and soiled linen bag remained in the room; -At 9:59 A.M. LPN P walked into the resident's room to check on the resident and walked back out; -At 10:00 A.M., LPN B walked into the resident's room and walked back out. During an interview on 12/6/24 at 10:59 A.M., LPN B said dirty linen should be taken out of the resident's room right away. He/She said it was not appropriate for the resident's dirty bedding to remain in the resident's room after the resident's bedding was removed and placed in the bag. Observation on 12/9/24 at 12:49 P.M., showed the resident's bedding to have various brown stains. A strong urine odor permeated from the resident's laundry basket, which was full of dirty clothing. During an interview on 12/9/24 at 12:58 P.M., Housekeeper Q said the CNAs are responsible for collecting the laundry. They used to have set days to do laundry, but with so many residents who are incontinent, they did not want to wait to do the laundry because of potential odors. The aides can bring the laundry down. The residents that are more independent bring their own laundry. 2. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Diagnoses included dementia, anxiety, and major depressive disorder; -Cognitively intact. Observation on 12/5/24 at 11:32 A.M., showed the resident's fitted sheet dirty with a brown stain. The top sheet had a dried yellow stain. During an interview on 12/5/24 at 2:12 P.M., the resident said nursing staff do not change his/her bedding enough. His/Her roommate is incontinent and staff leave his/her dirty linen and laundry in the room causing the whole room to smell. He/She uses his/her oxygen to try and mask the smells. Observation and interview on 12/9/24 at 6:44 A.M., showed the resident in his/her bed, awake. A strong odor of urine permeated the room. The resident said the smell in his/her room is horrible. He/She has given up on asking staff to help get rid of the smell. The resident was observed to wear oxygen. During an interview on 12/9/24 at 1:13 P.M. the Social Worker said she had not received any complaints about the resident's room having a smell. This would be a nursing department concern. Nursing staff should remove incontinence laundry from the resident's room as soon as possible or as soon as they provide care to the resident or his/her roommate. 3. Review of Resident #23's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included: anemia (low iron in the blood), irregular heartbeat, and peripheral vascular disease (reduction of blood flow due to narrowing or hardening of blood vessels). During an interview and observation on 12/5/24 at 11:34 A.M., the resident said there is a draft of cold air that comes through the spaces around the air conditioner unit, in the wall, and below the window in the room. There was missing floor tile near the door to the resident's room. Observation showed a draft felt from the top of the air conditioner unit and tiles, approximate two complete pieces, missing from the entry was into the resident room. 4. Review of Resident #37's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis: anemia, coronary artery disease (the blood vessels for the heart are narrow or become blocked), high blood pressure, pneumonia, high cholesterol, and depression. During an interview and observation on 12/6/24 at 7:00 A.M., the resident said there is cold air coming in around the air conditioner unit. The resident's bed located near the wall by the window. There were gaps in the frame around the air conditioner unit, light visible from outside coming through the gaps, and the air was cold coming in from outside. 5. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes, aphasia (inability to understand or express speech), stroke, anxiety, and depression. Observation on 12/6/24 at 9:59 A.M. and 12/11/24 at 9:30 A.M., showed two broken tiles under the resident's bed. One of the tiles was missing a piece. 6. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses include diabetes, stroke, hemiplegia (paralysis on one side of the body), and high blood pressure. Observation on 12/5/24 at 11:49 A.M. and 12/11/24 at 11:00 A.M., showed the bottom of the baseboard by the resident's window peeled back into a roll. The resident's blinds bent backwards in multiple spots. 7. Review of Resident #1's medical record, showed: -Diagnoses included epilepsy, major depressive disorder, and obesity; -Cognitively intact. During an interview on 12/5/24 at 1:19 P.M., the resident said his/her bathroom drawers, located by the sink in the room, were broken. He/She had reported this to staff. Observation on 12/5/24 at 1:19 P.M., 12/6/24 at 9:48 A.M., and 12/9/24 at 6:43 A.M., of the resident's room, showed the drawers next to the sink were broken. The top drawer was positioned to keep it from falling. 8. Review of Resident #65's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included stroke, high blood pressure, diabetes, hand hemiplegia (paralysis or weakness on one side of the body). Observation on 12/6/24 at 8:52 A.M., 12/9/24 at 9:29 A.M., 12/10/24 at 11:54 A.M., and 12/11/24 at 10:24 A.M., showed a white towel underneath the wall unit in the room. The fabric was stiff and slightly warped from absorbing water and dried in place. There was a missing piece of tile floor on the left side of the resident's bed. The resident's bed mattress cover ripped on both sides. During an interview on 12/11/24 at 10:24 A.M., the resident had difficulty communicating and was able to answer yes or no questions. The resident was asked if the wall unit leaked and he/she said yes, oh yes. Surveyor confirmed the ripped mattress cover, and the resident again said yes. 9. During an interview on 12/11/24 at 7:55 A.M., CNA J said he/she would expect staff to ensure residents have clean sheets. Sheets are changed every other day or as needed. Nursing staff are required to take dirty linen out of the room once they are finished making the resident's bed. Dirty laundry should be taken out of the resident's room and brought to the laundry department. If staff notice an issue with furniture in resident rooms, staff are to make a maintenance request. 10. During an interview on 12/11/24 at 8:27 A.M., the Maintenance Director said he would expect the residents' furniture to be in working order. He was aware that the drawers in Resident #1's room are broken. He would expect all staff to report any issues with resident furniture to him using the work order book. 11. During an interview on 12/11/24 at 9:35 A.M., LPN B said he/she would expect for residents' sheets to be clean. Sheets and bedding are to be changed daily for the residents. He/She would expect staff to bring dirty linen and clothing to the laundry room to bins as soon as possible, ensure resident rooms have no harsh odors, and resident's furniture to be in working order. If staff notice an issue with furniture in a resident's rooms, they can report this to maintenance staff. 12. During an interview on 12/11/24 at 12:33 P.M., the Director of Nursing said she would expect all resident rooms to be free from odors that could distress to the resident. She would expect for the residents' dirty linen to be removed from the resident's room daily as soon as staff make the bed and dirty clothing should be removed from the resident's room daily. It is not appropriate for dirty linen to be in a resident's room for hours. She would expect for staff to report maintenance issues to the maintenance director or to their direct supervisor. MO00244882 46888 49992

46888 Based on observation, interview, and record review, the facility failed to ensure residents' Activities of Daily Living (ADL) care needs were met. The facility failed to ensure one resident was repositioned and toileted timely and did not have dirty nails (Resident #4), failed to ensure one resident's lips were cared for resulting in dry, cracked lips (Resident #65), failed to ensure one resident was free from body odor and chin hair (Resident #3), failed to ensure one resident's face was cleaned (Resident #1), and failed to ensure another resident had clean nails (Resident #24). The sample was 19. The census was 72. Review of the facility's Turning and Repositioning policy, reviewed 1/2023, showed: -When the resident is sitting up in a chair, they shall be repositioned at least every two hours or per the plan of care. This may be accomplished by shifting the resident's weight to the side or the opposite side of the previous position. Review of the facility's Personal Care Needs policy, reviewed 1/2022, showed: -The facility strives to promote healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident's plan of care (POC). Personal care and support include but is not limited to bath/shower, grooming, dressing, nail care, repositioning, splints, toileting, and transfers. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/24, showed: -Adequate hearing and vision; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Usually; -Ability to Understand Others: Usually, misses some part/intent of the message but comprehends most conversations; -Severe Cognitive impairment; -Diagnoses included: high blood pressure, diabetes, high cholesterol, stroke, aphasia (language disorder that makes it difficult to communicate, understand, read or write), and depression; -Dependent on staff for transfers; -Needs substantial/maximal assistance with eating and oral hygiene; -Dependent on staff for toileting, showering, bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of the resident's care plan, dated 10/6/22, showed: -Focus: resident has an ADL self-care performance deficit related to decreased mobility, health status, mood/behavior status, stroke with one sided weakness, pain, and shortness of breath. Requires staff assistance for completion of ADLs. Self-performance varies at times; -Goal: will continue to have aspects of care met on a daily basis; remaining clean, dry, dressed, groomed and free of odors through next review; -Interventions: Mechanical lift use with assist with 2 persons. Staff to assist with completion of ADLs on a daily basis; -Focus: resident has limited physical mobility and pain related to contractures (permanent tightening of muscle, tenons, or skin around a joint) to both hands and may be resistant to hygiene and nail care; -Goal: resident will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin breakdown, fall related to injury through next review; -Interventions: splints as ordered; -Focus: resident has noted incontinence; -Goal: resident will have less than two episodes of incontinence per day through review date; -Interventions: check resident every two hours and assist with toileting as needed. Encourage and assist resident to toilet every two hours each day. Observation on 12/6/24 at 6:52 A.M., showed the resident sat near then nurse's station in his/her wheelchair, both thumb nails had dried brown substance and were very long. At 9:15 A.M., staff propelled the resident down the hall and to the area of the nurse's station. At 10:24 A.M., the resident sat near the nurse's station in his/her wheelchair. Observation on 12/9/24 at 7:06 A.M., showed the resident lay in bed in his/her room. At 9:02 A.M., staff propelled the resident out of the dining room to the nurse's station, both thumb nails had dried brown substance and were very long. At 9:45 A.M., 10:03 A.M., and 10:27 A.M., the resident sat near the nurse's station in his/her wheelchair. At 10:41 A.M., staff propelled the resident to the lobby to attend activities. Review of the resident's shower sheet, dated 12/9/24, showed a circled area on the buttocks and noted as red. Observation and interview on 12/9/24 at 1:18 P.M., showed Certified Nursing Assistant (CNA) L showered the resident, he/she said that the resident had reddened areas in the genital area when he/she got the resident out of bed this morning. CNA M entered the shower to assist with transferring the resident. Observation of the resident's genitals showed reddened areas. The brief removed from the resident appeared heavily soiled and had a strong odor of urine. The resident's nails were not cleaned or trimmed during the shower. During an interview on 12/11/24 at 9:26 A.M., CNA O said he/she has access to the medical record to know how to perform care for the residents. Residents should be toileted at least every two hours. If the resident is bed bound, the resident should be turned and repositioned every two hours. When showering a resident, he/she washes the whole body and hair. Nails should be cleaned and cut if needed. He/she does not cut the nails of the residents who are diabetic, but he/she would note on the shower sheet that the resident's nails need to be trimmed. When a shower is completed, he/she documents on a shower sheet any areas that are red, opened, or discolored, and signs his/her name on the shower sheet. The sheet is turned into the charge nurse for review. He/she said the resident is a one-person transfer. During an interview on 12/11/24 at 9:47 A.M., Licensed Practical Nurse (LPN) B said CNAs complete and sign shower sheets, and he/she reviews them. The shower should include washing the entire body, hair, and cleaning the nails. If an area is noted to be red, opened, or discolored he/she will go and assess the resident and contact the physician, wound nurse, and supervisor for new areas. He/She will document finding and any new orders in the progress note. The CNAs have access to the medical record and can review the care plan. The care plan contains how the resident transfers, eats, showers, and any special devices. Residents should be toileted or repositioned at least every two hours. The resident is supposed to be a two-person transfer. During an interview on 12/11/24 at 12:03 P.M., the Director of Nursing (DON) said when the staff do the showers, they are to mark any issues with the skin on the shower sheet and turn the shower sheet into the charge nurse. The charge nurse is responsible for reviewing the shower sheet, and if there are noted skin issues, he/she is expected to go assess the resident. The residents' nails should be kept neat in appearance and the residents should not have dark brown substances under their nails and nails should be cut to prevent injury. Staff should check the residents for incontinence and reposition the residents at least every two hours. It is the expectation that the nursing staff review the plan of care. During an interview on 12/11/24 at 12:03 P.M., the Administrator said she expects the nursing staff to follow the policies for skin, toileting, repositioning, and showering. 2. Review of Resident #65's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included stroke, atrial fibrillation (irregular heartbeat), deep venous thrombosis (blood clots), high blood pressure, diabetes, aphasia (language disorder), and hemiplegia (paralysis or weakness on one side of the body); -Impairment to both sides of upper and lower extremity; -Receives tubes feeding; -Requires substantial/maximal assistance with oral hygiene; -Dependent with personal hygiene. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has an ADL self-care performance deficit related to activity intolerance, disease process, fatigue, hemiplegia, impaired balance, limited mobility, range of motion, pain shortness of breath, requires staff assistance for completion of ADLs. Self-performance varies at times; -Goal: Will continue to have aspects of care met daily, remaining clean, dry, dressed, groomed, and free of odors; -Interventions: Staff to assist with completion of ADLs on a daily basis, ensure needs are met daily. Monitor and report changes in physical functioning ability. Nail care as needed (PRN). Encourage the resident to participate to the fullest extent possible with each interaction. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Observation and interview on 12/9/24 at 11:55 A.M. and 12/10/24 at 11:54 A.M., showed the resident in bed, unable to verbally communicate; however, he/she was able to answer yes/no questions. The resident confirmed that staff assist with care and believed they do a good job. The resident had cracked lips. The top and bottom lip showed peeling, loose skin on the lips. During an interview on 12/11/24 at 12:00 P.M., the DON said she was unaware of any concerns regarding the resident's cracked, peeling lips. She would expect staff to ensure the resident is groomed. 3. Review of Resident #3's medical record, showed: -Diagnoses included aphasia (language disorder that affects a person's ability to communicate), dementia, and major depressive disorder; -Severe cognitive impairment. Review of the resident's care plan, dated 11/11/24, showed: -Focus: the resident has an ADL self-care performance deficit; -Goal: will continue to have aspects of care met daily; remaining clean, dry, dressed, groomed and free of odors through review date; -Interventions: staff to assist with completion of ADLs on a daily basis to ensure needs are met daily. Observation and interview on 12/5/24 at 11:38 A.M., showed the resident in his/her bed awake. The resident had a patch of hair on his/her chin. A strong stale body odor permeated from the resident. The resident shook his/her head yes when asked if he/she wanted the hair on his/her face shaved. Observation on 12/6/24 at 6:46 A.M., showed the resident in his/her bed awake. The resident's chin had a patch of hair. A strong stale body odor permeated from the resident. Observation on 12/6/24 at 7:27 A.M., of the resident's skin, showed: -The resident's super pubic catheter (tube inserted into the bladder to drain urine) site had bloody discharge surrounding the tubing; -Clear, bloody drainage observed in the folds of the resident's abdominal skin; -A strong stale body odor permeated from the area with the drainage. Observation on 12/9/24 at 8:15 A.M., of the resident's skin, showed: -The resident's super pubic catheter site had bloody discharge surrounding the tubing; -Yellow, bloody drainage observed in the folds of the resident's abdominal skin; -A strong stale odor permeated from the area with the drainage. During an interview on 12/11/24 at 7:52 A.M., CNA J said he/she would expect the resident's catheter site to be clean. He/She would expect staff to ask the resident if he/she wants his/her facial hair trimmed and to trim it if the resident says yes. During an interview on 12/11/24 at 9:31 A.M., LPN B said he/she would expect the resident's catheter site and body to be clean to avoid infection and discomfort. He/She would expect the resident's facial hair to be trimmed. During an interview on 12/11/24 at 12:36 P.M., the DON said she would expect staff to ensure the resident's catheter site and body are cleaned. She would expect staff to ask residents if they want their facial hair trimmed. 4. Review of Resident #1's medical record, showed: -Diagnoses included epilepsy, major depressive disorder, and obesity; -Cognitively intact. Review of the resident's care plan, dated 10/28/24, showed: -Focus: resident has an ADL self-care performance deficit; -Goal: will continue to have aspects of care met daily; remaining clean, dry, dressed, groomed and free of odors through review date; -Interventions: staff to assist with completion of ADLs on a daily basis; ensure needs are met daily. Check nail length and trim and clean on bath day and as necessary. During an interview on 12/5/24 at 12:18 P.M., the resident said staff do not always help him/her wash his/her face. Observation on 12/5/24 at 1:08 P.M., showed the resident had white matter around his/her mouth. The resident's left eye had white matter on the skin next to the outer corner. Observation on 12/6/24 at 12:00 P.M., showed the resident had white matter around his/her mouth. The resident's left eye had white matter on the skin next to the outer corner. During an interview on 12/11/24 at 7:52 A.M., CNA J said he/she would expect staff to wash resident's faces during care or whenever they see something on the resident's face. During an interview on 12/11/24 at 9:31 A.M., LPN B said he/she would expect staff to wash resident's faces during care or whenever they see something on the resident's face. During an interview on 12/11/24 at 12:36 P.M., the DON said she would expect staff to wash the resident's face during care or whenever they see something on the resident's face. She would expect staff to be checking the resident's face to ensure it is clean after meals. 5. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Diagnoses included dementia, anxiety, and major depressive disorder; -Cognitively intact. Review of the resident's care plan, dated 10/28/24, showed: -Focus: resident has limited physical mobility and requires staff assistance for completion of ADLs. Self-performance varies at times; -Goal: will continue to have aspects of care met on a daily basis; remaining clean, dry, dressed, groomed and free of odors through review date; -Interventions: staff to assist with completion of ADLs on a daily basis; ensure needs are met daily. Observation on 12/5/24 at 2:21 P.M. and 12/6/24 at 8:55 A.M., showed the resident's nails with dark matter underneath. Observation on 12/9/24 at 12:50 P.M., showed the resident awake in his/her room and ate lunch with his/her hands. His/Her nails contained dark matter underneath. During an interview on 12/11/24 at 7:52 A.M., CNA J said he/she would expect resident's nails to be clean. If the resident refuses help, CNAs are to document this and tell the nurse. During an interview on 12/11/24 at 9:31 A.M., LPN B said he/she would expect residents' nails to be clean. If a resident refuses help with ADL care, staff should attempt to ask the resident at a later time. During an interview on 12/11/24 at 12:36 P.M., the DON said she would expect staff to ensure residents' hands are clean to prevent spread of germs. She would expect staff to document if a resident refuses to be helped. MO00244882 MO00245183 49992

