Every finding on record at Bluebird Wellness and Rehabilitation

Based on interview and record review, the facility failed to ensure medical records were complete and accurate, in accordance with professional standards, when staff failed to accurately document insulin administration or rationale for not administering insulin for six residents (Residents #2, #5, #8, #9, #10, and #11). The sample was 11. The census was 147.Review of the facility's Insulin Pen Administration policy, revised January 2026, showed:-Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes.-Policy: The type of insulin, dosage requirements, strength and method of administration must be verified before administration to assure that it corresponds with the order on the medication sheet and physician's orders;-Procedure: Document the resident's blood sugar and insulin administration on the resident's medication administration record (MAR). Review of the facility's undated Medication Administration policy, showed:-Purpose: To provide practice standards for safe administration of medications for residents in the facility;-Policy:--When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (blood pressure, pulse, finger stick blood glucose monitoring etc.);--If the medication is given by injection, the site will be noted on the MAR;-Documentation:-The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment;-Recording will include the date, the time and the dosage of the medication or type of the treatment;-Holding Medications: Whenever a medication is held for any reason, the nurse will initial the appropriate area on the MAR and circle his/her initials and will document the reason the medication was held on the back of the MAR. Review of the facility's Blood Glucose Monitoring policy, revised January 2026 showed:-Purpose: To monitor blood glucose concentrations as ordered by the attending physician, ensuring compliance with evidence-based practices and regulatory standards;-Policy:-Licensed nurses will perform blood glucose testing as ordered by the physician, following the manufacturer's instructions for the testing device and facility protocols;-Documentation of blood glucose testing will be maintained in the resident's record on the MAR. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/17/26, showed:-Cognitively intact;-Diagnoses included diabetes;-Received insulin in the past seven days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Goal: Resident will be free from any signs and/or symptoms of hypoglycemia (blood glucose too low);-Approaches included administering diabetes medications as ordered;-The care plan did not address what to do if the resident refused his/her insulin. Review of the resident's physician order sheet (POS) and August 2026 MAR, showed:-An order, dated 07/18/26, for Lantus Solostar subcutaneous (SQ, under the skin) solution pen-injector (insulin glargine, a long acting insulin) 100 unit/milliliters (ml), inject 36 units SQ one time a day for diabetes;-The space designated on the MAR for insulin administration at 8:00 A.M. was blank on 08/06/26 and 08/10/26 with no documentation why the space was blank. Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. During an interview on 08/19/26 at 12:15 P.M., the resident said he/she did not receive his/her insulin on a regular basis. He/She had missed his/her dose up to four days in a row. He/She never refused to take his/her insulin. He/She knew how important the medication was. If staff were documenting they provided his/her insulin on a daily basis, or if they said he/she refused to take the insulin, they were falsifying the medical records. During an interview on 08/19/26 at 12:20 P.M., Family Member (FM) A said he/she visited the resident almost daily and the resident told him/her all the time that staff did not administer the resident's insulin. 2. Review of Resident #5's significant change MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes;-Received insulin in the past six days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Goal: Resident will have no complications related to diabetes;-Approaches included administering diabetes medications as ordered;-The care plan did not address what to do if the resident refused his/her insulin. Review of the resident's POS and August 2026 MAR, showed:-An order, dated 06/09/26, for insulin glargine SQ solution pen-injector 100 unit/ml, inject 55 units SQ every morning and at bedtime;--The space designated on the MAR for insulin glargine administration in the morning was blank on 08/10/26 with no documentation why the space was blank;-The space designated on the MAR for insulin glargine administration at bedtime was blank on 08/02/26, 08/10/26, and 08/15/26, with no documented reason the space was blank;-An order, dated 06/10/26, for insulin lispro (fast acting insulin) injection solution 100 unit/ml, inject as per sliding scale (guide that shows how much short or rapid acting insulin to administer based on the resident's current blood glucose level) SQ three times a day in the morning, the afternoon, and in the evening;--Blood glucose of 141 to 180 = 3 units;--Blood glucose of 181 to 220 = 6 units;--Blood glucose of 221 to 260 = 9 units;--Blood glucose of 261 to 300 = 12 units;--Blood glucose of 301 to 350 = 15 units;--Blood glucose of 351 to 351= give 18 units, call physician to notify if above 350 after 18 units given SQ;---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration in the morning was blank on 08/10/26, with no documentation why the space was blank;---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration in the afternoon was blank on 08/10/26, with no documentation why the space was blank;---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration at night was blank on 08/02/26, 08/10/26, 08/12/26, 08/13/26, 08/14/26 and 08/15/26, with no documentation why the space was blank Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation regarding insulin administration, including if the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. During an attempted interview on 08/19/26 at 9:30 A.M., the resident said he/she did not feel like talking about his/her insulin and declined to answer any questions. 3. Review of Resident #8's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes;-Received insulin in the past seven days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Goal: Resident will be free from any signs or symptoms of hypoglycemia;-Approaches included administering insulin injections per orders, rotate injection sites. Review of the resident's POS and August 2026 MAR, showed:-An order, dated 03/08/26, for insulin glargine SQ solution pen-injector 100 unit/ml, inject 40 units SQ every morning,--The space designated on the MAR for insulin glargine administration was blank on 08/02/26, 08/10/26, and 08/15/26, with no documented reason the space was blank;-An order, dated 04/08/26, for insulin lispro injection solution100 unit/ml, inject as per sliding scale three times a day in the morning, the afternoon at 12:00 P.M., and at night;--Blood sugar of 150 to 200 = 2 units;--Blood sugar of 201 to 250 = 4 units;--Blood sugar of 251 to 300 = 6 units;--Blood sugar of 301 to 350 = 8 units;--Blood sugar of 351 to 400 = 10 units;--Call physician if above 400.---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration in the afternoon was blank on 08/06/26, with no documentation why the space was blank;---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration at night was blank on 08/06/26 and 08/14/26, with no documentation why the space was blank. Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation regarding insulin administration, including if the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. 4. Review of Resident #9's annual MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes;-Received insulin in the past seven days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Approaches: Identify areas on non-compliance or other difficulties in resident's diabetic management. Review of the resident's POS and August 2026 MAR,, showed:-An order, dated 02/03/26, for insulin glargine SQ solution pen-injector 100 unit/ml, inject 36 units SQ every night;--The space designated on the MAR for insulin glargine administration at bedtime was blank on 08/02/26 and 08/10/26, with no documented reason the space was blank;-An order, dated 07/26/26, for insulin lispro injection solution 100 unit/ml, inject as per sliding scale before meals and at night;--Blood sugar of 200 to 300 = 3 units;--Blood sugar of 301 to 400 = 6 units;--Call physician if below 60 or above 400.