85.042 (14) cl. II* Resident #20 Resident #278 Resident #30 Resident #32 Not priming needle, walking away from resident with medications, and eye was not pulled down for eye drops. [NAME] will organize Resident #20 FTag Initiation 12/10/24 10:09 AM CMT was placing the box of eye drops under her arm, and did not pull the left eye lid down. Resident #30 FTag Initiation 12/10/24 10:13 AM Nurse did not prime insulin pen Resident #32 FTag Initiation 12/10/24 10:11 AM Nurse did not prime the insulin pen. Resident #278 FTag Initiation 12/10/24 10:24 AM CMT left resident with medications in the therapy gym and went to get resident water bottle.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice when the facility failed to store medications, located in the Assistant Director of Nursing's (ADON) office, locked, and not accessible to individuals without authority to access the medications. The facility identified four medication carts, two treatment carts, and two medication rooms. The ADON's office was not identified as a medication storage room. The ADON failed to ensure it was secured when she left her office. The office had several shelves on the back wall that contained multiple bottles of over-the-counter medications and vitamins. An open bottle of medication was also found in the ADON's office that was not labeled. The sample was 19. The census was 72. Review of the facility's Medication Administration Policy, revised 7/17/24, included: -Lock medication cart before entering resident/patient room. Never leave the medication cart open and unattended; -Lock the cart and store in a secure, locked location; -Keep medication room locked at all times; -Maintain medication key with licensed nurse at all times. During an interview on 12/05/24 at 12:32 P.M., Licensed Practical Nurse (LPN) N said there are two medication rooms that are located behind the nurses station, two wound carts, two nurse carts, and two Certified Medication Technician (CMT) carts in the facility. Observation on 12/6/24 at 8:30 A.M., showed the ADON's office open with no one in the office. Located on the shelf on the back wall were multiple over-the-counter (OTC) medications visible from the hallway. At 10:00 A.M., the ADON's office door was open with the light off and no one in the office. At 10:15 A.M., the back wall of the office had shelves with multiple OTC medications such as liquid ibuprofen, acetaminophen, Imodium (used to treat diarrhea), hydrogen peroxide, and a bottle of magnesium citrate (liquid laxative used for constipation) on the second shelf. The bottle of magnesium citrate appeared to have been opened with approximately one fourth liquid missing. No date it was opened was identified on the bottle. At 11:19 A.M., the ADON was not in her office. The office door was opened and the light was on. The medications located on the back shelf were visible from the hallway. During an interview on 12/6/24 at 11:34 A.M., the Director of Nursing (DON) said there are only two medication rooms in the facility. They are both located directly across from the nurse's station. Observation on 12/9/24 at 9:14 A.M., showed the ADON out of her office. The door was opened and the medications were visible from the hallway. Observation on 12/10/24 at approximately 10:45 A.M., showed the ADON's office door was opened and the light was on in the office. No staff were in the office. Observation on 12/11/24 at 9:14 A.M., showed the ADON out of her office. The office door was opened and medications were visible from the hall. During an interview on 12/11/24 at 12:03 P.M., the DON and ADON said a room that contains medications should be locked. The DON said the ADON's office should be considered a medication room if medications are stored in the room. They said the ADON's office should be shut and locked. It should not be left open. The ADON said she does lock the door at night when she leaves for the day. The night shift does not have access to that room. The DON would have to allow them access. Observation on 12/11/24 at approximately 2:00 P.M., showed the ADON was out of her office with the light turned off. The door was open.

Based on observation, interview and record review, the facility failed to ensure call lights were in working order for two sampled residents (Residents #24 and #29). In addition, the facility found issues with call lights in 24 additional resident bedrooms. This had a potential to affect all residents who resided in rooms with non-functioning call lights. The sample was 19. The census was 72. Review of the facility's undated call light policy, showed: -Purpose: To respond to resident/patient's request and needs; -Procedure: -Answer call lights in a reasonable amount of time; -Determine resident/patient's request; -Turn off call light; -Listen to resident/patient for further requests or needs; -Respond to request. If unable to meet request obtain assistance from caregiver that can meet request; -Assist resident/patient as needed to a comfortable position with call light within reach. 1. Review of the facility's nurse call system report, dated 11/19/24, showed: -room [ROOM NUMBER]: Does not annunciate right console; -room [ROOM NUMBER]: Does not annunciate right console; -room [ROOM NUMBER]: Does not annunciate both consoles -room [ROOM NUMBER]: Does not annunciate right consoles; -room [ROOM NUMBER]: Does not annunciate right console; -room [ROOM NUMBER]: Does not light up corridor light; -room [ROOM NUMBER]: Comes in as 203 and does not light hall light; -room [ROOM NUMBER]: Does not annunciate either console; -room [ROOM NUMBER]: Comes in as 205 on both consoles; -room [ROOM NUMBER]: Comes in as 207 on both consoles; -room [ROOM NUMBER]: Does not light up left console; -room [ROOM NUMBER]: No annunciation on either console; -room [ROOM NUMBER]: No annunciation on either console; -room [ROOM NUMBER]: No annunciation on left console; -room [ROOM NUMBER]: No annunciation on either console; -room [ROOM NUMBER]: No annunciation on left console; -room [ROOM NUMBER]: No annunciation on left console; -room [ROOM NUMBER]: No annunciation on left console; -room [ROOM NUMBER]: Does not annunciate left console; -room [ROOM NUMBER]: Does not annunciate either console; -room [ROOM NUMBER]: Does not light corridor light; -room [ROOM NUMBER]: Does not annunciate left console; -room [ROOM NUMBER]: Does not annunciate either console; -room [ROOM NUMBER]: Does not annunciate either console; -room [ROOM NUMBER]: Does not annunciate left console; -room [ROOM NUMBER]: Does not annunciate right console; -Problems noted/plan of correction: Yes we are in the process with electronic company per their assessment. 2. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/24, showed: -Diagnoses included dementia, anxiety and major depressive disorder; -Cognitively intact. Review of the resident census, dated 12/5/24, showed the resident located in a room that does not light up a corridor light. During an interview on 12/5/24 at 12:27 P.M., the resident said it sometimes takes a long time for staff to answer his/her call light. Observation on 12/10/24 of the resident's call light, showed: -At 6:53 A.M., the call light panel at the nurse's station indicated that the resident's call light was activated. The call light above the resident's bedroom door was off. Certified Nursing Assistant (CNA) D sat at the nurse's station and said the resident's call light was broken and that the indication on the call light panel was a ghost light; -At 6:59 A.M., the Wound Nurse walked up to the nurse's station. He/She noticed the call light panel indicated the call light for the resident's was activated. He/She said phantom light and walked away to assist a different resident; -At 7:01 A.M., the Wound Nurse walked past the nurse's station and said he/she was going to find the Maintenance Director to tell him the resident's call light was broken; -At 7:05 A.M., Licensed Practical Nurse (LPN) B walked into a different resident's room and the call light indicator at the nurse's station turned off for Resident #24's room. 3. Review of Resident #29's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure and schizophrenia (a serious mental health condition that affects how people think, feel and behave). Review of the facility's resident census, dated 12/5/24, showed the resident was located in a room that the call system comes on at the nurse's station as the call light for a different resident's room, and does not light up at the hall light. Observation and interview on 12/6/24 at 11:40 A.M., showed the call light to a different resident's room activated on the console at the nurses station. The light above the indicated room was not on. The resident said he/she was the one who activated his/her call light. CNA E entered the room. The resident said he/she wanted water. CNA E grabbed the resident's cup and left the room. During an interview on 12/6/24 at 11:45 A.M., CNA E said the light outside the resident's room does not light up, but it will at the nurse's station. Observation and interview 12/6/24 at 11:50 A.M., showed the resident's call light was activated, however, a different resident's room was indicated on the console at the nurse's station. The resident said he/she was unaware there were issues with the call light. He/She believed it was fixed. He/She also held up a bell and said staff gave him/her a bell to ring. 4. During an interview on 12/10/24 at 12:12 P.M., LPN B said there is a ghost light. When call lights are indicated in rooms 203, 204 or 205, staff check all the rooms to see who needed assistance. On 12/11/24 at 9:35 A.M., LPN B said he/she was aware the call lights for Residents' #24 and #29 were not working. If Resident #29 pushes his/her call light, the call light panel at the nurse's station lights up, indicating that a different room's call light is going off. He/She expected the residents' call light to be in working order. 5. Observation on 12/6/24 at 11:58 A.M., showed the call light was activated by the surveyor in room [ROOM NUMBER]. The light above the entrance to the room turned on, but room [ROOM NUMBER] not on the console at the nurse's station. 6. During an interview on 12/11/24 at 8:27 A.M. and 10:50 A.M., the Maintenance Director said he was aware of the call light issue. The system needed repair and a tech came out. On the 200 hall, there are several rooms that register room [ROOM NUMBER] at the nurse's station. The company was out a few weeks ago and each resident is to have a bell in the room if the call light is malfunctioning. He was going to get more bells today for any room affected by call lights. They did in-service staff on what was going on and to do 15-minute checks on the room without working call lights. He expected call lights to be in working order. It is important for call lights to work so residents can get help. 7. During an interview on 12/11/24 at 10:55 A.M., LPN P said he/she was agency staff and it was his/her first day at the facility. He/She knew to check the call light when they go off but was not in-serviced on the call lights not working. He/She was not aware some rooms on the 200 unit show up as 203 on the console. He/She was assigned to the 500 unit, and he/she was not informed some rooms on 500 unit did not show at the nurse's station. He/She was not aware residents were given bells. 8. During an interview on 12/11/24 at 12:00 P.M., the Administrator said she expected the call lights to be in working order. Staff should be informed on the current call light system, which resident has bells, and which rooms did not have a working light. They currently have a proposal to fix the lights and they are waiting for another one. She expected agency staff to be verbally educated with the policy at the nurse's station and on the 24 hour report. 46888

Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for one resident who had an order to get up before lunch and required the use of a Hoyer lift (mechanical lift) when the staff could not find a Hoyer lift pad and did not obtain another one for use (Resident #21). The sample was 19. The census was 72. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/24/24, showed: -Cognitive impairment; -Dependent, helper does all the effort and resident does none of the effort to complete the activity for toileting, shower/bathing, upper and lower body dressing, and personal hygiene; -Substantial/Maximum assistance for resident to roll left and right; -Setup or clean up assistance for eating; -Incontinent of bowel and bladder; -Diagnoses included diabetes, aphasia (inability to understand or express speech), stroke, anxiety and depression. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 5/7/24, client to be up in wheelchair before lunch in the morning for prophylaxis (measures designed to preserve health); -An order, dated 5/7/24, client to lay back down after dinner for offloading in the afternoon for prophylaxis. Review of the resident's care plan, revised 11/15/22, showed: -Focus: Resident has activity daily living (ADL) self-care performance deficit related to disease process. Requires staff assistance for completion of ADLs. Self-performance varies at times; -Goal: Will continue to have aspects of care met daily; remaining clean, dry, dressed, groomed, and free of odors through review date; -Interventions: Mechanical lift with assist of two. Offer to assist resident out of bed at approximately 9:00 A.M. Resident voiced this is the preferred time, with the option to alter as desired. Provide incontinence care. Staff to assist with completion of ADLs on a daily basis; ensure needs are met daily. Monitor and report changes. Observation on 12/9/24 at 9:05 A.M., showed the resident lay in bed. At 9:27 A.M., the resident's call light was on and visible outside his/her room. The Certified Medication Technician (CMT) entered the room to check on the resident, then exited the room and told the Unit Manager the resident wanted to see the nurse. At 9:35 A.M., Licensed Practical Nurse (LPN) C entered the room. LPN C asked the resident what was wrong. The resident pulled at his/her brief. LPN C unfastened the brief and assessed the area. LPN C said he/she would send in the Certified Nurse Assistant (CNA) to provide care. LPN C requested CNA E and CNA L provide care to the resident. At 9:55 A.M., CNA E and CNA L entered the resident's room. Personal hygiene care was provided. Staff did not offer the resident to get out of bed. At 10:20 A.M., LPN C entered the resident's room. The resident lay in bed. LPN C did not offer the resident to get out of bed. At 12:00 P.M., the resident lay in bed asleep. At 12:45 P.M., the resident lay in bed with his/her food tray in front of him/her on the bed side table. The tray was covered. At approximately 1:05 P.M., staff in and out of the resident's room while the resident lay in bed. Staff exited the room with the resident's food tray. At 2:00 P.M., the resident lay in bed. Observation on 12/10/24 at 9:48 A.M., showed the resident lay in bed with his/her breakfast tray in front of him/her, on the bed side table. At 10:55 A.M., the resident lay in bed. Two Hoyer pads lay on the resident's chair. CNA M entered the room. CNA M said he/she was going to provide care and then get the resident up for the day. CNA M said the resident was not up yesterday during his/her shift because yesterday was one of those days and staff did not have a Hoyer pad for the resident. CNA M is not sure if the facility has a backup one but he/she looked in laundry and around for one but never found one, so the resident stayed in bed. CNA M said the resident likes to be up every day. The resident uses his/her cell phone to communicate and can use hand gestures like thumbs up. The resident is normally up most of the day. While providing care, CNA M found two Hoyer pads in the resident's drawer by the sink. CNA M said he/she was not aware the pads were in that drawer. CNA M placed the Hoyer pad under the resident. CNA M requested CNA O enter the room to assist with the Hoyer transfer. Both CNAs assisted the resident out of bed and into his/her chair. During an interview on 12/11/24 at 12:03 P.M., the Director of Nursing (DON) and Administrator said it is not ok to leave a resident in bed because the staff could not find a Hoyer pad. The DON said she expected staff to notify her so they could figure out a solution or find a pad. The Administrator said she has extra Hoyer pads in her office.

Based on observation, interview and record review, the facility failed to ensure privacy during care for one resident (Resident #3). The census was 72. The sample was 19. Review of the facility's Resident's Rights policy, revised 1/5/22, showed the following: -Protocol: the facility will address ethical issues and respect resident rights in providing care. The facility recognizes the resident right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making, consistent with state law and federal regulation; -Procedure: explain rights to resident and/or responsible party at or before admission. Give resident and/ or responsible party a copy of the resident rights in writing. Involve residents/responsible party in all aspects of care. Involve resident/responsible party in resolving conflicts about care decisions. Involve residents. Review of Resident #3's Medical Record showed: -Diagnoses included aphasia (language disorder that affects a person's ability to communicate), dementia, and major depressive disorder; -Severe cognitive impairment. Observation on 12/6/24 at 1:58 P.M., showed Certified Nursing Assistant (CNA) F walked to the resident's bed after putting on gloves and pulled the resident's blanket down, exposing the resident's stomach and brief. The resident's door was wide opened and his/her privacy curtain was not pulled. The resident was visible from the hallway. The Nurse Manager walked to the door and poked his/her head in to ask if CNA F needed any assistant and then walked away, leaving the door open. During an interview on 12/11/24 at 7:54 A.M., CNA D said when providing care to a resident staff should close the door to the resident's room. It is important to give the resident privacy as much as possible. During an interview on 12/11/24 at 9:34 A.M. Licensed Practical Nurse (LPN) B said when providing care to a resident, staff should close the resident's door and pull the privacy curtain if they have a roommate. Is important to ensure the dignity of the resident. During an interview on 12/11/24 at 12:07 P.M., the Director of Nursing (DON) said she would expect staff to provide privacy to residents when providing care. She would expect staff to pull the privacy curtain and close the door to the resident's room.

Based on interview and record review, the facility failed to provide an appropriate discharge for one sampled resident (Resident #7) out of four residents sampled for discharge. Resident #7 received an immediate discharge after a resident to resident altercation that was de-escalated by staff without incident or any reported injuries. Despite the absence of severe behaviors, the facility issued an immediate discharge, citing the resident's care and protective oversight currently exceeded current capacity. The census was 72. Review of the facility's Room Changes, Transfers, and Discharge policy, revised July 2022, showed: -Protocol: The purpose of this Protocol is to inform residents/patients of the facility's protocol regarding room changes, transfers, and/or discharges and to provide sufficient preparation and orientation to residents/patients to ensure safe and orderly room changes, transfers, and/or discharges; -Transfers and discharges will be conducted according to State and Federal regulations; -Discharges: Residents/patients will be discharged from the facility as soon as reasonably possible pursuant to a written physician's order or upon signing a Release Against Medical Advice form. If the resident/patient, family and/or responsible party requests the discharge against medical advice, the reason for the discharge and evidence that the issue was discussed with the resident/patient, family, and/or responsible party will be recorded in the resident/patient's medical record; -Reasons for which a resident/patient may be discharged from the facility: The facility determines that the discharge is necessary for the resident's/patient's welfare and the resident/patient's needs cannot be met in the facility; -The resident/patient's physician must document evidence in the resident/patient's clinical record that a discharge is necessary; -Such action is appropriate because the resident/patient's health has improved sufficiently so that the resident/patient no longer needs the services provided by the facility; -The resident/patient's physician must document evidence in the resident/patient's clinical record that a discharge is necessary; -The safety of individuals in the facility is endangered; -The resident/patient's physician must document evidence in the resident/patient's clinical record that a discharge is necessary; -The health of individuals in the facility would otherwise be endangered; - The resident/patient's physician must document evidence in the resident/patient's clinical record that a discharge is necessary; -The resident/patient has failed, after reasonable and appropriate notice to the resident/patient and/or the resident/patient's responsible party, to pay for a stay at the facility; -The facility loses its license, certification, or otherwise ceases to operate; -For facility initiated transfers the facility will provide the resident and/or responsible party with a copy of the bed hold notice, a copy of the facility initiated transfer from within upon discharge and/or within 24 hours/as soon as possible. These forms are to be uploaded into the Electronic Health Record (EHR) as verification. Any signed forms returned should also be uploaded into the EHR. The local Ombudsman will be provided a monthly notification of facility-initiated transfers; -Preparation for discharge: Residents/patients being discharged from the facility will be provided with adequate preparation to ensure a safe and orderly transfer from the facility, and the home or setting to which the resident/patient is discharged will have accepted the resident/patient; -Notification: The facility will provide residents/patients with a 30-day written notice of an impending discharge from the facility, except in an emergency or where otherwise exempted by statue, rule, or regulation wherein written notice will be given as soon as practicable. The Notice of Discharge will be given to the resident/patient or sent certified mail, return receipt requested, to the resident/patient's legal guardian. The notice will include: -The reason for the discharge; -The effective date of the discharge; -The location to which the resident/patient will be discharged ; -A statement that the resident/patient has the right to appeal the action to the state within 10 days after the receipt of the notice of the proposed action to the State's legal services office to which the appeal should be sent; -The name, address, and telephone number of the State's Long-Term Care Ombudsman; -The address and the telephone number of the State Legal Rights Service for residents/patients who are developmentally disabled and/or mentally ill. Review of the facility's undated Resident Rights policy, showed: -Rights During Discharge/Transfer: Right to appeal the proposed transfer or discharge and not be discharged while an appeal is pending; -Receive 30 day written notice of discharge or transfer that includes: the reason, the effective date, the location going to, appeal rights and process for filing an appeal, and the name and contact information for the long-term care ombudsman; -Preparation and orientation to ensure safe and orderly transfer or discharge; -Notice of the right to return to the facility after hospitalization or therapeutic leave. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/24, showed: -Brief Interview Mental Status (BIMS) score 15 out of 15, shows cognitively intact; -Diagnoses included high blood pressure, gastroesophageal reflux (GERD, acid reflux), diabetes, dementia, depression, manic depression, and post traumatic stress disorder (PTSD, disorder caused by extremely stressful or terrifying event); -Mood severity score of 15 out of 27, shows moderately severe depression; -No physical or verbal behaviors exhibited; -No wandering behavior exhibited. Review of the resident's care plan, in use during survey, showed: -Focus: The resident is resistive to care related to refusing medications, treatments, assessments, noncompliance, soft helmet use; -Goal: The resident will cooperate with care; -Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control; Give clear explanation of all care activities prior to and as they occur during each contact; If possible, negotiate a time for Activities of Daily Living (ADLs) so that the resident participates in the decision making process. Return at the agreed upon time; If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again; Praise the resident when behavior is appropriate; Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible; Provide resident with opportunities for choice during care provision; -Focus: The resident is/has potential to be physically and verbally aggressive related to anger, poor impulse control, combative, striking out, and throwing items, yelling out, and screaming. On 5/12/24, yelling/screaming at another resident over phone placement. Educated, not easily directed. On 9/17/24, involved in resident-to-resident altercation. On 10/14/24, reported altercation; -Goal: The resident will demonstrate effective coping skills; -Interventions: 15 minute checks; Administer medications as ordered. Monitor/document for side effects and effectiveness; Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; Assess and address for contributing sensory deficits; Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain; Communication: Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; Give the resident as many choices as possible about care and activities; Modify environment; Monitor/document/report as needed (PRN) any signs and symptoms of resident posing danger to self and others; Psychiatric/Psychogeriatric consult as indicated; When the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Review of the resident's progress notes, dated October 2024, showed: -On 10/11/24 at 1:44 P.M., Social Service Director (SSD) follow up with resident no behavior at the time. SSD will continue to monitor; -On 10/14/24 at 11:44 A.M., During this writers 15 min check this writer questioned resident about his/her lip being swollen and he/she stated that a person hit him/her in it the other day. When he/she flipped his/her upper lip and there is a cut maybe from a tooth or a bite. Physician was notified, his/her responsible party notified. Director of Nursing (DON) conducted a head to toe assessment upon investigation. This writer placed an ice pack to help with swelling. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated October 2024, showed an order, dated 10/29/24, to monitor behaviors. Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above observed. N if monitored and none of the above observed, select chart code other/see nurses notes and progress note findings every morning and at bedtime reported to unspecified dementia, unspecified severity, with other behavior disturbances. Review of the resident's electronic Medical Administration Record (eMAR), dated October 2024, showed an order, dated 10/29/24, to monitor behaviors. Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above observed. N if monitored and none of the above observed, select chart code other/see nurses notes and progress note findings every morning and at bedtime reported to unspecified dementia, unspecified severity, with other behavior disturbances; -Staff documented Y on the following dates and times: -10/11/24 at 8:15 A.M.; -10/14/24 at 8:44 A.M.; -10/19/24 at 9:23 A.M.; -10/20/24 at 10:12 A.M.; -10/22/24 at 9:44 P.M.; -10/29/24 at 9:33 P.M.; -10/31/24 at 8:36 P.M. Review of the resident's progress notes, dated October 2024, showed: -No documentation of behaviors on 10/11/24 at 8:15 A.M., 10/14/24 at 8:44 A.M., 10/19/24 at 9:23 A.M., 10/20/24 at 10:12 A.M., 10/29/24 at 9:33 P.M., and 10/31/24 at 8:36 P.M.; -On 10/22/24 at 10:29 P.M., Resident voiced feeling sad about not being able to see and talk to his/her spouse. Resident stated, I want to go to see my spouse. I haven't seen him/her in months, I can't talk to him/her or nothing. I just want to die. I want to get out of here. Resident continues on every 15-minute checks; -No documentation of the resident having aggressive behaviors towards other residents. Review of the resident's hospital record, dated 10/23/24 through 10/28/24, showed: -He/She has a history of major neurocognitive disorder (decreased mental function) with behavioral disturbances. He/She was admitted due to increasing agitation at nursing home and was sent to hospital emergency department for his/her safety and that of others. Resident has limited-little insight into his/her deficits and is unable to understand the situation, most of the time when interviewed (mostly questions written on paper and shown to him/her and he/she nods his/her head, though at times his/her frustration status is involved in his/her answers. Because of significant lack of communication, his/her care may be difficult at times, that causes significant frustration for him/her and staff. He/she does have a history of depression for which he/she had been treated for since 2000s. Review of the resident's eMAR, dated November 2024, showed an order, dated 10/29/24, to monitor behaviors. Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above observed. N if monitored and none of the above observed, select chart code other/see nurses notes and progress note findings every morning and at bedtime reported to unspecified dementia, unspecified severity, with other behavior disturbances; -Staff documented Y on the following dates and times: -11/2/24 at 11:45 A.M.; -11/2/24 at 8:25 P.M.; -11/3/24 at 9:58 A.M.; -11/4/24 at 9:48 A.M.; -11/6/24 at 9:10 P.M.; -11/7/24 at 8:20 P.M.; -11/8/24 at 8:22 A.M.; -11/9/24 at 8:18 A.M.; -11/10/24 at 8:36 A.M.; -11/11/24 at 8:12 A.M.; -11/16/24 at 9:17 P.M.; -11/17/24 at 8:09 A.M.; -11/17/24 at 9:12 P.M.; -11/22/24 at 8:03 A.M.; -11/25/24 at 8:36 A.M.; -11/27/24 at 8:41 A.M.; -11/28/24 at 10:09 A.M.; -11/29/24 at 12:06 P.M.; -11/30/24 at 11:00 A.M. Review of the resident's progress notes, dated November 2024, showed: -No documentation of behaviors on 11/2/24 at 11:45 A.M., 11/2/24 at 8:25 P.M., 11/3/24 at 9:58 A.M., 11/4/24 at 9:48 A.M., 11/6/24 at 9:10 P.M., 11/7/24 at 8:20 P.M., 11/8/24 at 8:22 A.M., 11/9/24 at 8:18 A.M., 11/10/24 at 8:36 A.M., 11/11/24 at 8:12 A.M., 11/16/24 at 9:17 P.M., 11/17/24 at 8:09 A.M., 11/17/24 at 9:12 P.M., 11/22/24 at 8:03 A.M., 11/25/24 at 8:36 A.M., 11/27/24 at 8:41 A.M., 11/28/24 at 10:09 A.M., 11/29/24 at 12:06 P.M., and 11/30/24 at 11:00 A.M.; -On 11/3/24 at 3:03 P.M., resident touched on another resident breast. The house supervisor and Assistant Director of Nursing (ADON), doctor and spouse were made aware. This nurse separated the resident from the other resident and educated him/her about touching people in an inappropriate manner. On 11/4/24 at 11:11 A.M., Per investigation, this incident did not occur; -On 11/5/24 at 1:04 P.M., A care plan meeting was held. Present in the meeting was the Interdisciplinary Team (IDT) (SSD and Nurse Supervisor) and resident. Resident's spouse was unable to attend in person or via phone. Spouse would like a copy of the care plan mailed to him/her. Resident alert and oriented (A&O) x 3, able to make his/her needs known and understand others. Resident ambulates using a wheelchair. Resident quite pleasant and cooperative. No behaviors at this time but the resident is known for being non-compliant when it comes to wearing his/her helmet and has history of exit seeking. Resident did voice that he/she wanted to go to see his/her spouse. During the care plan resident was able to voice feeling related to placement; no concerns voiced. Resident voiced that the food was good and didn't provide a suggestion on an activity that he/she would like to see on the calendar. Current care plan was reviewed with no changes. Medications were also reviewed along with resident rights. There's no discharge plans at this time. Long term care anticipated; -On 11/7/24 at 3:27 P.M., Resident's spouse was made aware of the decision to send referrals to alternate placement for resident. Resident's exit seeking behavior/care is exceeding facility current capacity. Spouse voiced understanding; -On 11/14/24 at 12:01 P.M., Late entry, Resident has had no significant change. Resident continues to be a full code and Long-Term Care. Resident has had some behaviors verbal/physical. Ambulate using a wheelchair, requires assistance with ADLs. Independent activities such as watching tv/resting and group parties, ice cream social, events, etc. Veterans Day was on Monday, 11/11/24. A pinning ceremony was held for all Veterans at facility. Resident was proud to attend the ceremony and really appreciated being honored by staff. SSD will continue to monitor; -No documentation of the resident having aggressive behaviors towards other residents. Review of the resident's electronic Medical Administration Record, dated December 2024, showed an order, dated 10/29/24, to monitor behaviors. Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above observed. N if monitored and none of the above observed, select chart code other/see nurses notes and progress note findings every morning and at bedtime reported to unspecified dementia, unspecified severity, with other behavior disturbances; -Staff documented Y on the following dates and times: -12/1/24 at 10:08 A.M.; -12/6/24 at 10:51 A.M.; -12/6/24 at 3:28 P.M. Review of the resident's progress notes, dated December 2024, showed: -No documentation of behaviors on 12/1/24 at 10:08 A.M.; -On 12/6/24 at 3:18 P.M., resident transfers with min assist. Resident ambulated up to 25 feet with a w/w and min assist; slow. Independent with bed mobility. Contact guard assist with standing and independent with wheelchair mobility. No complaints of pain with mobility. Independent with feeding and stand by assistance with grooming. Minimum assist with upper body dressing and maximum assist with lower body dressing. Resident very impulsive and unsafe; -On 12/6/24 at 3:28 P.M., Client placed on 1:1 related to striking another client; -On 12/6/24 at 3:50 P.M., Resident issued immediate discharge after physical altercation with another resident. Physician aware, call placed to Emergency Medical Service (EMS) to transport resident to hospital for psych eval and treat, resident continues with 1:1, resident is calm and cooperative at this time. Will continue to monitor for change in condition; -On 12/6/24 at 4:03 P.M., Client is to be sent to VA hospital; -On 12/6/24 at 4:03 P.M., At 3:14 P.M., Administrator and DON made aware that during a Bingo game, the client was up ad-lib in his/her wheelchair, propelled self over to another client, and picked up their Bingo card. When the other client pulled his/her card from resident's hand and tapped his/her hand away from his/her Bingo card, resident returned strike to the clients arm with a closed fist. Staff intervened and separated. The client will remain on 1:1 monitoring until EMS arrives for transport to the VA; -On 12/6/24 at 4:06 P.M., Call placed to emergency medical services (EMS), this writer requested he/she is sent to VA Hospital, call placed to spouse notified him/her that resident will be sent to the hospital with an immediate discharge. Spouse stated his/her understanding and thanked this writer for letting him/her know; -On 12/6/24 at 11:09 P.M., Resident is currently receiving 1:1 room visit. This week we played sorry, candy land, checkers, cleaned his/her fingernails, messaged his/her hands, and combed his/her hair. He/She also participated in group activities, exercising, parachute, find the ball, ice cream social, and movie time. There are no concerns/issues to report; -On 12/6/24 at 11:54 P.M., Resident transferred to hospital via ambulance, resident took all belongings with him/her. Notified EMS of immediate discharge. Review of the facility's investigation into a resident to resident altercation, dated 12/6/24, showed: -Background: Resident was admitted to the facility on [DATE]; -Resident has a diagnoses of dementia without behavioral disturbance, bipolar, and major depressive disorder; -History of attempting to leave the facility unsupervised and physical aggression; -Currently on 15 minute checks and alternate placement; -Medical records sent to other VA contracted facilities, all denied; -Resident was involved in another resident to resident on 12/6/24 where it was precipitated by resident when he/she picked up Resident #45's Bingo card; -Remit of investigation: Staff witnessed Resident #7 and #45 strike one another; -Administrator and DON were notified; -An investigation was immediately initiated by Administrator; -Investigation process: Interview staff and resident; -Watch camera footage; -Findings: Resident #7 interrupted Resident #45 while playing Bingo by messing with Resident #45's belonging; -Resident #45 initiated the first hit by slapping Resident #7's right hand; -Resident #7 returned a punch to Resident #45's left arm and the two started swinging at one another; -No physical injuries; -Interventions: Resident #45 placed on 15 minute checks; -Resident #7 placed on 1:1 until ambulance arrived; -Immediate discharge issued to Resident #7 related to care exceeding current capacity related to dementia progression. Review of Resident #7's witness statement, dated 12/6/24, showed: -Who was involved: Resident #7 and Resident 45; -What happened: Resident #7 states, I was looking at the Styrofoam and he/she started hitting me. Review of Resident #45's witness statement, dated 12/6/24, showed: -Who was involved: Resident #7 and Resident #45; -What happened: Resident #45 was playing bingo and Resident #7 grabbed at his/her hat and bag and Resident #45 said, that is mine, then Resident #7 started swinging; -Where did it happen: Dining room; -Additional comments: This writer asked Resident #45 if he/she was hurt and he/she said no. During an interview on 12/11/24 at 8:39 A.M., Resident #45 said he/she was playing bingo and had two packs of cigarettes on the table. There were inside a bag. Resident #7 tried to take the bag, but Resident #45 put his hand on the bag and Resident #7 started hitting him/her on the arm. There was no pain and Resident #7 did not hit hard enough to be painful. Staff immediately took him/her out of the room. Resident #45 said he/she did not hit Resident #7. His/her arm could not reach far enough to hit Resident #7. He/She had witnessed Resident #7 hit other residents. The last time was during the summer. Resident #7 was not the type of resident others were afraid of. When people annoy Resident #7, he/she tries to hit them. That was his/her behavior. Review of the facility's camera footage, received 12/10/24, showed Resident #7 self-propelled to the table where Resident #45 sat. Resident #7 came up to the table where there was a bag siting on the left side of Resident #45. Resident #7 used his/her right hand and started to touch the bag on the table. Resident #45 immediately stopped Resident #7 by using his/her left hand to hit Resident #7's right hand. Resident #7 started to swing his/her right arm that made contact with Resident #45 on the left shoulder. Both residents started to swing their arms at one another, with Resident #7 using both of his/her arms to swing at Resident #45. Resident #45 used his/her left arm to swing at Resident #7. The resident's arms made contact with each other before the video ended. Review of the resident's immediate discharge notice, dated 12/6/24, showed: -The welfare and needs of the resident cannot be met in the facility; -The safety of other individuals in the facility is endangered; -This discharge will take place immediately; resident's care and protective oversight currently exceeds current capacity. Resident #7 has been in two resident to resident physical altercations; 9/17/24 and 12/6/24. Resident requires a facility better suited for his/her aggressiveness and continued exit seeking behavior. During an interview on 12/10/24 at approximately 10:00 A.M., the Administrator said Resident #7 was given an immediate discharge. His/Her dementia was progressing, and it was becoming a risk if he/she hit another resident. Many residents are younger, alert, and oriented. She did not want anything to happen to the resident. They have been trying to find placement for the resident. During an interview on 12/11/24 at 8:37 A.M., Licesced Practical Nurse (LPN) B said Resident #7 did have a lot of behaviors. He/She hit staff and residents. He/She would often call out for his/her spouse. During an interview on 12/11/24 at 8:45 A.M., Certified Nurses Aide (CNA) S said he/she was a little familiar with Resident #7. He/She only worked for three weeks, but did not witness the resident having aggressive behavior. During an interview on 12/11/24 at 8:50 A.M., the Assistant Director of Nursing (ADON) said the resident was hard of hearing and he/she did not like using the board because of the sound. He/She he tried to throw the board out once. He/She had dementia with behavior disturbances. He/She could not be re-orientated back to reality. He/She was verbally abusive to staff and residents and tried to get out of the building. His/Her history at home was he/she attacked his/her spouse and held him/her at gun point. He/She had not been home in two years. He/She does talk to his/her spouse on the phone. They tried placement with several VA facilities and other facilities. They sent a lot of referrals, but was not accepted because of his/her behaviors. He/She needed a secured unit. During an interview on 12/11/24 at 9:00 A.M., the Activity Supervisor said he/she was familiar with the resident and never witnessed behaviors. The resident wanted attention. Once he/she started talking to the resident, he/she wanted the attention of that person. It did not have to make sense what the resident was talking about as long as he/she had your attention. He/she liked to move around during activities. He/She did not bother other residents other than saying, how are you doing. He/She liked to go to activities. He/She was not a bad resident. During an interview on 12/11/24 at 12:00 P.M., the Director of Nursing (DON) clarified the question, was a behavior observed today on the eMAR and progress notes. She said it will show up in the electronic medical record, but the actual question is asking if staff observed the resident's behavior, to see if they are actually monitoring the behavior. It did not mean that the resident had a behavior. Staff are aware of that. If there was a behavior, she would expect it to be documented. During an interview on 12/11/24 at 12:00 P.M., the Administrator said the decision for an immediate discharge rather than a 30 day discharge was more for safety for the residents. Resident #7's dementia was progressing. They were looking for alternate placement for him/her. He/She had exit seeking behaviors. They have more cognitively intact residents and if Resident #7 took something from another resident, they could him/her and hurt him/her. They did 15 minute checks to see if there were any continued behaviors. He/She also had a history of suicidal ideation. There was also a resident to resident altercation in the last three or four months. He/She verbally voiced, I just want to die. He/She wanted to see his/her spouse, but the spouse will not come because he/she is fearful of the resident.

Based on interview and record review, the facility failed to notify the Ombudsman in the timely manner after an immediate discharge was issued to one resident after a resident-to-resident altercation. The facility issued an immediate discharge, citing the resident's care and protective oversight currently exceeded current capacity (Resident #7). The census was 72. Review of the facility's Room Changes, Transfers, and Discharge policy, revised July 2022, showed: -Protocol: The purpose of this Protocol is to inform residents/patients of the facility's protocol regarding room changes, transfers, and/or discharges and to provide sufficient preparation and orientation to residents/patients to ensure safe and orderly room changes, transfers, and/or discharges; -Transfers and discharges will be conducted according to State and Federal regulations; -Reasons for which a resident/patient may be discharged from the facility: The facility determines that the discharge is necessary for the resident's/patient's welfare and the resident/patient's needs cannot be met in the facility; -The resident/patient's physician must document evidence in the resident/patient's clinical record that a discharge is necessary; -The safety of individuals in the facility is endangered; -The resident/patient's physician much document evidence in the resident/patient's clinical record that a discharge is necessary; -Preparation for discharge: Residents/patients being discharged from the facility will be provided with adequate preparation to ensure a safe and orderly transfer from the facility, and the home or setting to which the resident/patient is discharged will have accepted the resident/patient; -Notification: The facility will provide residents/patients with a 30-day written notice of an impending discharge from the facility, except in an emergency or where otherwise exempted by statue, rule, or regulation wherein written notice will be given as soon as practicable. The Notice of Discharge will be given to the resident/patient or sent certified mail, return receipt requested, to the resident/patient's legal guardian. The notice will include: -The reason for the discharge; -The effective date of the discharge; -The location to which the resident/patient will be discharged ; -A statement that the resident/patient has the right to appeal the action to the state within 10 days after the receipt of the notice of the proposed action to the State's legal services office to which the appeal should be sent; -The name, address, and telephone number of the State's Long-Term Care Ombudsman; -The address and the telephone number of the State Legal Rights Service for residents/patients who are developmentally disabled and/or mentally ill. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/24, showed: -Cognitively intact; -Diagnoses included dementia, depression, manic depression and post traumatic stress disorder (PTSD, disorder caused by extremely stressful or terrifying event); -Mood severity score of 15 out of 27, shows moderately severe depression; -No physical or verbal behaviors exhibited; -No wandering behavior exhibited. Review of the facility's investigation, dated 12/6/24, showed: -Background: Resident was admitted to the facility on [DATE]; -Resident has a diagnoses of dementia without behavioral disturbance, bipolar, and major depressive disorder; -History of attempting to leave the facility unsupervised and physical aggression; -Currently on 15 minute checks and alternate placement; -Medical records sent to other VA contracted facilities, all denied; -Resident was involved in another resident to resident on 12/6/24 where it was precipitated by resident when he/she picked up the resident's (Resident #45) Bingo card; -Remit of investigation: Staff witnessed Resident #7 and #45 strike one another; -Administrator and Director of Nursing (DON) were notified; -An investigation was immediately initiated by Administrator; -Investigation process: Interview staff and resident; -Watch camera footage; -Findings: Resident #7 interrupted Resident #45 while playing Bingo by messing with Resident #45's belonging; -Resident #45 initiated the first hit by slapping Resident #7's right hand; -Resident #7 returned a punch to Resident #45's left arm and the two started swinging at one another; -No physical injuries; -Interventions: Resident #45 placed on 15 minute checks; -Resident #7 placed on 1:1 until ambulance arrived; -Immediate discharge issued to Resident #7 related to care exceeding current capacity related to dementia progression. Review of the resident's immediate discharge notice, dated 12/6/24, showed: -The welfare and needs of the resident cannot be met in the facility; -The safety of other individuals in the facility is endangered; -This discharge will take place immediately, resident's care and protective oversight currently exceeds current capacity. Resident #7 has been in two resident to resident physical altercations; 9/17/24 and 12/6/24. Resident requires a facility better suited for his/her aggressiveness and continued exit seeking behavior. During an interview on 12/10/24 at approximately 10:00 A.M., the Administrator said the resident was given an immediate discharge. His/Her dementia was progressing and it was becoming a risk if he/she hit another resident. Many residents are younger, alert and oriented. She did not want anything to happen to the resident. They have been trying to find placement for the resident. On 12/11/24 at 12:00 P.M., the Administrator said the decision for an immediate discharge rather than a 30 day discharge was more safety for the residents. The Administrator said the Ombudsman was not notified of the immediate discharge. The Social Worker was responsible for sending the information. She expected staff to notify the Ombudsman timely.

Based on interview and record review, the facility failed to ensure when a resident is being admitted to a Medicaid certified facility, regardless of payment source, a DA-124 Level 1 screen (used to evaluate for the presence of mental illness and intellectual disability, to determine if a preadmission screening\resident review (PASRR) Level 2 screen is required) was completed, for one of six residents sampled for the PASRR requirements (Resident #4). The census was 72. Review of the facility's PASRR Protocol showed: -Procedure: Review hospital records and determine PASRR. Does the resident meet level of care and/or require a Level 2 PASRR to be appropriate for admission. Was a Level 1 screen for possible mental disability, intellectual disability, or a related condition completed prior to admission or if the resident was expected to be in the facility less than 30 days and remained in the facility for more than 30 days (as allowed by the state) was a Level 1 screen performed, if not the social service designee will implement the process. If the mental disability, intellectual disability, or related condition is noted the social service director will make a referral to the Council on Aging for a Level 2 PASRR evaluation and determination. 1. Review of Resident #4's face sheet, showed: -Initial admitted [DATE]; -Current admitted [DATE]; -Diagnoses of right-sided weakness due to a stroke, diabetes, depression, aphasia (loss of speech) due to stroke, high blood pressure, epilepsy (seizure disorder), and bipolar disorder (mental health condition that causes extreme mood swings). Review of the resident's medical record, showed: -No DA-124 Level 1 screen found; -No PASRR Level 2 screen found. During an interview on 12/9/24 at approximately 11:00 A.M., the Business Office Manager (BOM) was not able to locate the resident's level 1 or a level 2 screen for the resident. The BOM was going to request a copy from the Missouri Central Office Medical Review Unit (COMRU). The BOM said that screens should be done on admission. During an interview on 12/9/24 at 1:06 P.M., the BOM was unable to obtain a copy from COMRU. As of the date of exit on 12/11/24, the facility failed to provide a copy of the Level 1 screen. During an interview on 12/11/24 at 2:46 P.M., the Administrator said that she would expect the staff to follow the policy for obtaining PASRR pre-screening. During a phone interview on 12/17/24 at 9:36 A.M., the BOM said that the Admission Coordinator is responsible for obtaining the PASRR pre-screening, and she is responsible for making sure the PASRR is completed.