---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration before dinner was blank on 08/02/26, 08/10/26, 08/14/26 and 08/15/26, with no documentation why the space was blank;---The space designated on the MAR for sliding scale blood glucose monitoring and insulin lispro administration at night was blank on 08/02/26, with no documentation why the space was blank. Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation regarding insulin administration, including if the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. During an interview on 08/19/26 at 12:30 P.M., the resident said he/she didn't always get his/her insulin like he/she was supposed to. 5. Review of Resident #10's quarterly MDS, dated [DATE], showed:-Cognitively impaired;-Diagnoses included diabetes;-Received insulin three days in the past seven days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Goal: Resident will be free from any sign or symptoms of hypoglycemia;-Approaches: Diabetes medications as ordered. Review of the resident's POS and August 2026 MAR, showed:-An order, dated 08/04/26, for NovoLog (fast acting insulin) flex pen SQ solution 100 unit/ml inject 6 units SQ every morning and evening; --The space designated on the MAR for Novolog administration was blank on 08/10/26 and 08/14/26, with no documentation why the space was blank. Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation regarding insulin administration, including if the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. 6. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Cognitively impaired;-Diagnoses included diabetes;-Received insulin three days in the past seven days. Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident has diabetes;-Goal: Resident will have no complications related to diabetes;-Approaches: Resident will have no complications related to diabetes. Review of the resident's POS and August 2026 MAR, showed:-An order, dated 04/18/26, for Humalog (fast acting insulin) Kwik Pen SQ solution 100 unit/ml, inject per sliding scale four times per day in the morning, at noon, evening, and night;--Blood glucose of 181 to 200 = 2 units;--Blood glucose of 201 to 250 = 4 units;--Blood glucose of 251 to 300 = 6 units;--Blood glucose of 301 to 350 = 8 units;--Blood glucose of 351 to 400 = 10 units;--Call physician if below 60 or above 400; ---The space designated on the MAR for Humalog administration in the evening was blank on 08/03/26, 08/05/26, and 08/17/26, with no documentation why the space was blank. Review of the resident's progress notes, dated 08/01/26 through 08/19/26, showed no documentation regarding insulin administration, including if the resident refused his/her insulin and/or if the resident's physician was notified of the missed insulin doses. 7. During an interview on 08/19/26 at 3:00 P.M., the Director of Nursing (DON) said both licensed nurses and certified medication technicians (CMTs) were responsible for blood glucose testing and insulin administration. Staff should document on the MAR if the resident refused the medication. If a non-insulin certified CMT was working, a licensed nurse would be responsible for blood glucose testing and insulin administration. A blank space on the MAR without any additional documentation would be difficult to prove if the insulin was given or not. Blank spaces usually meant the medication was not administered. She expected staff to notify the resident's physician if the resident refused their insulin. 3153639

Based on interview and record review, the facility failed to follow physician orders and facility policy when anti-anxiety medications were not administered as ordered for one resident (Resident #4). The sample was 8. The census was 151.Review of the facility's undated Medication - Administration policy showed:-Purpose: To provide practice standards for safe administration of medications for residents in the facility;-Policy:--Medication will be administered by a Licensed Nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law;--Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law;--Medications may be administered one hour before or after the scheduled medication administration time;--Medications and treatments will be administered only by Licensed Medical or Licensed Nursing Staff;-Procedure:--If resident is refusing to take medication, the Licensed Nurse who is passing the medications will initial and draw a circle around his/her initials in the designated area on the medication administration record (MAR). Documentation will be entered on the back of the MAR stating the reason for the refusal;--If the resident repeatedly refuses medication, the Licensed Nurse will contact the physician to discuss alternative measures for medication administration. The plan of care will be updated as indicated;--The Licensed Nurse will chart the drug, time administered, and initial his/her name with each medication administration and sign full name and title on each page of the MAR;-Holding Medications:--Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason for the medication was held on the back of the MAR. Review of the facility's Unavailable Medications policy, dated 09/2018, showed:-Policy: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident;-Procedures:-The pharmacy staff shall:--Notify nursing staff that the order product(s) is/are unavailable;--Notify nursing staff of when it is anticipated that the drug(s) will become available;--Suggest alternative, comparable drug(s} and dosage of drug(s} that is/are available;-The nursing staff shall:--Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available;.--If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction;--Obtain a new order and cancel/discontinue the order for the non-available medication.--Notify the pharmacy of the replacement order. Review of Resident #4's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/27/26, showed:-Cognitively intact;-Adequate vision and hearing;-Makes self-understood and understand others;-Diagnoses included high blood pressure, anxiety disorder, and depression;-Received anti-anxiety medication for the past seven days. Review of the resident's care plan, revised 04/01/26, showed:-Focus: Resident uses anti-anxiety medications related to anxiety disorder;-Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy;-Interventions/Tasks included give anti-anxiety medications as ordered by the physician. Review of the resident's Mental Status Exam (MSE), dated 06/03/26, showed:-Problem List: Generalized anxiety disorder;-Plan of Treatment Overview: Will begin Ativan 0.5 mg twice daily. Review of the resident's electronic physician's order sheet (ePOS), showed an order, dated 06/03/26, for Ativan (anti-anxiety medication) oral tablet 0.5 milligram (mg). Give one tablet by mouth twice daily. Review of the resident's MAR for Ativan 0.5 mg. and progress notes, showed:-Ativan 0.5 mg scheduled for administration at 8:00 A.M. and 5:00 P.M.;-On 06/03/26 at 5:00 P.M., the MAR blank;-On 06/04/26 at 5:00 P.M., the MAR blank;-On 06/05/26 at 8:00 A.M., a 3 documented (3 = resident away from facility) on the MAR;-On 06/05/26 at 5:00 P.M., the MAR blank;-On 06/06/26 at 8:00 A.M., a 9 documented (9 = other, see nurses notes) on the MAR;-On 06/06/26, at 5:00 P.M., the MAR blank;--Progress notes, dated 06/06/26 at 8:50 A.M. and 6:55 P.M., showed the resident refused meds;-On 06/07/26 at 8:00 A.M. and 5:00 P.M., a 7 documented (7 = not administered/see progress notes) on the MAR; --Progress notes, dated 06/07/26, showed no documentation why the medication not administered. At 5:36 P.M., doctor notified of need for signed script for Ativan 0.5 mg. Unable to administer;-On 06/08/26 at 8:00 A.M. and 5:00 P.M., showed a 7 documented on the MAR;--Progress notes, dated 06/08/26, showed at 10:50 A.M., waiting on arrival of medication. No documentation why medication not administered at 5:00 P.M.; -On 06/09/26 at 8:00 A.M. and 5:00 P.M., a 7 documented on the MAR;--Progress notes, dated 06/09/26, showed at 10:19 A.M., awaiting arrival of medication. No documentation why medication not administered at 