Based on observation, interview and record review, the facility failed to ensure the safety of one of seven sampled residents (Resident #1) when staff allowed a resident with moderate cognitive impairment to leave the building unaccompanied. On 9/10/23 at approximately 8:00 A.M., Housekeeper G entered the front door keypad code to allow Resident #1 out of the building. The resident told Housekeeper G he/she was a staff member. Registered Nurse (RN) D witnessed the housekeeper open the door for the resident, but was not familiar enough with the resident to realize the housekeeper allowed a confused resident to leave the building. At least two other staff saw someone outside in the neighborhood during the day, but they were also not familiar enough with the resident to report this to management in a timely manner. The staff members assigned to the resident's care thought he/she was out on a leave of absence (LOA). The resident missed meals and medications throughout the day. Staff found the resident on 9/10/23 at 4:30 P.M. outside a church, approximately three blocks away, on the other side of a busy four-lane road. The census was 56. The administrator was notified on 9/29/23 at 3:16 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 9/10/23. The facility conducted an investigation and immediately in-serviced staff on elopements, LOAs, staff name badges, resident presence at meals, management notification and protective oversight. Management training occurred on 9/19/23 and included elopement binders, documentation in medical charts and follow-up of all verbalizations. The IJ was corrected on 9/19/23. Review of the facility's Elopement Prevention and Management Unsafe Wandering and Exit Seeking Behavior Policy, reviewed 1/5/21, showed: For the purpose of continuity, unsafe wandering and exit seeking behavior will be referred to as elopement throughout this protocol; -Protocol: The facility defines elopement as follows: Definition-Elopement: When a cognitively impaired resident/patient leaves the physical structure of the facility unattended and without staff knowledge or not within sight; -Purpose: -To identify residents/patients at risk for unsafe wandering and exit seeking behavior; -To develop individualized prevention and management interventions based on assessment; -Procedure: -Review and evaluate assessments; -Develop individualized interventions and communicate to staff; -Provide staff training and resident/patient and family education; -Initiate the Missing Resident Protocol if unable to locate a resident/patient; -Reassess and/or re-evaluate resident/patient if elopement is unsuccessfully or successfully attempted; Elopement: Prevention: -Protocol: The facility recognizes that elopement prevention is an interdisciplinary process that must include the cognitively impaired resident/patient and family. The facilities will implement individualized interventions to strive to prevent elopement; -Procedure: -Develop individualized interventions which may include, but are not limited to, the following: -Electronic/alarm systems; -Environmental modifications; -Protected list of names and photographs of those at risk for elopement; -Psychosocial interventions; -Regular rounds; -Resident/patient and family education; -Staff interventions; -Structured group activities; -Review and correct deficiencies in practices as they relate to the following, including but not limited to: -Resident/patient identification systems; -Maintain a current protected list of names and photographs of residents/patients identified at risk for elopement. Assure picture contains the following information: -Name; -Description; -Height; -Weight; -Age; -Pertinent medical information; -Monitor the whereabouts of the at risk resident/ during rounds; -Record residents/patients at risks for elopement on assignment sheets. Review of the facility's Missing Person Policy, updated 8/16/07, showed: -Purpose: To assure for the timely and responsible notification of administrative staff and other health care professionals, the families and/or responsible parties, and the law enforcement authorities; -When the resident is found to be missing, the supervisor will notify all staff by paging: Code White, and a thorough search of the facility is to be completed; -Report missing person to administrative staff and the Director of Clinical Operations; -Report missing person to physician and family member; -Keep searching interior and exterior grounds of the facility and as otherwise designated by administrative staff; -Address and notify authorities of any potential health hazards while the resident is missing medication due, blood sugar testing due, etc.; -Document the proper sequence of events thoroughly in the resident's record. Review of the facility's LOA policy, dated 9/1/11 and revised 7/11/22, showed: -Policy: -The facility encourages outside socialization for the resident/patients when appropriate. A cognitively intact resident/patient may leave the facility independently or families and/or friends may take the cognitively impaired resident/patient from the facility when it is approved by a physician's order. The facility will track the departure and return on a sign out sheet. -Protocol: -Infrequent Leave of Absence: -Obtain a physician's order for the resident/patient to leave the facility; -Assure that a therapeutic LOA is documented on the Plan of Care; -Ensure the resident/patient and/or responsible party agrees to the outing; -Provide scheduled medication with written instructions to the resident/patient and/or responsible party, as applicable; -Document that medications were given to the resident/patient and/or responsible party with written instructions in the nursing notes; -Obtain signature of the resident/patient or the responsible party taking the resident/patient from the facility on the resident's sign out sheet. This is a part of the legal record; -Provide the resident/patient or responsible party with the facility phone number and request they contact the supervisor/Assistant Director of Nursing (ADON)/designee if a delay of more than one hour is anticipated; -Request the resident/patient or responsible party enter the date and anticipated time of return to the facility; -Attempt to contact the responsible party if they have not returned within one hour of the anticipated time; -Instruct the resident/patient or responsible party to notify the supervisor/ADON/designee when they return from the outing; -Record the date and time on the form when the resident/patient returns and enter your signature and the signature of person bringing the patient back; -Initiate the Missing Person Protocol if the resident/patient has not returned within two hours of the anticipated time and the facility has not received a call indicating a change in the anticipated time. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/8/23, showed the following: -admitted [DATE]; -Moderately impaired cognition; -Independent for bed mobility, transfers, walking in room and corridor, locomotion on unit, dressing and toilet use; -No physical impairments of either upper and/or lower extremities; -Wandering not exhibited; -Diagnoses of stroke, high blood pressure, and depression. Review of the resident's face sheet, showed additional diagnoses of major depressive disorder and vascular dementia. Review of the resident's elopement assessments, showed the resident was evaluated as an elopement risk on the following dates: 4/4/23 and 7/5/23. Review of the summary of the self-report provided with the investigation, showed: -On the morning of 9/10/23, upon further investigation it was found that Resident #1 was allowed to leave the facility between 7:45 A.M. and 8:00 A.M. The resident was standing at the front entry door pushing numbers on the key pad when Housekeeper G walked up and asked was he/she a resident. The resident replied, no, he/she worked at the facility just like Housekeeper G. Housekeeper G then put in the code and resident was able to leave the facility; -Receptionist L stated he/she saw the resident standing at the corner near the facility as he/she was walking to work around 8 A.M. Receptionist L stated he/she initially did not know that the person he/she saw was a resident, only that he/she was an older person and that he/she thought the person looked familiar. Receptionist L went into the facility and stated to a Certified Nursing Assistant (CNA) there was a person standing on the corner. Receptionist L said he/she was told it was a resident with a different name and that he/she signed him/herself out. Activity Aide (AA) A stated around 4:15 P.M., Receptionist L stated to him/her that he/she had seen Resident #1 standing on the corner and that a CNA told him/her the resident had signed him/herself out. AA A said the resident could not sign him/herself out. AA A alerted his/her supervisor, Social Services Director (SSD/Activities Director (AD). The SSD/AD then alerted the Administrator, and Receptionist L alerted the Human Resource Manager I, who alerted the Assistant Director of Nursing (ADON). AA A and two other staff members searched the exterior of the facility, and others searched the interior. The resident was found safe on a street corner sitting on the step of the church between 4:30 P.M. and 5:00 P.M. The resident was assisted back to the facility with no problems. Blood pressure checks were initiated since he/she did not receive his her Lisinopril (blood pressure medication). Fluids given to hydrate. Family was notified and visited shortly afterwards. Skin assessments revealed no abnormalities; -In conclusion, it was verified that staff failed to follow the facility's elopement and missing person policy. It was also verified that staff did not round, ensure resident ate, and received prescribed medications. Review of additional information, dated 9/11/23, submitted with the facility's self-report, showed: -The resident missed the following medications: Lisinopril 40 milligrams (mg), Aspirin EC (slow-release aspirin) 81 mg, Ferrous Sulfate (iron supplement) 325 mg, and Vitamin D. Review of the resident's progress notes for 9/10/23, showed: -On 9/10/23 at 6:17 P.M., the resident left the facility unsupervised. The resident was located safely. No injuries noted. The family and Physician were notified. The investigation and education was initiated; -On 9/10/23 at 6:19 P.M., the physician and the resident's emergency contact were made aware of the incident. Skin assessment head to toe completed with no apparent skin alterations, bruises, redness, or edema noted. No complaints of pain or discomfort noted. 98% oxygen saturation on room air (normal 95-100%), 120/76-blood pressure (normal 90/60-120/80), 95-pulse (normal 60-100), 22- respirations (normal 12-18), 98.3-temperature (normal 97.8-99.1); -On 9/10/23 at 6:21 P.M., spoke with the resident's family member who was aware the resident left the facility unsupervised. Resident was in his/her room at that time with no physical abnormalities noted. Resident did not appear lethargic, or in any acute distress. He/She stated to his/her family member that he/she had just got in from work and that he/she was going to take a bath. Staff were aware that resident was to remain on every fifteen minute checks. Observation on 9/20/23 and 9/21/23, showed the facility located in a residential neighborhood, approximately three blocks from a busy four-lane road. During an interview on 9/21/23 at 1:18 P.M., Resident #1 said he/she lived at the facility for almost one year. He/She remembered leaving the facility, but didn't remember where he/she went or how and/or when he/she returned to the facility. The resident did not remember the reason he/she left the facility. The resident couldn't remember if anything had happened to him/her while he/she was out. He/She exited out of the facility by the receptionist desk, but he/she couldn't remember how he/she got out of the facility. During an interview on 9/21/23 at 3:00 P.M., Resident #7 said he/she has lived at the facility for about eight months. His/Her roommate is Resident #1. The day the resident left the facility, Resident #1 woke up between 5:00 A.M. to 6:00 A.M. and went to the bathroom. That was the last time Resident #7 saw Resident #1 before he/she left the building. Staff brought breakfast in the room between 8:30 A.M. to 9:00 A.M., that morning and said they were looking for Resident #1 to give him/her his/her breakfast. Receptionist L came into the room and Resident #7 told Receptionist L that he/she didn't know where his/her roommate was. Receptionist L said he/she saw Resident #1 lying down on the corner. Receptionist L went to the nurses' station and told one of the nurses this same thing. Resident #7 said Resident #1 had never mentioned to him/her about wanting to leave the facility. Resident #1 normally stayed and sat in the dining room a lot. With all the doors in the facility, you have to be buzzed in/out. During an interview on 9/26/23 at 11:38 A.M., Housekeeper G said he/she was not familiar with Resident #1 but is now. At approximately 8:00 A.M., Housekeeper G was at the front sweeping the floor and Resident #1 was standing there pushing the key pad to get out. He/She asked Resident #1 was he/she a resident at the facility and Resident #1 said he/she worked there just like Housekeeper G worked there. Housekeeper G unlocked the door and let the resident out. The resident was well dressed so Housekeeper G thought he/she was a worker. There was no one at the front desk. When he/she let the resident out, the resident didn't go to the parking lot, he/she went to the left side of the building. Housekeeper G was wondering why the resident didn't go to the parking lot, but he/she thought the resident was taking a smoke break. He/She didn't realize that Resident #1 was a resident. Housekeeper G was off-duty when he/she was made aware that he/she let Resident #1 out. The residents walk around so freely that he/she did not know. He/She knew the residents by sight but not by name. During an interview on 9/25/23 at 11:03 A.M., RN D said he/she worked at the facility through an agency and worked on 9/10/23. There was not an elopement book to say who could not go out. That morning, he/she was RN coverage. RN D saw a person in a shirt and jeans, dressed like staff. Between 8:30 A.M. to 9:00 A.M., when RN D went to the door, he/she saw Housekeeper G let the person in jeans and a shirt out. Housekeeper G told RN D that he/she was letting the person out. The resident said he/she was going out so RN D figured it was a resident going out, or someone who worked there. RN D didn't know this person was Resident #1. The resident looked like a normal staff person, but did not have any identification on. The other nurse arrived about 10:20 A.M., so Licensed Practical Nurse (LPN) M was the nurse responsible from 10:30 A.M. to 3:00 P.M. for that wing. LPN M called RN D and asked why has this resident had been missing all day, but he/she did not give a name as to who was missing. When LPN M called RN D at home to tell him/her the resident was missing, RN D called the ADON and asked, Oh did that resident have a blue shirt on? The ADON confirmed with another staff member the resident had on a blue shirt. RN D then told the ADON he/she saw the resident go out. During an interview on 9/26/23 at 12:32 P.M., CNA H, an agency employee, said he/she worked on the next hall and was not really familiar with Resident #1. CNA H went to go take Resident #1 his/her breakfast tray. When he/she exited the resident's room, he/she asked if any one had seen the resident and told the nurse that he/she couldn't find the resident. The nurse was passing medications and said okay. CNA H walked back down the hall and saw Resident #1's roommate, Resident #7. Resident #7 told CNA H that Resident #1 was sitting up by the dining room by the front door. During an interview on 9/25/23 at 11:12 A.M., LPN E, said he/she worked at the facility for about 1.5 years through an agency. LPN E said he/she had arrived to work a little before 7:00 A.M. that morning (9/10/23). They have a resident who goes out on leave every day. LPN E was in the middle of working with that resident along with another resident, when Resident #7 rolled past and asked if somebody had seen his/her roommate, but he/she said the name of the resident who goes on leave every day; not the name of his/her roommate. If LPN E had seen Resident #1 at the door, he/she wouldn't have let the resident out. Resident #1's family always comes to get him/her. He/She never just goes out. LPN E worked that day from 7:00 A.M. to 3:00 P.M. No staff had reported the missing resident to LPN E during the day shift. Staff should do rounds on the residents every two hours, but it's not always being done. During an interview on 9/29/23 at 10:40 A.M., Receptionist L said he/she had worked at the facility since January of this year but was not familiar with Resident #1. He/She is the receptionist at the facility, but he/she was not at work when Resident #1 was let out on 9/10/23. Receptionist L was walking to work when he/she saw a person walking his/her way, but didn't really look at the person. The person didn't look distressed or lost. When Receptionist L got to work, he/she asked a nurse if any residents signed themselves out on leave, and the nurse said, Yes, two people. Receptionist L asked the nurse what were their names, and the nurse said he/she didn't know. Later that day about 11:00 A.M., Receptionist L still didn't feel comfortable with who was let out, so he/she started asking staff and residents, but no one knew anything. Around 11:30 A.M., Dietary Cook (DC) B said he/she saw someone outside as well, and it looked like a resident. Resident #7 (Resident #1's) roommate went out to smoke around 1:30 P.M., and said since he/she had been up, he/she had not seen his/her roommate. Between 1:30 to 2:00 P.M. is when Receptionist L put it together and called Human Resource Manager I, and he/she told him/her to call the Administrator. He/she told the Administrator what happened and the Administrator said do not leave, call a Code White, and that is when everyone started looking for the resident. The residents can sign themselves in and out. Receptionist L always made sure the people who pick up the residents could sign the resident in and out. The residents who are not cognitively functional can't sign themselves in and out. During an interview on 9/28/23 at 9:45 A.M., Human Resources Manager I said he/she had been employed at the facility since about June of this year and is familiar with Resident #1. Human Resources Manager I is the one that received the call from Receptionist L. Human Resources Manager I said Receptionist L wasn't clear if the resident was supposed to be out by him/herself or not. Human Resource Manager I asked Receptionist L several times, why was he/she was just now calling him/her at 4:30 P.M., in the evening. He/She immediately called the ADON who said that other staff were calling the Administrator at the same time. Management all found out at the same time. During an interview on 9/21/23 at 1:00 P.M., DC B said he/she had worked at the facility since 11/1/22. He/She was not familiar with Resident #1 but had heard of him/her. DC B knew that Resident #1 was Resident #7's roommate. DC B arrived to work on 9/10/23 at approximately 9:20 A.M. DC B saw a person across the street sitting on the curb, but did not recognize the person as the resident. The Receptionist told DC B when he/she came into the building, he/she saw Resident #7's roommate sitting outside on the corner. Receptionist L said he/she told one of the nurses. DC B asked Receptionist L was it the person who was sitting across the street. At approximately 9:30 A.M., DC B walked Receptionist L to the back of the building to show/him where he/she had seen the person. They looked out the back dialysis unit window and did not see anyone. DC B asked Receptionist L was the resident sitting at the spot where he/she pointed and Receptionist L said yes. DC B then returned to the kitchen. During an interview on 9/28/23 at 12:42 P.M., Certified Medication Technician (CMT) K, said he/she was not familiar with the resident and was an agency staff member. He/She said he/she could not remember anything from 9/10/23. He/she couldn't recall if he/she had looked for Resident #1 to administer his/her medication. There were a couple of residents who he/she was looking for and couldn't locate when he/she was passing medications. If he/she could not locate a resident, he/she would ask an aide or a nurse to locate that resident. He/She was not aware there was a resident who had been missing on the day that he/she worked. No one never told him/her that a resident was missing or said anything to him/her about it. CMTs do rounds on the residents, about three times during the medication passes. During an interview on 9/26/23 at 11:04 A.M., CNA F, said when he/she arrived to work at 2:30 P.M. (on 9/10/23), Resident #7 said he/she had not seen Resident #1. CNA F did not know Resident #1 had left the building. CNA F didn't tell anyone because he/she didn't realize why Resident #7 was saying that he/she had not seen Resident #1. CNA F realized what was happening about 3:30 P.M. when he/she started hearing staff saying they hadn't seen Resident #1. When a resident is missing, you were supposed to let someone know and count all the residents. Nurses tell the rest of the staff what to do when there is a missing resident. CNA F was directed to drive around. Resident #1 was found between 4:30 P.M. to 5:00 P.M. CNA F worked the previous night shift and knows the resident was in the building at 7:00 A.M. on 9/10/23. During an interview on 9/28/23 at 10:46 A.M., LPN J said he/she worked the evening on 9/10/23 and came in at 3:00 P.M. Staff said Resident #1 had been gone since day shift on that day. When he/she arrived, he/she wasn't the nurse on Resident #1's wing. CNA F told LPN J that Resident #1's roommate (Resident #7) said Resident #1 had been gone all day. Alert residents are allowed to sign themselves in and out. For the residents who are not alert, their family members have to sign them in and out. LPN J thought a family member had taken the resident out on LOA. If LPN J thought the resident had eloped, LPN J would have followed protocol, such as searching the entire building, looking outside, notified administration and the Administrator. Resident #1 was located between 4:30 P.M. and 5:00 P.M. Both CNAs and LPNs should be doing rounds on residents. LPN J realized Resident #1 was out of the building when the ADON called around 4:00 P.M. and said the secretary said the resident was missing. During interviews on 9/21/23 at 12:22 P.M. and 9/28/23 at 11:06 A.M. AA A, said he/she has worked at the facility for almost nine months, and he/she is familiar with the resident. AA A worked the day the resident left the building (9/10/23). He/She arrived to work around 11:00 A.M. and was made aware of the incident later in the day. Somewhere around 4:30 P.M., he/she went up front to take a cigarette break. The person at the desk, Receptionist L, said he/she saw Resident #1 outside standing on the corner at about 8:30 A.M., that morning when he/she was on his/her way in to work. AA A called his/her supervisor, SSD/AD at 4:30 P.M., once he/she found out the resident was gone. SSD/AD told AA A to call the Administrator, which he/she did. AA A said he/she would go and look for the resident. AA A asked CNA F to assist with the search and and asked him/her to drive in one direction while AA A drove in another direction. AA A and Floor Technician (FT) C found the resident on the corner, a few blocks away, on the opposite side of a busy four-lane road. The resident sat by him/herself on a brick wall, alongside a church. When they asked the resident if he/she was okay, the resident said he/she was tired and thirsty. They drove the resident back to the facility. When they made it back to the facility, the ADON arrived and then the Director of Nursing (DON), and then the Administrator. AA A asked the resident how he/she got to the church. The resident said he/she made it across the street, but he/she wasn't able to make it back across the street, and that was why he/she was sitting at the church lot the entire time he/she had been gone. AA A did not know what time the resident made it to the church. The resident had no bruises or marks on him/her. AA A asked the resident how he/she got out of the building, and the resident said he/she walked out with some people. AA A thought the resident was pretty alert. To his/her knowledge, the resident hadn't expressed wanting to leave the facility, and he/she was usually in his/her room. The resident did not have any prior elopements. During an interview on 9/21/23 at 2:36 P.M., FT C said he/she has worked at the facility for about two years and is familiar with Resident #1. At approximately 4:30 P.M. (on 9/10/23), FT C said he/she was asked to ride with AA A to go and look for the resident. They rode a couple of blocks and within five minutes of leaving the facility, they found the resident sitting at a church located at a corner, a few blocks away. The resident sat on the church steps by him/herself. Both AA A and FT C tried to ask the resident how long had he/she been at the church and how he/she had got there, but he/she didn't give them an answer. FT C was unsure what time the resident left the facility. When AA A asked FT C to go with him/her to look for the resident, this was his/her first time being aware that the resident was gone. During an interview on 9/29/23 at 10:22 A.M., Resident #1's family member said the facility contacted him/her and informed him/her the resident had left the facility. He/She went to the facility that same evening. Resident #1 has vascular dementia. The resident imagines him/herself going to work and that was one of the things the resident thought he/she was doing that day. He/She thought he/she was going home from work. That was the first time the resident had left the facility. The resident does not have a car. If the resident were out unsupervised, he/she would not be able to navigate around on his/her own. He/She did cross a main street to get to the church where he/she was found. It was absolutely not safe at all for the resident to cross that street on his/her own. During interviews on 9/20/23 at approximately 11:30 A.M. and 9/21/23 at approximately 12:30 P.M., with the Administrator and the ADON, the Administrator said the resident tricked Housekeeper G. The resident was at the door and pushing on the key pad. Housekeeper G asked the resident was he/she a resident, and he/she responded he was an employee, just like Housekeeper G. The ADON said Receptionist L was the first person who saw the resident outside and said something to one of the aides. The receptionist did not let management know. Staff didn't call the ADON until that evening. There was a system in place. The have an LOA book and an elopement book, which is updated. There was no reason for staff to do anything differently. During interviews on 9/28/23 at 10:34 A.M. and on 9/29/23 at 3:16 P.M., the Administrator said the nurse assigned to the resident's hall would have been RN D. The medications would likely have been passed by the CMT and not the nurse. Resident #1 missed his/her morning medications when he/she was gone. The Administrator said she was made aware of the resident not being in the facility via the SSD/AD. The SSD/AD called her during the same time Receptionist L called Human Resource Manager I, and then he/she called the ADON. The Administrator, the ADON, Nurse N, and the Maintenance Director were part of the management team who went in. When staff first became aware the resident had left and was not in the facility, they should have provided protective oversight. Everyone in the building is responsible for providing protective oversight to the residents. MO00224270 MO00224332

Based on observation, interview and record review, the facility failed provide pain management when staff failed to give the correct dose of a scheduled narcotic pain medication. The resident received a lower dose for several days, which increased the resident's pain, for one resident (Resident #3). The sample size was 11. The census was 62. Review of the facility's Physician Orders policy, reviewed 1/5/21, showed: -Protocol: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician's orders will be verified by the attending physician at the facility. All physician orders will be dated and singed according to State and Federal regulations; -Procedure: -Obtain one of the following types of physician orders: Verbal, telephone, transmitted by facsimile machine, written by the physician; -Assure physician's orders include the drug or treatment and a correlating medical diagnosis or reason; -Assure medication orders include: route, dosage, frequency, strength, reason for administration, and stop date; - Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician's Telephone Order form as an Orders Clarification; -Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change; -Fax all orders immediately to the pharmacy; -Confirm accuracy of orders when the new monthly orders arrive from pharmacy; -Transcription of errors; -Errors of omission. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/23, showed: -Cognitively intact; -Diagnoses included: Neurogenic bladder (the bladder does not empty properly due to a neurological condition), multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), anxiety, and depression. Review of the resident's care plan, last revised 10/1/22, showed: -Focus: Resident is at risk for pain related to decreased mobility, health status, MS, muscle spasms, depression, anxiety, fibromyalgia (chronic muscle pain), chronic pain syndrome, neurogenic bowel and bladder; -Goal: Risks associated with alteration in comfort will be minimized through review date; -Interventions: Administer pain medications per order, if non-medication interventions are ineffective. Education resident/representative on pain management treatment plan. Encourage non-medication suggestion for pain relief. Evaluate pain. Review of the resident's electronic physician order sheet (ePOS) showed: -An order, dated 2/15/23 to 3/15/23, Oxycodone Oral tablet 20 milligrams (mg). Give one tablet by mouth every six hours for pain; -An order, dated 3/15/23, Oxycodone Oral tablet 30 mg. Give one tablet by mouth every six hours for pain; -Both medication doses to be given four times a day at the following times: -12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of the Controlled Substance log for Oxycodone 20 mg tablet, showed: -3/15/23 at 6:00 P.M., 1 tablet; -3/16/23 at 12:00 P.M., 1 tablet; -3/16/23 at 12:00 A.M., 1 1/2 tablet; -3/16/23 at 6:00 A.M., 1 1/2 tablet; -3/17/23 at 12:00 A.M., 1 tablet; -3/17/23 at 6:00 A.M., 1 tablet; -3/18/23 at 12:00 P.M., 1 tablet; -3/19/23 at 6:00 A.M., 1 tablet; 3/20/23 at 12:00 A.M., 1 tablet; -3/20/23 at 6:00 A.M., 1 tablet. Review of the Controlled Substance log, for Oxycodone 30 mg tablet, showed: -3/17/23 at 12:00 P.M., 1 tablet; -3/17/23 at HS (bedtime), 1 tablet; -3/18/23 at 6:00 P.M., 1 tablet; -3/19/23 at 12:00 P.M., 1 tablet; -3/19/23 at 5:30 P.M., 1 tablet. Review of the resident's March medication administration record (MAR) from 3/15/23 to 3/22/23, showed Oxycodone 30 mg administered: -3/15/23 at 6:00 P.M.; -3/16/23 at 12:00 A.M., 12:00 P.M., and 6:00 P.M. (6:00 A.M. dose is blank on the MAR); -3/17/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/18/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/19/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/20/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/21/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/22/23 at 12:00 A.M., 6:00 A.M. dose not given with reason 7 (sleeping), 12:00 P.M. dose not given with reason 9 (other-see progress notes), 6:00 P.M., dose not given with reason 6 (hospitalized ); -Staff documented the 30 mg as given on the MAR but signed out 20 mg on the controlled substance log for several doses. During observation and interview on 3/20/23 at 11:20 A.M., Nurse C performed the resident's wound treatment. Nurse C asked the resident if he/she had pain. The resident responded that everything hurts all the time. The resident said it would be better if the nurses gave the resident his/her correct dose of his/her pain pill consistently. The resident said the dose was changed to 30 mg but he/she had been getting less than 30 mg at times. Nurse C said the nurse should check the order before giving the medication. During an interview on 3/20/23 at 11:25 A.M., Nurse B was asked to verify the resident's pain medication dosage in the electronic MAR. Nurse B looked up the orders and stated the physician orders showed 30 mg of Oxycodone every six hours for pain. During an observation and interview on 3/20/23 at 11:30 A.M., Nurse B looked in the medication cart's narcotic box to verify the dose of Oxycodone for the resident. Nurse B opened up the box and showed the resident's two Oxycodone medication cards. The cards showed a medication card for Oxycodone 20 mg and a medication card for Oxycodone 30 mg. Nurse B pulled out the Controlled Substance log and showed the night shift nurse gave the incorrect dose of 20 mg at 12:00 A.M. and 6:00 A.M. Nurse B said normally the Associate Director of Nursing (ADON) pulled out the old card to destroy per policy but had not yet for some reason. Nurse B said the night shift nurse charted they gave the right dose in the electronic MAR but signed off and gave the wrong dose. Nurse B said the nurse should verify the order before the medication is administered to the resident. Nurse B showed the correct dose was given yesterday during the day shift by cutting one of the 20 mg tablets in half. Nurse B said the nurse should not have given 1 and 1/2 because the medication is not scored (There is no line in the middle of the pill to ensure an accurate half dosage). Nurse B was not sure when the Oxycodone dose changed. During an interview on 3/20/23 at 11:35 A.M., the ADON said she would expect nursing staff or any staff that is certified to pass out medications to double check correct dose and give medication according to the order. The ADON said they are now aware of the error. They will call the physician to notify, fill out the medication error form and will do in-services with the night shift nurse and all staff that pass out medication. During an interview on 3/21/23 at 12:00 P.M., Nurse D verified he/she worked the night shift on 3/19/23. The nurse said he/she is familiar with the resident and knows the dosage changes all the time. It was 15 mg, then 20 mg and now 30 mg. Nurse D said he/she did not double check the order and made a mistake. Review of the resident's progress notes, showed: -A progress note, dated 3/20/23 at 12:06 P.M., This writer was asked to verify the resident's controlled substance on the cart to the MAR by the surveyor. This writer went to the medication in the MAR and saw the resident's order for Oxycodone had been changed 5 days ago to Oxycodone 30 mg. This writer was asked by the surveyor when the last time the 20 mg was given and it was signed out on the 19th and the 20th from the overnight nurse. The surveyor asked for a copy of the control log for both of the Oxycodone prescriptions. This writer informed the ADON of the medication error. This writer left a message for the physician to call back to see what he/she would like to do about the error. The resident's next dose is scheduled at 12:00 P.M. and the resident will receive the 30 mg as ordered; -A note, dated 3/20/23 at 12:30 P.M., The physician called back and was informed of the medication error. The physician said to remove the old medication card from the cart and dispose of them and to continue to give the correct dose from here on out and to be more careful in the future; -A note, dated 3/22/23 at 4:05 P.M., Ambulance here at facility to transport resident to hospital. The resident is alert and oriented and transferred without any assistance. Paperwork and report given and family notified of transfer. During an interview on 3/23/22 at 10:15 A.M., Nurse B said the resident was sent out to the hospital because of pain and he/she was out of pain medication. Nurse B opened the medication cart to show the removed card of Oxycodone 20 mg. During an interview on 3/23/23 at 12:10, the Director of Nursing (DON) said she would expect staff to notify the pharmacy if a medication was out. She said she thinks the 20 mg Oxycodone could be scored pretty accurate if a pill cutter was used. She would expect staff to check orders and follow the physician orders. The DON also said the 30 mg Oxycodone card came today for the resident but since the resident is not here, they sent the card back. They are not sure if the resident will return but if the resident returns to the facility, they will call the pharmacy to get the medication. MO00215853 MO00213710