5:00 P.M.;-On 06/10/26 at 8:00 A.M., a 9 documented on the MAR;--Progress notes, dated 06/10/26, showed at 10:19 A.M. awaiting pharmacy. At 3:20 P.M., waiting on script;-On 06/10/26 at 5:00 P.M., a 7 documented on the MAR;--No progress note on 06/10/26 about why medication not administered at 5:00 P.M.;-On 06/11/26 at 5:00 P.M., a 7 documented on the MAR;--A progress note, dated 06/11/26 at 5:29 P.M., showed waiting on script;-On 06/12/26 at 8:00 A.M., and 5:00 P.M., a 7 documented on the MAR;--No progress notes on 06/12/26 about why medication not administered;-On 06/13/26 at 8:00 A.M. and 5:00 P.M., a 7 documented on the MAR;--Progress notes, dated 06/13/26, showed at 11:16 A.M., awaiting pharmacy. At 7:26 P.M., script needed;-On 06/14/26 at 8:00 A.M. and 5:00 P.M., a 7 documented on the MAR; --Progress notes, dated 06/14/26, showed at 10:13 A.M., awaiting pharmacy. No documentation why medication not administered at 5:00 P.M.;-On 06/15/26 at 8:00 A.M. and 5:00 P.M., a 7 documented on the MAR;--Progress notes, dated 06/15/26, showed at 9:31 A.M., no script. At 5:26 P.M., awaiting script;-On 06/16/26 at 8:00 A.M. and 5:00 P.M., the MAR blank;-On 06/17/26 at 8:00 A.M. and 5:00 P.M., the MAR blank;-On 06/18/26 at 8:00 A.M. and 5:00 P.M., a 7 documented on the MAR;--Progress notes, dated 06/18/26, showed no documentation why medication not administered at 8:00 A.M. At 6:24 P.M., medication awaiting arrival;-On 06/19/26 at 8:00 A.M. and 5:00 P.M., the MAR blank;-On 06/20/26 at 8:00 A.M. and 5:00 P.M., a 9 documented on the MAR;--A progress note, dated 06/20/26 at 3:59 P.M., showed med not available;-On 06/21/26 at 8:00 A.M. and 5:00 P.M., a 9 documented on the MAAR:--A progress note, dated 06/21/26 at 7:34 P.M., showed med not available, not received from pharmacy;-On 06/22/26 at 8:00 A.M. and 5:00 P.M., the MAR blank;--A progress note, dated 06/22/26 at 9:29 A.M., showed med not available, not received from pharmacy;-On 06/23/26 at 8:00 A.M. and 5:00 P.M., the MAR blank;-On 06/24/26 at 5:00 P.M., the MAR blank;-On 06/25/26 at 8:00 A.M., the MAR blank. During an interview on 06/23/26, at 9:45 A.M., the resident said the facility's inability to get his/her medications had been going on for almost a month. He/She did not believe staff contacted his/her psychiatrist and/or primary care physician to get the prescription filled. He/She was used to taking an anti-anxiety medication daily and he/she was getting very anxious about not having his/her medications. He/She spoke to the charge nurses and they just blow him/her off. He/She felt like his/her mental status was going to decline due to not having his/her anti-anxiety medications. During an interview on 06/24/26 at 8:20 A.M., Licensed Practical Nurse (LPN) D said the resident did not have his/her Ativan 0.5 mg because the pharmacy would not fill his/her prescription. It had been almost three weeks. He/She did not know what the holdup was. He/She contacted the pharmacy on multiple occasions and they kept telling him/her the physician had not sent over the written prescription. LPN D did not call the resident's primary care physician, the Medical Director, and/or the Director of Nursing (DON). He/She did not know if anyone else attempted to contact the resident's primary care physician or Medical Director. During an interview on 06/24/26 at 12:45 P.M., Physician B, the resident's primary care physician, said he/she didn't usually order psychotropic medications. The psychiatrist that ordered the resident's medication should have sent the written script over to the pharmacy. If the resident had not received the medication in a couple of days because the pharmacy did not have a written script, Physician B expected the nursing staff to notify the psychiatrist, Physician B, or the DON. Physician B was not notified the resident went for 22 days without his/her ordered medication. He/She expected staff to follow physician's orders and to notify the primary care physician if they had difficulty getting medications. During an interview on 06/24/26 at 2:35 P.M., the DON said she expected staff to provide the resident's medication as ordered. The nurses were responsible for ordering medication. The resident's psychiatrist should have sent the pharmacy a written script so the medications could be filled. Residents should not have to go without their medication. If the staff could not get the medication from the pharmacy, they should have notified her so she could check with the pharmacy or contact the resident's physician. She was not aware the resident had gone three weeks without getting his/her prescribed medications. 304964730494943051491

Based on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one resident (Resident #2) when one staff repositioned the resident, who had a diagnosis of quadriplegia (loss or partial loss of movement and sensation in all four limbs) onto their side and left the resident unattended to obtain supplies. When the staff member returned to the room, the resident was on the floor. The sample was 16. The census was 158.The administrator was notified on 10/9/25 at 6:30 P.M., of past noncompliance which began on 8/9/25. Once the nurse was made aware of the incident, he/she assessed the resident, completed a skin and pain assessment, administered pain medication, started neurological checks, and notified the Medical Doctor (MD). The resident complained of pain and requested to go to the hospital. The resident was sent out to be evaluated. The facility obtained a statement from the Certified Nurse Aide (CNA) and the resident. Staff were in-serviced on proper incontinence care, taking supplies with them when they entered the room, and not leaving residents unattended. In addition, the Administrator and Director of Nursing (DON) had a care plan meeting with family. The CNA is no longer employed by the facility. This deficient practice was corrected on 8/11/25. Review of the facility's Activities of Daily Living (ADL) policy, dated March, 2018, showed the following:-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good personal hygiene;-A resident's ability to perform ADLs will be measured using clinical tools, including the [NAME] Data Set (MDS). The following MDS definitions: total dependence - full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. Review of Resident #2's medical record, showed:-Alert to person, place, time, and situation;-Diagnoses included: generalized muscle weakness and quadriplegia;-Used a low air loss mattress (a specialized type of mattress that used a pump to circulate air through the mattress). Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident had an ADL Self Care Performance Deficit:--Goal: Resident will improve current level of function in (bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score) through the review date;--Interventions included: Bed mobility: roll left to right: dependent; Personal and toilet hygiene: dependent;-Focus dated 8/11/25: Resident has had an actual fall, 8/9/25 minor injury,:--Goal: The resident will resume usual activities without further incident through the review date; the resident's injured areas will resolve without complication by review date;--Interventions included: Educate staff that there is to be two people providing ADL care, such as turning, bathing, dressing, transfers, and incontinent care, at all times; for no apparent acute injury, determine and address causative factors of the fall; monitor/document /report as needed for 72 hours to medical doctor (MD) for signs and symptoms for pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Review of the facility's Fall report dated 8/9/25 at 4:46 P.M., showed the following for the resident:-Fall: no injury;-Nursing description: CNA informed the nurse that as he/she had the resident on his/her right side to provide personal care, he/she (the resident) had a spasm causing his/her legs to jump, making him/her fall out of bed. Upon entering the room, resident was noted to be on the floor, lying on his/her back with his/her bedside table overturned next to him/her. Upon assessment, no injury was noted at this time. Resident complained of pain to his/her neck and back of head. Resident stated that he/she hit his/her head on the bedside table on the way down. Resident stated that he/she fell when being changed and hit the back of his/her head on the bedside table