Based on observation, interview and record review, the facility failed to adequately monitor one resident who had a physician's order and a speech therapist's recommendation for NPO (nothing by mouth). The facility staff allowed the resident to continue to eat solids foods and drink liquids after being identified as a high risk for aspiration (choking). The facility identified two residents who had orders for NPO. Both residents were sampled and problems were identified with one (Resident #18). In addition, the facility failed to implement resident-directed care and treatment consistent with the resident's preferences, physician's orders, and professional standards of practice by failing to reposition a resident with total dependence on staff for mobility, and consistently apply treatment to the resident's skin, which was 90% covered [MEDICAL CONDITION](Resident #23). In addition, facility staff failed to promptly notify the physician of one closed sample resident (Resident #86) of a condition change. That resident was sent to the hospital where he/she was intubated and admitted into the intensive care unit. The sample size was 16. The census was 65. 1. Review of Resident #18's medical record, showed: -A document dated 11/14/18, signed by the resident and facility, indicating the resident was non-compliant with physician's and dietician's recommended diet. The resident chooses to eat what he/she desired. Because of this behavior, the resident releases the former named facility of any responsibility shall anything occur due to being non-compliant with physician and/or dietician's order. He/she chose to consume a regular diet and drink beverages of his/her choice; -The document did not specify the type of diet recommended on 11/14/18. Further review of the resident's medical record, showed no other documentation signed by the resident or resident's family indicating the resident was non-compliant with the recommended diet. During an interview on 10/28/20 at 8:25 A.M., Certified Nursing Assistant (CNA) K said he/she worked at the facility for [AGE] years. The resident has been NPO since January 2020. Review of the resident's medical record, showed: -An order dated 4/24/20 for enteral feed (tube feeding) three times per day; -On 5/28/20 at 12:23 P.M., the Social Services Director (SSD) presented the resident with a brief interview of mental status (BIMS) assessment. The resident was unresponsive to the assessment. The resident scored a zero (severe cognitive impairment); -On 7/25/20 at 11:15 P.M., the resident returned from the hospital this night, from earlier choking episode. Resident is okay, vital signs stable, no noted signs and symptoms of acute distress, no complaint of pain, distress. Head of bed elevated. Will continue to monitor; -On 7/27/20 at 3:04 A.M., the emergency room doctor reported to the evening nurse that x-ray's showed the resident had aspiration pneumonia (lung infection due to relatively large amount of material from the stomach or mouth entering the lungs). The physician was notified; -On 8/4/20 at 5:01 P.M., the resident's family brought White Castle's for dinner. The SSD called the family to remind them the resident has a doctor's order to only have food through a [DEVICE] ([DEVICE], a feeding tube inserted through the abdomen that brings nutrition directly to the stomach). Resident's family verbalized understanding and they will discontinue to bring food. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/20, showed: -Cognitively intact; -No behaviors; -Required total dependence of one staff for eating; -Feeding tube. Further review of the resident's medical record, showed: -[DIAGNOSES REDACTED]. -An order, dated 9/11/20 for skilled speech therapy to assess dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus) and potential for by mouth intake. Review of the resident's speech therapy evaluation and plan of treatment, showed: -Start of care on 9/11/20; -[DIAGNOSES REDACTED]. -Resident will complete trials of puree and nectar progressing up as needed with the speech therapist only with no overt signs and symptoms of aspiration; -Resident will implement safe swallow strategies into by mouth intake trials with speech therapy only; -On 9/11/20, the resident was treated upright in wheelchair in personal room. Resident with poor awareness related to deficits and reason for his/her NPO status currently. The speech therapist trialed puree, nectar thin on this date. Oral phase overall demonstrated delayed mastication (chewing) and residue on the mid-blade of the tongue. Pharyngeal phase (the vocal folds close to keep food and liquids from entering the airway) there was inconsistent coughing with all textures, given nectar and thin again inconsistent gurgled coughing. The speech therapist talked with the social worker who said he will contact the Veteran's Administration for a Modified [MEDICATION NAME] Swallow Study (MBSS) due to the resident's history of aspiration; -On 9/13/20, the resident treated at bedside on this date. Resident was noted to have a soda can at bedside and a can of a nutritional drink. When asked if the resident drank the items, he/she nodded his/her head yes. The speech therapist educated the patient regarding the concern for aspiration, with resident just looking at the therapist. Resident also educated on the need for an MBSS prior to making any changes in his/her diet due to history and risk of choking and aspirations/silent aspirations. NPO diet and if resident goes against the recommendation and consumes thin liquids/solids, he/she needs to be up on edge of the bed or in wheelchair, go slow, take small sips/bites and double swallow as needed. Resident nodded head yes but carry-over is poor by the resident and the facility does not enforce NPO restrictions; -On 9/16/20, the resident was treated at bedside on this date. Resident was reclined totally flat in bed. Noted a sign above resident's bed that he/she needed to be at 45 degrees as he/she is a tube feeder. Resident noted to be lethargic and had a wet quality to breathing at rest. The speech therapist presented puree solids with patient barely opening oral cavity for oral acceptance. Resident took one half teaspoon bite with minimal clearance. The therapist continues to recommend a MBSS prior to any diet as the patient has a history of dysphagia, aspiration and most recently choking resulting in the [MEDICATION NAME] maneuver (abdominal thrust used to treat upper airway obstructions by foreign objects) having to be completed by nursing and a hospital stay for resident. Resident was NPO when he/she was given food and choked; -On 10/1/20, the resident was treated upright in wheelchair in room. Resident was offered a snack, however, the he//she refused and stated a CNA was getting him/her snacks from the vending machine. The resident is still NPO and should not be getting snacks from staff. The therapist educated the resident and nurse also present, regarding NPO status and the need for the physician to be notified and diet to be addressed if patient is eating and nursing staff buying him/her solids/liquids. Continue to recommend NPO status unless with speech therapist for trials. Review of the resident's care plan, revised on 10/5/20, showed: -Focus: The resident has nutritional problems, [DEVICE] feeder; -Goal: The resident will comply with recommended diet for weight reduction daily through review date; -Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. [DEVICE] feeding, NPO. Resident is non-compliant with feeding and visits the vending machine frequently. Review of the resident's Radiology Report, dated 10/6/20, showed: -Purpose of Visit: Swallowing Evaluation; -Test Conditions: The patient was viewed laterally in a sitting and standing position. He/she was tested with thin liquids, nectar-thick liquids, honey-thick liquids and applesauce; -Impression: Severe oropharyngeal dysphagia (problems with the preparatory phase of swallowing (chewing and preparing the food)), oral phase (moving the food or liquid through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the esophagus) with high risk for aspiration; -Plan: No further interventions. Patient's prognosis for significant swallowing recovery remains low due to severity of dysphagia, long-[MEDICATION NAME] nature of his/her dysphagia and limited improvement in prior therapy; -Recommendations: Recommended remain NPO. If there is allowances for pleasure purposes only, recommend restrict those items to puree consistency only with further limitations to three to four teaspoon sizes only in a setting. Also, with any by mouth intake, there is a risk for aspiration. Further review of the resident's medical record, showed no documentation indicating the resident released the facility of any responsibility from not following the physician's order or the speech therapist's recommendation for NPO after the resident completed the MBSS on 10/6/20. Further review of the resident's speech therapy evaluation and plan of treatment, showed: -On 10/12/20, the resident treated in personal room, bedside. Resident was alert, reclined in bed eating crackers. He/she is NPO. Resident was educated on NPO status. Resident continued to eat crackers and then started holding. Resident motioned for trash can and vomited crackers and thick phlegm-an overt sign of aspiration. CNA was present and was educated regarding NPO status and that staff should not be going to get food or drinks out of the vending machine for patient. Speech therapist then went to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) office to ask about MBSS completed on 10/6/20. There is no report in the electronic or hard medical record. The DON and ADON did not even know the resident had gone out last week for a MBSS. The DON double checked in the electronic chart for any report with DON unable to find any results and neither one had heard report from the nurse who went out with the resident. The speech therapist continues to recommend NPO with staff not buying resident any snacks or drinks. Resident is aspirating at bedside and is a higher choking and aspiration pneumonia risk. Given education, staff does not comply and is placing resident at higher risk. Session completed this date with the speech therapist putting in for a discharge, as resident and staff are all non-compliant with the speech therapists's recommendations. Further review of the resident's medical record, showed: -An order, dated 10/12/20. Therapy completed; -An order, dated 10/14/20. NPO diet; -An order, dated 10/19/20. Discharge resident from skilled speech therapy at this time with recommendations of NPO diet as resident is a high risk for aspiration and not safe on any texture of solid or liquid. Further review of the resident's speech therapy evaluation and plan of treatment, showed on 10/19/20, the resident was treated in his/her room. Speech therapist is not recommending a diet texture for resident, as he/she had previously failed his/her MBSS completed a few weeks ago. Speech therapist educated staff and DON with DON voicing understanding and agreement regarding resident's high risk for aspiration or choking if he/she continues to eat orally. CNA however, did not seem to understand the speech therapist's recommendation and stated, I was told even if we were to take one of those tests, we would fail. Education provided however attention to the speech therapist was poor by the CNA. Discharge completed at this time as patient did not pass MBSS with any texture and staff and resident aware of concern and risk for further by mouth intake and high risk for choking and aspiration. Observation on 10/22/20 at 1:52 P.M., showed the resident lay in bed on his/her back and did not respond when asked if he/she was doing okay. Observation on 10/23/20 at 8:34 A.M., showed, the resident lay in bed with his/her eyes opened. When asked how he/she was doing, the resident smiled but did not verbally respond. Observation on 10/26/20 at 8:08 A.M., showed the resident sat in his/her wheelchair in his/her room. When asked how he/she was doing, the resident smiled but did not respond verbally. Observation on 10/27/20 at 7:51 A.M., showed the resident propelled in his/her wheelchair toward the vending machine, located in the main dining room. The resident purchased a soda, opened the can and took a drink. During an interview on 10/27/20 at 7:51 A.M., the administrator, who was present when the resident drank from the soda can, said she was not sure who the resident was, when asked if the resident should have anything by mouth. She said she would ask the nurse however, she did not remove the soda can. During an interview on 10/27/20 at 7:55 A.M., the DON said the resident was NPO but non-compliant. He/she had a swallow test on 10/6/20 and the recommendation was for NPO with no pleasure foods. The resident goes to the vending machine on his/her own and sneaks food. When they see the resident, they discourage him/her from eating. The resident signed a waiver indicating he/she was non-compliant with his/her diet. The social worker also spoke with the family regarding the resident's non-compliance. If the resident insists on eating or drinking, staff should watch him/her to ensure he/she does not choke. Observations of the resident on 10/27/20, showed: -At 8:01 A.M., he/she propelled in his/her wheelchair out of the dining room, down the hallway and drank from the soda can. No staff watched the resident. He/she coughed after taking a drink; -At 8:05 A.M. and 8:09 A.M., the resident propelled in his/her wheelchair down the hallway with the soda can, taking a drink from the can and coughing. Staff walked past the resident; -At 8:09 A.M., 8:30 A.M., the resident alone in his/her room, sat in the wheelchair, drinking from the soda can. The resident coughed after he/she drank from the can. During an interview on 10/27/20 at 8:36 A.M., Nurse J was asked to come into the resident's room. He/she said the resident was non-compliant and should be watched when having food or drinks due to being at risk for choking. The resident was NPO. When asked what NPO meant, Nurse J said nothing by mouth. He/she walked into the resident's room and saw the resident with the soda can, taking a drink. He/she said all staff were responsible for watching the resident when he/she had anything to eat or drink. The nurse did not take the soda, encourage the resident or assess the resident. Nurse J left the resident's room. Further review of the resident's medical record, showed a nurse's note, dated 10/27/20 at 8:09 A.M., completed by Nurse J. The resident, whom is NPO was noted drinking a can soda this A.M. The resident was educated of the risk and danger of drinking and eating. The resident was also assessed by this nurse for aspiration precautions. His/her lungs were clear and no distress noted. Further review of the resident's medical record, dated 10/1/20 through 10/31/20, showed no documentation regarding monitoring for signs and symptoms of choking/aspiration. Observations on 10/27/20 at 8:42 A.M., 8:47 A.M., 10:04 A.M. and 11:05 A.M., showed the resident sat in his/her wheelchair in his/her room. The soda can sat on the night stand. No staff were present during the observations. The resident drank 80 percent of the soda. Observation on 10/28/20 at 7:12 A.M., showed the resident propelled in his/her wheelchair toward the vending machine. One staff member passed the resident. At 7:16 A.M., the resident placed money in the machine and made a selection. The resident had a difficult time retrieving the item from the vending machine. At 7:23 A.M., the maintenance director and Nurse J walked toward the vending machine. The maintenance director pushed the opening to retrieve the items from the vending machine and Nurse J retrieved the items and gave them to the resident. At 7:27 A.M., the resident propelled from the vending machine, down the hallway toward his/her room and ate the donut sticks purchased from the vending machine. At 7:29 A.M., two additional staff and Nurse J walked past the resident. At 7:31 A.M., the resident propelled down the hallway and ate the donut sticks. He/she coughed as he/she ate. At 7:37 A.M., the DON walked past the resident as he/she ate the donut sticks. No staff assessed the resident or tried to discourage him/her from eating the donut sticks. Further review of the resident's medical record, showed a nurse's note dated 10/28/20 at 8:14 A.M., completed by Nurse J. The resident, who is NPO was found at the vending machine purchasing snacks. The nurse educated this resident on the safety of his/her intake. Resident stated I know. He/she is being monitored for possible choking and/or aspiration. Further review of the resident's medical record, dated 10/1/20 through 10/31/20, showed no documentation regarding the monitoring for signs and symptoms of choking/aspiration. During an interview on 10/28/20 at 8:25 A.M., CNA K said the resident was alert with some confusion and was non-compliant with his/her diet. He/she signed a waiver when the facility was under a different company and management. The resident has had three swallowing tests done since January 2020 and failed each one. The resident tries to sneak food and when he/she does, staff are supposed to take the food away. If the resident is non-compliant, they are to watch the resident for signs and symptoms of choking as he/she eats or drinks and report it to the charge nurse immediately. During an interview on 10/29/20 at 12:37 P.M., the SSD said the resident was non-verbal, alert with some confusion. He spoke with the family in either late July or early August of this year because the family brought in food and the resident choked. The family was told they could no longer bring food in and agreed to no longer bring food. The resident was NPO back when he/she choked and has been NPO since he worked at the facility. The resident signed a waiver regarding his/her non-compliance. When shown the form, the social worker said he did not realize the form was signed in 2018. The form should have been updated and signed by the resident and the resident's representative at least quarterly. During an interview on 10/28/20 at 12:43 P.M., the speech therapist said the resident was NPO and she did not recommend pleasure foods. He/she was a very high risk for aspiration. When she evaluated the resident, he/she did not pass any of the tests for any textures of food. The staff will not watch the resident. Staff will watch the resident go to the vending machine and will not stop him/her. She also witnessed staff giving the resident food and tried to educate the staff and also spoke with the DON. She recommended the swallowing test, which the resident failed, and staff continued to feed him/her snacks. During an interview on 10/28/20 at 9:32 A.M., the DON said the resident had a swallow test completed on 10/6/20 and signed a waiver back in 2018. It was considered good practice to obtain a recent waiver from the resident and family. It was also considered good practice to watch the resident when he/she eats or drinks as he/she was at risk for aspiration. During an interview on 10/30/20 at 10:53 A.M., the medical director said the resident's cognition was not so great. The resident is at risk for aspiration but is non-compliant with a NPO diet. The resident or family should sign an updated form explaining the risks of eating food and drinking liquid. The staff should not give the resident any food if the order is for NPO as the resident could choke. During an interview on 10/30/20 at 11:07 A.M., the administrator and DON said the resident should be watched if he/she eats or drinks. The resident is at a high risk for aspiration and should not be eating or drinking. Staff should not provide him/her with any food or drinks. During an interview on 11/4/20 at 10:45 A.M., the resident's responsible party (RP) said the resident signed a waiver releasing the facility of any responsibility associated with not following the recommended diet back when it was another facility. They have not signed one since the facility changed names or management. The resident's physician at that time explained to the responsible party that the resident could make decisions for him/herself. The RP was not aware the resident had a new physician and had not spoken to him. In the summer, the RP spoke with the social worker, who told him/her not to bring food to the facility. He/she had not brought any since then. The RP contacted the facility for information about a month ago and spoke with the DON. The DON told the RP the resident had a swallow test and was recommended to have nothing by mouth. When asked if the resident understood this, the RP said since he/she had not physically seen the resident, he/she could not make the determination. However, the resident would call him/her on occasions and hold the phone while the RP spoke. The resident has a difficult time verbalizing, due to a stroke. Although the resident was recommended a diet of NPO, the RP said the facility leaves the resident alone and laying in bed with no schedule. Because of this, the resident is only focused on eating. 2. Review of the facility's Skin Program Policy and Procedure, dated 5/28/19, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed up on admission and as needed for actual and/or potential skin problems. All residents with skin problems will receive an active skin plan of care at admission; -Procedure: -The nurse assesses/evaluates all residents upon admission. The initial skin assessment is a full body audit and completion of the Braden Skin Risk Assessment. After admission the Braden Skin Risk Assessment will be completed weekly for three weeks and then a minimum of quarterly, a significant change of condition, and annually; -A plan of care (POC) is initiated and individualized by the nurse on the day of admission; -Certified nurse aides (CNA) will complete the Bath/Shower Report Sheet with each resident's scheduled bath/shower. Each resident will be assessed/evaluated a minimum of weekly by the nurse. Review of Resident #23's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Rejection of care not exhibited; -Total dependence of two (+) person physical assist required for bed mobility and transfers; -Total dependence of one person physical assist required for dressing and personal hygiene; -Upper and lower extremities impaired on both sides; -[DIAGNOSES REDACTED]. Review of the resident's medical record, showed: -A physician's order, dated 4/17/20, for weekly skin assessments in the afternoon every Friday; -A physician's order, dated 7/31/20, to cleanse right upper extremities with wound cleanser or soap and water. Apply topical antibiotic ointment (TAO) daily and cover with dry dressing daily; -No Bath/Shower Report Sheets completed in September 2020. Review of the resident's treatment administration record (TAR) for September 2020, showed: -Skin assessment completed 9/4/20; -TAO not documented as administered 9/5, 9/7, 9/8, 9/9, 9/10/20; -Skin assessment not documented as completed 9/11/20; -TAO not documented as administered 9/11, 9/12, 9/15, 9/17/20; -Skin assessment completed 9/18/20; -TAO not documented as administered 9/18, 9/23/20; -Skin assessment completed 9/25/20; -TAO not documented as administered 9/26, 9/30/20. Further review of the resident's medical record, showed no Bath/Shower Report Sheets for October 2020. Review of the resident's TAR for October 2020, showed: -Skin assessment not documented as completed 10/2/20; -TAO not documented as administered 10/2, 10/3, 10/4/20; -Skin assessment completed 10/9/20; -TAO not documented as administered 10/9, 10/14, 10/15/20; -Skin assessment not documented as completed 10/16/20; -TAO not documented as administered 10/16, 10/17, 10/18, 10/20, 10/21/20; -Skin assessment completed 10/23/20. Review of the resident's care plan, revised 10/5/20, showed: -Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to 90% or more of body surface with 90% or more of third degree burns; -Interventions/tasks included: -Resident is totally dependent on 1-2 staff for repositioning and turning in bed every 2 hours and as necessary; -Resident requires skin inspections weekly. Observe for redness, open areas, scratches, bruises, and report changes to the nurse; -Focus: Resident has [MEDICAL CONDITION] affecting unspecified side; -Goal: Resident will maintain optimal status and quality of life within limitations imposed by [MEDICAL CONDITION] through review date; -Interventions/tasks included: -Give medications as ordered; -Pain management as needed. See physician's orders. Provide alternative comfort measures as needed; -The care plan failed to identify the resident's preferences for repositioning and desire to be out of bed, and failed to identify his/her individual skin care needs. Observation and interview of the resident on 10/22/20, showed: -At 8:46 A.M., the resident lay on his/her back in bed. He/she had no left arm and his/her right hand was severely contracted with fingers bent backwards, approximately 45 degrees.[MEDICAL CONDITION] the resident's face and forearm, with chunks of skin flaking off; -At 9:55 A.M., the resident lay on his/her back in bed. He/she leaned to the right side of the bed with his/her head off the pillow. He/she said he/she could not reach his/her call light and asked to be repositioned; -At 1:23 P.M., the resident lay on his/her back in bed, positioned in the middle of the bed. CNA EE entered the room and the resident asked him/her to get the resident out of bed. CNA EE said he/she would find the CNA assigned to the resident's hall and exited the room; -At 1:47 P.M., the resident lay on his/her back in bed. He/she called out to CNA M, who stood in the hall outside of the resident's room. CNA M asked the resident what he/she wanted and the resident said he/she wanted to get up. CNA M entered the resident's room and shut the door; -At 1:58 P.M., CNA M exited the resident's room. The resident lay on his/her back in bed with visibly flaky skin; -At 3:38 P.M., the resident lay on his/her back in bed. He/she said he/she wanted to get out of bed, but staff would not help him/her. Observation and interview of the resident on 10/26/20, showed: -At 9:13 A.M. and 10:33 A.M., the resident lay on his/her back in bed. The resident's skin on his/her face visibly dry and flaking off his/her face; -At 11:57 A.M., the resident lay on his/her back in bed with skin visibly dry and flaking off his/her face and forearms. He/she said he/she would like to get out of bed and has been waiting on staff to help. His/her roommate pressed their call light to alert staff; -At 12:05 P.M., CNA M entered the resident's room and asked what the resident wanted. The resident said he/she wanted to get out of bed. CNA M said the facility was about to serve lunch and he/she could not get the resident out of bed at that time; -At 12:41 P.M., the resident lay on his/her back in bed. Observation and interview of the resident on 10/28/20, showed: -At 8:57 A.M., the resident lay on his/her back in bed. He/she said he/she did not enjoy spending all his/her time in bed. He/she would like to be out of bed more often because he/she gets bored. When out of bed, he/she likes to be around people and to socialize. His/her skin is very itchy and sometimes staff put ointment on it, but most of the time, they don't; -At 11:19 A.M., 12:32 P.M., and 1:46 P.M., the resident lay on his/her back in bed with visibly flaky skin. Observation and interview on 10/29/20 at 9:30 A.M., showed the resident lay on his/her back in bed, dressed in regular clothing with flaky skin on his/her face and right arm. He/she said staff dressed him/her today, but did not put topical ointment on his/her skin. Staff never got him/her out of bed yesterday. During an interview on 10/30/20 at 7:28 A.M., CNA M said the resident likes to be out of bed. The resident must be transferred via Hoyer (mechanical lift), which requires two staff to perform. Sometimes, the resident is left in bed because there is not enough staff available to get him/her out of bed. During an interview on 10/30/20 at 10:14 A.M., the ADON said she was unaware the resident preferred to be out of bed more often. If he/she expresses the desire to get out of bed, staff should accommodate his/her request. The DON and administrator agreed skin assessments should be completed on all residents on a weekly basis. If a resident refuses a skin assessment, it should be documented in their medical record. It is the nurse's responsibility to ensure treatments are applied as ordered. If a resident refuses treatment, such as application of TAO, the resident's refusal should be documented in their record. The resident's care plan should accurately reflect the resident's skin care needs and preference to be out of bed. 3. Review of Resident #86's admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -Understood/understands; -BIMS score of 13 (a score of 13-15 indicates cognitively intact); -Limited assistance of one person required for bed mobility, transfers, walking in room/corridor, locomotion on/off the unit, dressing, toilet use, personal hygiene and bathing; -Moving from seated to standing position: Not steady but able to stabilize without human assistance; -Walking (with assistive device if used): Not steady, but able to stabilize without human assistance; -Turning around and facing the opposite direction while walking: Not steady, but able to stabilize without human assistance; -Moving on and off toilet: Not steady, but able to stabilize without human assistance; -Surface to surface transfer (transfer between bed and chair or wheelchair): Not steady but able to stabilize without human assistance; -Functional limitation in range of motion: No impairment of upper/lower extremities; -Mobility devices: Wheelchair; -[DIAGNOSES REDACTED]. -Did the resident have a fall any time in the last month prior to admission: No; -Did the resident have a fall any time in the last two to six months prior to admission: No; -Has the resident had any falls since admission: No. Review of the resident's progress notes, dated 7/28/20 at 3:45 A.M., showed staff found the resident on the floor in his/her room with a broken tooth and a bruise to the right upper, inner arm. Resident denies pain or discomfort, but while getting him/her up he/she showed facial grimacing. Emergency medical services (EMS) called, here at 4:20 A.M. and resident transferred to hospital. Review of the resident's progress notes, dated 7/28/20 at 10:26 A.M., showed the resident returned to the facility. Shows no signs or symptoms of distress. Resident denies pain or discomfort at this tim (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident #192), who the facility identified as receiving intravenous (IV) antibiotics, received a dose at the correct infusion rate and failed to ensure IV antibiotics were administered to the resident as prescribed by the physician. The resident received three different IV antibiotics due to an abcess that occurred after brain surgery. The sample size was 16._The facility census was 65. 1. Review of Resident #192's facility face sheet, showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan, dated 10/20/20, showed IV access and IV antibiotics not addressed. Observation on 10/22/20 at 9:05 A.M., showed 1250 milligrams (mg) of [MEDICATION NAME] in 250 ml NS hung on an IV pole with an IV pump (used to control rate of flow) next to it. The label on the antibiotic read to infuse at 167 cubic centimeters (cc) an hour to infuse over 90 minutes. The IV tubing did not thread through the the resident's pump. The IV tubing valve was wide open, the medication did not drip and the bag was full. The tubing was connected to the left upper arm peripherally inserted central catheter (PICC-long catheter (tube) inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned through the vein into a large vein that carries blood into the heart). Continued observation on 10/22/20 at 9:16 A.M., showed no change in the fluid level of the bag and the clamp on the tubing remained wide open. Further observation on 10/22/20 at 9:40 A.M., showed Licensed Practical Nurse (LPN) I at the bedside administering tube feeding through the gastrostomy tube ([DEVICE]-thin catheter surgically inserted through the abdomen in to the stomach to provide nutrition and fluids). The [MEDICATION NAME] bag lay empty in the sink. During an interview on 10/22/20 at approximately 9:41 A.M., LPN I said he/she hung the antibiotic at about 8:00 . He/she said It shouldn't have gone in that fast. He/she was having trouble with the IV pump not working and would have to call the pharmacy for a replacement. He/she had opened the clamp on the tubing because he/she was having trouble getting the antibiotic to infuse. It should have run over 60-90 minutes (The antibiotic would have infused in less than 30 minutes). During an interview on 10/23/20 at 12:02 P.M., the pharmacist from the facility's participating pharmacy said the facility rents the IV pumps from the pharmacy and presently the facility had one pump. He/she said the facility has a dial-a-flow (a device on IV tubing used to dial the flow rate of the liquid being infused) because the pharmacy sent it to the facility. He/she said [MEDICATION NAME] is normally infused over a period of 60 to 90 minutes to avoid adverse effects such as Red Man's Syndrome (an infusion-related reaction that typically consists of pruritus (itching), a red rash that involves the face, neck, and upper torso. Low blood pressure and swelling can occur). The pharmacy determines the dose of [MEDICATION NAME] and it is determined by the resident's kidney function and the peak (blood drawn immediately before a dose of [MEDICATION NAME] is administered) and the trough (blood drawn within one to two hours after completion of the dose). (The peak and trough determine the drug concentration level in the body system which determines the dose of medication to be administered). During an interview on 10/23/20 at 12:26 P.M., the Director of Nursing (DON) said an IV antibiotic should never be administered without a working IV pump. The facility has dial-a-flows which the nurse could have used. The other choice was the nurse could have waited for a new pump to arrive and notify the physician that a dose will be missed or delayed. The nurse should absolutely never open the tubing, and [MEDICATION NAME] should be administered for the time it is ordered. If the order for an antibiotic is ambiguous, the physician should be contacted for clarification. The antibiotic should be held until clarification is obtained. Even if it means a dose is missed, clarification should be obtained. Continued Review of the POS [REDACTED] -An order, dated 10/19/20 to administer [MEDICATION NAME] (antibiotic) 500 mg IV every six hours and discontinue after the last scheduled dose on 11/10/20; -An order, dated 10/20/20, to administer Cefipime (antibiotic) two grams (g) IV in 100 ml of NS every eight hours and discontinue after the last scheduled dose on 11/10/20. Review of the pharmacy's delivery manifest, dated 10/20/20, showed it included 16 doses of [MEDICATION NAME] and nine doses of Cefipime for the resident. The delivery was signed as received by facility LPN D on 10/20/20 at 1:22 A.M. Review of the pharmacy's delivery manifest, dated 10/23/20, showed it included 16 doses of [MEDICATION NAME] and 12 doses of Cefipime for the resident. The delivery was signed as received by facility LPN L on 10/23/20 at 1:40 A.M. Review of the October MAR, on 10/26/20 at 11:00 A.M., showed the following: -[MEDICATION NAME] scheduled to be administered daily at 12:00 A.M.,, 6:00 A.M., 12:00 P.M. and 6:00 P.M. Twenty-five total doses of [MEDICATION NAME] recorded as administered between 12:00 A.M. on 10/20/20 and 11:00 A.M. on 10/26/20; -The 6:00 A.M. dose of [MEDICATION NAME] on 10/26/20, not recorded as administered; -Cefipime scheduled to be administered daily at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Sixteen total doses of Cefipime recorded as administered between 10:00 P.M. on 10/20 and 6:00 A.M. on 10/26/20; -The 10:00 P.M. dose on Cefipime on 10/25/20, not recorded as administered. Review of the available doses of [MEDICATION NAME] and Cefipime on 10/26/20 at 11:20 A.M., showed the following: -Twelve doses of [MEDICATION NAME] remained available in the medication room; -The pharmacy sent a total of 32 doses of [MEDICATION NAME], which showed staff failed to administer seven doses of [MEDICATION NAME]; -Eleven doses of Cefipime remained available in the medication room; -The pharmacy sent a total of 21 doses of Cefipime, which showed staff failed to administer five doses of Cefipime. Review of the facility's Administration of Intravenous Policy, dated 2006, showed the following: -Purpose: -To maintain life by supplying the body with fluid, electrolytes, calories, vitamins, protein and medication; -To restore acid-base balance to the body; -To treat infection; -To administer medication; -Assessment Guidelines: -Condition of the intravenous insertion site; -Adverse reactions to the fluid/medication administered; -Reason for therapy; -Hydration and electrolyte levels; -General Nursing Care: -The resident should be under close observation by a licensed nurse as long as the solution is being administered in order to prevent infiltration (fluid leaks out of the vein in to surrounding tissues causing damage to the tissue) into the tissues and reassure the resident. Resident movement may alter the rate of flow or displace the needle; -All solutions administered must be free and clear of sediment; -When the resident's position is changed, care should be taken to maintain the position of the needle; -In the elderly and/or residents with conditions affecting the heart, lungs or arteries, the rate of administration must be carefully monitored for signs of fluid volume overload; -Observe sterile technique. During a follow up interview on 10/26/20 at 11:35 A.M., the representative from the facility's participating pharmacy said no further doses of [MEDICATION NAME] and/or Cefipime had been sent to the facility since 10/23/20. During an interview on 10/26/20 at 11:26 A.M., the DON said she expects staff to administer medications as ordered by the physician. If a medication is unavailable, staff should notify the nurse in charge and check in the emergency kit (E-kit, extra commonly used medications to be used when short on the medication cart) and order some from the pharmacy. Also staff should let the physician know the dose will more than likely be late or missed or staff could ask if a different medication can be substituted. If a medication is given, staff should sign it out. If a medication is not given, staff should not sign it out. She said she would check into the antibiotics, but if there were extra doses than what staff signed out, she can only think staff are signing out the medications but not administering them. During an interview on 10/30/20 at approximately 11:30 A.M., the resident's physician said [MEDICATION NAME] doses are typically determined by the pharmacist according to the resident's kidney function and the peak and trough. If staff have a question, they should contact the pharmacist and follow the pharmacist's instructions. [MEDICATION NAME] should be administered according to the time prescribed. If [MEDICATION NAME] infuses too fast, [MEDICAL CONDITION](damages) the vein. If a pump is not available, staff should wait for a replacement, or use a dial-a-flow. If the nurse is really good, they can count the drops, but would need to stay close by. The resident receives the antibiotics because he/she had brain surgery and developed an abscess. It is very important he/she receives the antibiotics as ordered. If a dose is missed, staff should contact him because he may have to lengthen the number of days the medication is administered. If there are extra doses he has no reason to think anything other than the drug was not administered, but recorded as though it were.