on his/her way to the floor;-Was this incident witnessed? No;-Mental Status: Oriented to person, place, time, and situation. Review of the resident's progress notes dated 8/9/25, showed:-At 4:30 A.M., and late entry 11:16 A.M., CNA informed the nurse that as he/she had resident on his/her right side to provide personal care, he/she had a spasm causing his/her legs to jump, making him/her fall out of bed. Upon entering room resident was noted to be on the floor, lying on his/her back with his/her bedside table overturned next to him/her. Upon assessment no injury was noted at that time. Resident complained of pain to his/her neck and back of head. Resident stated that he/she hit his/her head on the bedside table on the way down. Resident assisted to bed and personal care provided. Requested to be sent out. MD notified. Gave orders to send to hospital for further eval. Spouse made aware via phone;-At 5:37 A.M., Emergency Medical Service (EMS) here to transport resident via stretcher times two;-At 10:39 A.M., resident returned from hospital ER by ambulance. Computed tomography (CT, a diagnostic imaging procedure that used X-rays and computer technology to create detailed, cross-sectional images of the inside of the body) scans of head and neck were done and are negative. Contusion (bruise) noted to back of head. No other injuries were noted. Review of the facility's investigation, showed:-CNA B's handwritten statement dated 8/9/25: around 4:30 A.M.: CNA B was changing the resident in his/her room as CNA B had the resident rolled over cleaning him/her his/her foot dropped off the bed causing him/her to fall off before CNA B could catch him/her;-Registered Nurse (RN) C's handwritten statement, undated: The resident's statement of the incident as told to RN C. The resident stated that CNA came into his/her room to change him/her. He/She stated the CNA rolled him/her onto the edge of the bed and then left the room to get supplies. The resident stated he/she fell off the side of the bed and hit his/her head on the bedside table. The resident stated the CNA came back in his/her room and saw him/her on the floor. He/She then left the room and came back 10 minutes later to get him/her off the floor. He/She was then lifted off the floor back into bed. He/She stated at this time he/she asked to go to the hospital;-SSD's handwritten statement, dated 8/10/25: Resident verbal statement document by SSD, fell out of bed after being left on his/her side in bed. The CNA then left the room with no other statement, assumed to go get another aid. Resident does not know who other aid was. No explanations given but resident was assisted back into bed. Resident stated it was appropriate with no harm intended by physical touch. During an interview on 10/9/25 at 1:20 P.M. the SSD said she was not at the facility when the fall occurred. She got a statement from the resident, who said the caregiver was CNA B. The CNA prepped him/her to be changed or transferred and left out of the room. SSD said she could not recall any further details about the incident but said nursing followed up. The resident usually did not complain and if he/she had a concern he/she would tell us. During an interview on 10/9/25 at 6:55 A.M., Licensed Practical Nurse (LPN) D said he/she worked the morning on 8/9/25 when the resident fell, but he/she was not in the room when the incident occurred. The CNA reported he/she had the resident on their side, and he/she fell from the bed. When LPN D entered the room, he/she saw the resident on the floor on his/her right/back side. The bed was normal height (he/she pointed to approximate waist height). There was no immediate injury, he/she complained of neck and back of the head pain. He/She was given pain medication. The resident was sent to the hospital. LPN D could not recall the name of the CNA but said the CNA was no longer at the facility. After the resident returned from the hospital, he/she told the day nurse the CNA left out of the room and that's when he/she fell. The day shift nurse reported it to management. LPN D worked the evening shift on 8/9/25 and the resident also told him/her the same thing. The resident required two person assist for ADL care. LPN D assumed the CNA was caring for the resident by him/herself. During an interview on 10/9/25 at 11:03 A.M., RN B said if a resident's care plan showed the resident was dependent for ADL Care, that meant the resident required two-person assistance. CNAs knew which residents required two persons assistance from report, or they could look at the ADL sheet or the Kardex. The resident required two-person assistance for providing personal care/hygiene and for turning and positioning. Sometimes the resident would jerk. The fall occurred between 4:00 and 5:00 A.M. When the resident returned from the hospital, he/she told RN B there was only one aide in the room, the aide rolled him/her onto his/her side and left out of the room to go get something and he/she fell. RN B said staff should take their supplies with them when they enter the room. During an interview on 10/9/25 at 2:00 P.M., Assistant Director of Nursing (ADON) said the resident told them the CNA was doing care by him/herself and the CNA flipped his/her legs over (crossed legs). The aide forgot some items and left to obtain them. The resident was on a low air loss mattress, and he/she was top heavy and fell off the edge of the bed. He/She hit his/her head on the dresser and had a small laceration. The resident was sent to the hospital to be evaluated. She would expect staff to use two person assist for any resident who used a low air loss mattress and/or mechanical lift for transfers. Staff should gather all supplies before going into the room. Staff were in-serviced on keeping supplies in the residents' room and using two staff for care. During an interview on 10/9/25 at 3:45 P.M., The Director of Nursing (DON) said staff knew which residents required two-person assistance by looking in the computer or they could ask the nurse. The DON heard the CNA left out of the room to get supplies, the resident was left unattended and fell. The nurse assessed the resident; no injuries noted. He/She requested to go to the hospital and was sent out. Neurological checks were completed. Staff were in-serviced, the CNA was terminated, and the Administrator and DON had a care plan meeting with the family. The DON expected staff to obtain all supplies before going into the room to provide care, staff should not leave residents unattended, and quadriplegia residents should have two-person assistance. During an interview on 8/9/25 at 11:30 A.M., Certified Medication Technician (CMT) E said the resident required two-to-three-person assistance. If he/she did not know what type of care a resident needed he/she would ask the nurse. During an interview on 10/9/25 at 12:25 P.M., CNA F said the resident was only able to move his/her head and neck and needed two person assist. During an interview on 10/9/25 at 6:00 P.M., the Administrator said she would expect staff to use two-person assistance for care for residents who are dependent on staff for care and used a low air loss mattress, the care plan should have shown the number of staff required to provide assistance. Staff should make sure they have their supplies when they go into a resident's room. Staff are expected to follow the facility's policy and procedures. 2585289

Based on observation, interview, and record review, the facility failed to ensure resident's were free from accident hazards during resident smoking and in the smoking areas. The smoking area showed evidence of unsafe smoking practices such as trash in the ash bins and cigarette butts on the ground. Residents who smoke were not accurately and completely assessed for their ability to smoke safely. In addition, the facility did not follow their smoking policy as it relates to assessment, supervision, and securing smoking materials for three of four residents investigated for safe smoking practices (Residents #94, #4, and #16). The census was 165. The sample was 33. Review of the facility's Smoking by Residents policy, dated 6, 2020, showed:-To respect resident choices to smoke and to maintain a safe healthy environment for both smokers and non-smokers;-The facility permits smoking only in area(s) designated by the facility's safety committee;-The facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely;-Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in these areas;-Residents who are not able to smoke safely will be accompanied by facility staff while smoking;-Smokers shall be identified at the time of admission;-A licensed nurse will complete a safe smoking assessment for residents who wish to smoke. The assessment will be completed in the electronic medical record system;-The interdisciplinary team shall create a smoking care plan for the resident;-All smoking materials will be stored in a secure area to ensure they are kept staff;-All smoking sessions will be supervised by facility staff members;-Cigarette butts are disposed of only in provided receptacles. 1. Observation on 8/5/25 at 9:23 A.M., of the smoking area on the Long-Term Care (LTC) side of the facility, showed a sign on the door that no oxygen is allowed in the smoking area. There are two separate areas, a covered and screened-in porch and an open-air area. A sign posted near the entrance to the smoking area read: LTC and rehab smoke times 8a, 10a, 2p, 4p, and 8p. [NAME] Zone designated smoke area. Observation of the open-air area of the smoking area showed two self-closing red ash bins stuck in the open position. One with two packs of cigarettes and one with one cigarette pack in it. Cigarette butts also in the ash bins along with the trash. Multiple cigarette butts scattered around the grounds, in the grass, on the mulched areas, and on the concrete walkways. On the ground near the building, there are approximately 2-4 cigarette butts per square foot of Random cigarette butts on the concrete. Two residents smoke in the screened-in area of the smoke area. There was a door from the outside to the screened-in area. No staff present. At 9:37 A.M., a resident walked out to the outdoors smoking area with a cigarette that hung out of his/her mouth. He/She sat down and lit the cigarette. 2. Review of Resident #94's medical record, showed:-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease);-A Safe Smoking Evaluation, dated 5/23/25: Does the resident smoke: No. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: The resident smokes. Has been advised of the facility smoking policy. The resident requires supervision with smoking;-Goal: The resident will be compliant with the facility smoking policy;-Interventions included: Observe the resident during smoking for unsafe smoking. Reassess the resident's smoking ability quarterly and after reports of unsafe practices. Remind the resident and family that all cigarettes, lights, matches, and smoking paraphernalia must be kept at the nurse's station. During an interview on 8/4/25 at 9:42 A.M., the resident said when he/she smokes, he/she can go by him/herself. There are other residents who require staff assistance. He/She can go out whenever he/she wants. He/She is able to keep his/her own smoking supplies, lighters, and cigarettes. Observation on 8/5/25 at 8:09 A.M., showed the resident in his/her scooter, propelled away from the smoking area and said he/she just got done smoking. At 11:42 A.M., the resident propelled him/herself outside to the smoking area in his/his scooter. He/She grabbed cigarettes and a lighter out of his/her pocket and began to smoke with no staff present. 3. Review of Resident #4's medical record, showed:-Diagnoses included complete paraplegia (paralysis of both legs), COPD, and asthma;-A Safe Smoking Evaluation, dated 6/6/25: Does the resident smoke: No. During an interview on 8/4/25 at 9:40 A.M., the resident said he/she smokes. He/She prefers to go every two hours, he/she keeps his/her own cigarettes and lighter. He/She did not require staff assistance compared to the other residents. Observation on 8/6/25 at 12:15 P.M., showed the resident in his/her motorized chair, propelled to the smoking area. The resident was upset because he/she was instructed to come back inside because his/her chair tilted all the way back in a supine position and was unable to return to a sitting position. The staff assisted the resident back in the room to have the chair fixed. The resident said he/she just needed to smoke. During an interview on 8/7/25 at 12:56 P.M., the Social Worker Assistant said the admitting nurse was responsible for the initial smoking assessment. The social services will follow-up and make sure the assessments were completed correctly and timely. He/She said Resident #4 was a smoker but was not observed to have his/her smoking materials in the room. All the residents' smoking materials were kept in the nurses' stations. The resident was admitted prior to his/her employment and was not aware of the inaccurate initial assessment. 4. Review of Resident #16's medical record, showed:-Cognitively intact;-Diagnoses included: end stage renal failure (a condition where the kidneys lose their ability to adequately filter waste and excess fluids from the blood, and maintain proper chemical balance), anxiety, and depression;-A Safe Smoking Eval, dated 5/6/25, showed, does the resident smoke: no. Review of the care plan, in use at the time of survey, showed:-Focus: Resident smokes. They have been advised of the facility smoking policy. The resident requires supervision with smoking. Date Initiated: 12/11/2024;-Goal: will be compliant with facility smoking policy through review date;-Interventions: observe resident during smoking for unsafe smoking (dropping cigarette, hold to close to body, etc.) and report to nurse; offer and encourage use of safety devices (smoking apron, holder) when smoking; provide assistance as needed to assist resident to and from smoking area; reassess resident smoking ability quarterly and reports of unsafe practice. During an observation and interview on 8/5/25 at 1:45 P.M., showed the resident lay in bed and watched TV. The resident said he/she was a smoker. On 8/6/25 at 6:00 P.M., the resident sat in his/her wheelchair propelled him/herself in the hall and said he/she was going outside to smoke. On 8/7/25 at approximately 10:49 A.M., the resident sat outside in the smoking area with a cigarette in his/her right hand. Review of the safe smoking evaluation provided by facility on 8/7/25 showed a smoking assessment dated [DATE], showed:-Does the resident smoke: Yes;-Summary: This resident is safe to smoke with minimal supervision. During an interview on 8/8/25 at 7:45 A.M., Assistant Director of Nursing (ADON) L said the hospitality aide takes the residents outside to smoke. Smoking assessments are completed every quarter or if the residents' condition changed. The smoking assessment and the care plan should match. ADON L said she did not have a list of residents who smoked, and she has not seen the resident smoke. 5. During an interview on 8/7/25 at 8:26 A.M., the Director of Nursing (DON) said if the smoking assessment says no, that means they do not smoke. Smoking assessments should be accurate. She was not sure who is responsible to complete the smoking assessments. Smoking assessments should be done on admission and quarterly. She believes maintenance staff are responsible for maintaining the smoking area. There should be no trash in the ash cans. Cigarettes should be in ash cans and not on the ground. If staff notice this is an issue this should be reported so it can be addressed. Residents assessed safe to smoke independently should be occasional observed to ensure they are properly disposing of their cigarettes and to ensure they are following safe smoking practices. If staff notice cigarette butts scattered on the grounds, this should prompt staff to evaluate who is not properly disposing their cigarette butts.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored appropriately. The facility identified seven medication/treatment carts and two medication rooms. Four of the seven carts and both medication rooms were checked for medication storage. Issues were found in all four medication carts. Staff failed to discard expired bottles of over the counter (OTC) medications, and a bottle of Pro-Stat protein drink (increases wound healing). In addition, the staff failed to refrigerate a bottle of Latanoprost eye drops (treats glaucoma, an eye condition that causes blindness), a bottle of Lorazepam (used to treat anxiety), and a vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution. Furthermore, the staff failed to label one insulin pen with a resident's name. The census was 165.Review of the Facility's Storage of Medication, dated 9/2018, showed:-Policy: Medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications;-General Guidelines: all medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label;-Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 Fahrenheit (F) and 46 F with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator that is attached to the inside of the refrigerator or in accordance with state regulations and facility policy;-The nurse will check the expiration date of each medication before administering it;-All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 1. Observation and interview on 8/5/25 at 11:00 A.M., of the Certified Medication Technician (CMT) cart on the south hall showed, in the top drawer of the medication cart was:-One bottle of Lactobacillus tablets (probiotic) was open with an expiration date of 1/25;-One bottle of fish oil (supplement) 500 mg was open with an expiration date of 8/24;-One bottle of calcium citrate (supplement) 200 mg was open with an expiration date of 7/25;-One bottle of niacin (vitamin B3 supplement) 250 mg was open with an expiration date of 3/25;-One bottle of zinc (supplement) 50 mg was open with a best by date of 4/25;-One bottle of Latanoprost 0.005% eye drop with a refrigerate sticker on the bottle;-CMT R said both the nurses and the CMTs were responsible for checking the expiration dates. The eye drops should be stored in the refrigerator. 2. Observation and interview on 8/5/25 at 11:15 A.M., of the nurse one med cart on the South Hall, in the drawer, showed:-One bottle of vitamin C 250 mg, opened with an expiration date of 1/25;-One box of oral pain relief gel, opened with an expiration date of 2/25;-One bottle of Pro-Stat, opened and dated 7/14/25 with an expiration date of 2/15/25;-One out of eight insulin pens were not labeled with a resident's name on it;-CMT S said both the nurses and CMTs are responsible for checking the expiration dates. He/She did not know who the insulin pen belonged to. 3. Observation and interview on 8/5/25 at 11:35 A.M., of the CMT cart on the memory care hall in the top drawer of the cart showed:-One bottle of oyster shell calcium (supplement) 500 mg open with an expiration date of 10/24;-In the narcotic box was one bottle of lorazepam concentrate 2 mg/ml with a refrigerate sticker on the box. Assistant Director of Nurses (ADON) A removed the lorazepam from the cart and said they would reorder the medication because the name on the label was hard to read and Lorazepam should be stored in the refrigerator. The CMTs are responsible for checking the expirations. Review of Lorazepam Oral Concentrate, 2 milligram (mg) per milliliter (mL) package insert, showed store at 2 to 8 Celsius (C) (36 to 46 F). 4. Observation and interview on 8/5/25 at 11:53 A.M., of the nurse cart on the rehab hall, showed a vial of opened PPD in the top drawer. Registered Nurse (RN) U said PPDs should be stored in the refrigerator. 5. During an interview on 8/8/25 at 11:00 A.M., the Director of Nursing (DON) said all medications should be labeled with the resident's name on it. PPD, liquid lorazepam and latanoprost eye drops should be stored in the refrigerator. Medications should be checked daily for expiration dates by whomever is on the cart. Expired medications should be disposed.

Based on observation, interview and record review, the facility failed to follow their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to document pre/post dialysis assessments. The facility identified five residents who received dialysis services. Two residents were sampled, and issues was found with one (Resident #150). The sample was 33. The census was 165. Review of the facility's Dialysis Care Policy, revised 6/20, showed:-Policy: the facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all non-­ dialysis needs of the resident including during the time period when the resident is receiving dialysis;-Arteriovenous (AV) Shunt/Fistula (surgically created by connecting an artery and vein to provide a stable access point for dialysis), inspect shunt site area for color, warmth, redness, tenderness, pain, edema, drainage, and bruit (a pulsation felt of blood flow anastomosis (connection made surgically between adjacent blood vessels) once per shift;-To check for a bruit place fingertip slightly over the vein and feel for the thrill. Place the stethoscope over the vein and listen for the buzz or bruit. Document the findings in the medical record;-All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. Review of Resident #150's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/25, showed:-Severe cognitive impairment;-No behaviors or rejection of care;-Diagnoses included end stage renal disease (ESRD, chronic irreversible kidney failure);-Dialysis while a resident was not checked. Review of the care plan, in use at the time of survey, showed:-Focus: resident needs dialysis (hemodialysis, a medical procedure used to remove waste products and excess fluid from the blood when the kidneys are unable to perform this function adequately) related to renal failure;-Goal: will have no signs and symptoms of complications from dialysis through the review date;-Interventions: monitor/document/report to MD as needed any signs and symptoms of infection to access site: redness, swelling, warmth or drainage;-Monitor/document/report to MD as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds;-Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately;-The care plan failed to show the location of the access site and failed to show staff should document the bruit and thrill once per shift. Review of the physician order sheet, in use at the time of survey, showed:-A physician order for pre-dialysis assessment to be completed and sent with patient to dialysis every Tuesday, Thursday and Saturday,-A physician order for dialysis every Tuesday, Thursday, Saturday. Review of the Treatment Administration Record, dated 7/1/25 through 7/31/25, showed:-A physician order for pre-dialysis assessment to be completed and sent with patient to dialysis every Tuesday, Thursday and Saturday; -Documentation showed 7/8 and 7/19 were blank;-No documentation the access site was assessed for color, warmth, redness, tenderness, pain, edema, drainage and bruit once per shift. Review of the Dialysis Communication Forms, dated 7/1 through 8/7/25, showed:-12 forms were provided;-Two out of 12 nursing facility pre-dialysis documentation for thrill and bruit, dressing clean, dry, intact were blank;-Eight out of 12 nursing facility post-dialysis documentation, most recent temperature, pulse, respiration, blood pressure, oxygen saturation, location of access site, thrill and bruit, dressing clean, dry and intact, any new orders and assessment were blank;-Two out of four remaining nursing facility post-dialysis documentation, location of access site, thrill and bruit, dressing clean, dry and intact, any new orders and assessment were blank. Review of the progress notes, showed:-On 7/31/25, pre-dialysis assessment completed and sent with resident, bruit and thrill present, dressing remains clean and intact to right forearm, vital signs within normal limits (VSWNL); returned form dialysis, resident noted congestion with cough. MD made aware and stat chest x-ray ordered; -On 8/2/25, returned from dialysis, dialysis access site remains intact;-No other documentation the access site was assessed for color, warmth, redness, tenderness, pain, edema, drainage and bruit once per shift. During an interview on 8/8/25 at 7:45 A.M., Assistant Director of Nursing (ADON) L said the facility completed a pre and post dialysis assessment. The pre assessment would include the vital signs, weight, if the resident had pain, if they have eaten, any medications given and their Covid status. The post assessment would include vital signs and how the resident was feeling after dialysis. The assessment should be documented on the dialysis communication sheet or in the computer. During an interview on 8/8/25 at 11:00 A.M., the Director of Nursing (DON) said the physician's order should include the dialysis access site location. The bruit and thrill should be documented on the Nurse Administration Record (NAR). She expected the dialysis pre/post assessments to be completed.

Based on interview and record review, the facility failed to honor one resident's Durable Power of Attorney (DPOA, a legal document that allows a person to appoint another person to manage their financial and/or healthcare matters) to act on their behalf on financial matters (Resident #174). The facility failed get signed authorization from the resident's DPOA to open a resident trust account and to have his/her Social Security directly deposited into the resident trust account. In addition, the facility failed to notify the resident and his/her DPOA of a debited care cost at the time the resident was discharged from the facility. The census was 165. Review of Resident #174's face sheet, showed:-admitted on [DATE];-discharged on 7/11/25. Review of the resident's medical record, showed:-A Durable Power of Attorney (DPOA, a legal document that allows someone to appoint another person to act on their behalf in financial and/or medical matters), signed on 4/22/23, showed:-The DPOA was designated to act as initialed below, in the resident's name and for the resident's benefit, benefit, hereby revoking any and all financial powers of attorney resident may have executed in the past;-Resident grant attorney-in-fact the powers set forth herein immediately upon the execution of this document. These powers shall not be affected by any subsequent disability or incapacity resident may experience in the future;-Resident's attorney-in-fact shall exercise powers in the resident's best interest and for his/her welfare, as a fiduciary. His/Her attorney-in-fact shall have the following powers: -Banking: To receive and deposit funds in any financial institution, and to withdraw funds by check or otherwise to pay for goods, services, and any other personal and business expenses for resident's benefit. If necessary to effect my attorney-in-fact's powers, my attorney-in-fact is authorized to execute any document required to be signed by such banking institution. Review of the resident's Fund Authorization and Agreement, showed:-Transferring account (automatic care cost payments due to the facility) with a $50 monthly allowance;-Direct deposit: Social Security;-Signed by the resident on 8/15/24;-No signature from resident's DPOA;-No signature from witness. Review of the resident's benefit status, showed a monthly benefit in the amount of $1,512.47. Review of the resident's cash receipt report, showed:-On 3/24/24, a patient liability payment in the amount of $675.00;-On 4/1/24, a patient liability payment in the amount of $675.00;-On 5/1/24, a patient liability payment in the amount of $675.00;-On 6/26/24, a patient liability payment in the amount of $761.00. Review of the resident's progress notes, showed:-On 12/16/24, sent Social Security letter of income to County O for budget review;-On 12/19/24, resident does get his/her money when he/she asks for it. He/She has not been in lately to ask so I will also remind him/her that he/she can come in anytime and get money if his/her account shows it available. The invoices are old invoices from the facility. His/Her money comes into Resident Fund Management Service (RFMS) and the invoice gets care costed. I am also currently working with Medicaid to get his/her surplus adjusted because they have him/her paying more then he/she actually receives. I have sent Medicaid an email with supporting documentation;-On 5/1/25, sent another email to County O asking if they can tell me where resident's pension is coming from;-On 5/6/25, pension is coming from Company P. That is the only information we have;-On 6/3/25, resident tried calling Company P and unfortunately, they are not able to give him/her any info as resident could not remember any info about where/or which company the pension is coming from. They did give a fax number and also an email address to send request to;-On 6/25/25, call placed to resident's DPOA. He/She stated that he/she has all the paperwork from Company P for the pension. He/She stated he/she has concerns about the things that go on around at the facility. He/She asked that we hold a care plan meeting to discuss these concerns and to also ask resident if he/she would like to go live with him/her. Social Services aware and will set this up.During an interview on 7/10/25 at 11:41 A.M., the resident's DPOA said the facility did not respect his/her Power of Attorney (POA) status. They did not notify him/her of anything or give the DPOA any information. He/She did not want the resident's money switched to the facility because the resident had dementia. The DPOA asked the Business Office Manager (BOM) who gave the BOM the authority to call Social Security and have the resident's check moved? The BOM said the resident understood the question. The BOM was the bookkeeper. The BOM started asking where the resident's pension was. During an interview on 8/7/25 at 9:30 A.M., the BOM said the facility was not the representative payee for the resident's Social Security. The resident opened a new resident trust account at a new bank. He/She enrolled in direct deposit, so the Social Security was deposited into the resident trust. The resident's DPOA was contacted but refused to answer. He/She never answered the phone and did not give the resident's full Social Security payment. The DPOA finally made credit card payments after not paying for a long time. He/She never paid full payments. The DPOA had not contacted the facility about the resident's Social Security or payments. The credit card payments were all he/she made. The DPOA said that was all the resident had and that was not true. The BOM doubted any billing was mailed to the resident's DPOA because there was no address on file. The BOM confirmed the resident signed the authorization and agreement for a resident trust account. The DPOA was not contacted. The invoices were sent off by a third party. The BOM would also call residents and/or a responsible party if there were concerns. The resident wanted his/her money to come to the facility because his/her DPOA was not giving him/her money. The resident saw everyone else get their money, so he/she asked if he/she could have money. The BOM was asked if he/she was aware the resident had a DPOA. He/She said it would not take effect until the resident's death. Review of the resident's trust statement, showed:-On 8/21/24, an open transfer;-On 10/2/24, a Social Security deposit in the amount of $2,976.00;-Monthly care costs were debited from the account from 10/2/24 through 7/11/25;-Monthly Social Security deposits were credited to the account from 10/2/24 through 7/11/25. Review of the resident's progress notes, dated 7/7/25, showed staff had a meeting with resident's DPOA and resident. The DPOA now states that he/she knows nothing about the resident's pension and has no idea where it is going. The DPOA said that he/she has lots of concerns about the facility and the way that some things are handled. He/She stated that he/she will be taking the resident home with him/her on Friday, 7/11/25. He/She states that he/she has home health (HH) set up and a room just for the resident. During an interview on 7/11/25 at 5:48 P.M., the DPOA said he/she was presented with a check for money the resident had saved. The check was only for $260.00, and should have been for $490.04. During the care meeting held on 7/7/25, he/she was informed the resident would receive $490.04. He/She saw this figure on the computer. He/She was told the money was for insurance. Review of the resident's July 2025 resident trust statement, showed:-On 7/1/25, a balance of $490.02;-On 7/11/25, $20.00 was debited from the account for personal needs. The remaining balance was $470.02;-On 7/11/25, $260.00 was debited from the account for care cost payment. The remaining balance was $210.02;-Account was closed on 7/11/25. During an interview on 8/7/25 at 9:30 A.M., the BOM confirmed the money debited from the trust account on 7/11/25 was a care cost. The resident was being discharged from the facility and the care cost was debited from the resident trust. The DPOA was not contacted or informed about the care cost. During an interview on 8/8/25 at 8:57 A.M., the Administrator said she was aware the DPOA was upset about the resident's trust. She would expect staff to know if a resident had a DPOA for financial if it had been provided. The billing statements were mailed from the corporate office. She would expect documentation if a bill was sent or if there were call attempts regarding the resident's liability. She would expect the resident and/or responsible party to be notified if funds were debited from the trust account. 256072316764101676426

Based on interview and record review, the facility failed to ensure recommendations from a Level two Pre-admission Screening and Resident Review (PASARR) were incorporated into the plan of care for 1 of 3 residents reviewed for PASARR (Resident #119). This failure had the potential to negatively affect the resident's mental and psychosocial well-being. The census was 165.Review of Resident #119's medical record, showed:-The resident was admitted on [DATE];-The resident resided in a Medicaid certified bed;-A PASARR Level II Evaluation, Section II, dated 6/25/25, showed diagnoses included cerebral palsy (disorder of movement, muscle tone, or posture), learning disorder, and paraplegia (paralysis of both legs);-A PASARR Level II Summary of Findings, dated 6/27/25, showed:-The PASARR Level II Evaluation indicated the following supports and services are to be provided by the facility;-Medication therapy;-Crisis intervention services;-Discharge planning;-Structured development;-Personal support network. Review of the resident's care plan in use at the time of survey, did not address the resident's PASARR Level II recommendations. During an interview on 8/7/25 at 12:56 P.M., the Social Worker Assistant in the Long-Term Care (LTC) unit said he/she was not involved in following-up with the residents' PASARRs. The Social Services Director (SSD) in the Rehab side would have the information, including for the LTC residents. During an interview on 8/7/25 at 1: 49 P.M., the SSD said he/she was not responsible for following-up the residents' PASARRs recommendations and findings. He/She just made sure they were completed and filed in the residents' record but had no part to complete them. The admission Director was responsible for completing the residents' PASARR. During an interview on 8/7/25 at 2:53 P.M., the admission Coordinator said the residents' PASARR should always be included in the residents' record during admission. If the resident triggered for Level II, their liaison was responsible for completing it. Levels I and II need to be part of the admission process. Social Services would be responsible to make sure PASARRs are complete. The Minimum Data Set (MDS) staff will do their part, then will be filed in the medical records. During an interview on 8/7/25 at 3:27 P.M., the MDS Rehab nurse said he/she completes the second half or the nursing part of the residents' PASARR. He/She verified the resident had a Level II evaluation, and the recommendations were not included in the care plan. He/She said the care plan should reflect the resident's individual care and needs. During an interview on 8/8/25 at 10:58 A.M., the Director of Nursing (DON) said she expected the resident's Level II PASARR recommendations to be incorporated into the plan of care.

Based on observation, interview, and record review, the facility failed to provide services per professional standards for one resident who had an order for daily wound care and the treatment was not completed over the weekend (Resident #26). Staff failed to ensure one resident's treatment was applied as needed for a cancer lesion with drainage that was not covered and exposed (Resident #130). In addition, staff failed to obtain weights on one resident per their policy. When the weight was obtained, the resident had experienced a weight loss (Resident #1). The census was 165. The sample was 33.Review of the facility's Wound Management policy dated June 2020, showed:-Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injuries;-A resident who has a wound will receive necessary treatment and services to promote healing, prevent infections, and prevent new pressure injuries from developing;-The attending physician will be notified to advise on appropriate treatment promptly;-Per attending physician order, the nursing staff will initiate treatment and utilize interventions for wound management. 1. Review of Resident #26's medical record, showed:-Diagnoses included laceration right ankle;-An order dated 7/22/25, right medial malleolus (ankle), cleanse with normal saline/wound cleanser, pat dry, apply xeroform (non-adhesive dressing) and dry dressing every day and as neededfor wound care. During an interview on 8/4/25 at 9:20 A.M., the resident sat in a reclined Broda chair (medical reclining chair) and said staff do not take care of him/her right. Observation of the resident's right inner ankle showed a dressing dated 8/1 with staff initials. The resident said staff do not change the dressing every day. It should be done daily but is not done daily. Observation on 8/5/25 at 7:51 A.M., showed Wound Nurse M entered the resident's room to provide wound care. The resident lay in bed on his/her back. Wound Nurse M completed the resident's wound care as ordered and said the resident's ankle wound is to be changed daily. Observation showed the wound bed pink, no inflammation, and no drainage noted. The wound approximately quarter size. During an interview on 8/5/25 at 1:07 P.M., Wound Nurse M said the weekend nursing staff should do resident treatments on the weekends. He/She only does them Monday through Friday when working. 2. Review of Resident #130's medical record, showed:-Diagnoses included personal history of malignant melanoma of skin (skin cancer), cerebrovascular disease, and dementia;-An order, dated 7/17/25, for wound care to left forehead. Cleanse with normal saline (NS)/ wound cleanser (WC), pat dry, apply petroleum gauze to wound bed. Cover with dry dressing daily and as needed (PRN) every dayshift for wound care. Review of the resident's electronic Medication Administration Record (eMAR), dated 8/1/25 through 8/7/25, showed:-An order, dated 7/17/25, wound care to left forehead. Cleanse with NS/WC, pat dry, apply petroleum gauze to wound bed. Cover with dry dressing daily and PRN: -On 8/1/25 and 8/4/25, treatment documented as administered;-On 8/2, 8/3, 8/5, 8/6, and 8/7/25, treatment blank; -On 8/1 through 8/7/25, no documentation of treatment administered PRN. Review of the resident's care plan, in use during survey, showed:-Problem: The resident has potential for impairment to skin integrity: -Goal: The resident will be free from injury through the review date; -Interventions: Follow facility protocols for treatment;-Problem: The resident has an Activity of Daily Living (ADL) self-care performance deficit: -Goal: The resident will maintain current level of function through the review date; -Interventions: Skin inspection: The resident requires skin inspection weekly. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Review of the resident's skin assessment, dated 8/1/25, showed:-Does the resident have any skin impairments: yes;-Description: Status post-surgical biopsy to right side of head. Treatment in progress. Review of the facility's wound report dated 8/5/25, showed the following for the resident:-Location: Left head;-Measurements: Length: 4.00 centimeters (cm), width: 3.00 cm, depth: 0.10 cm;-Etiology: Basal Cell Carcinoma (skin cancer);-Epithelial (the cells that line the internal and external surfaces of the body): 50%;-Granulation (new tissue growth): 50%;-Exudate (drainage) amount: Light. Review of the resident's progress notes, dated 8/5/25, showed Basal Cell Carcinoma of skin of scalp and neck. Recommendations: Educated nursing team and/or patient to assess and communicate any significant changes in wound status, noting evidence of wound infection/cellulitis, infection, foul odor, osteomyelitis (bone infection), or acute ischemic changes and notify wound provider or primary care provider accordingly. If no evidence of healing within 2-4 weeks, re-evaluate plan of care and patient adherence. Plan of care discussed with facility staff. Dressing/ordered/applied. Observation on 8/4/25 through 8/7/25, showed:-On 8/4/25 at 9:31 A.M., the resident's left side of head with an exposed wound, some dried blood, and healing scabs. The resident did not have a bandage on the wound;-On 8/5/25 at 9:47 A.M., the resident in the activity room. The wound on the left side of the forehead was visible from across the room, no dressing in place. At 12:37 P.M., the wound was exposed, not covered. At 2:24 P.M., the resident was observed with a bandage that was wrapped around the top of his/her head. No date applied documented on the bandage;-On 8/6/25 at 12:35 P.M., the resident in the dining room. A bandage was wrapped around the top of the resident's head, dated 8/5/25. A soiled, pinkish color spot on the bandage, on the back of the head, not where the wound was located. It appeared the dressing had spun around;-On 8/7/25 at 1:18 P.M. and 1:43 P.M., the resident in the dining room. The wound on the left forehead was exposed, without a bandage. At 1:43 P.M., the resident in a bathroom, looking into the mirror. No bandage wrapped around his/her head. The wound exposed. During an interview on 8/7/25 at 1:43 P.M., Certified Medication Technician (CMT) V said the resident was suspected of having cancer. The wound team completes the treatments when they are here. The nurse will do it if the wound team is not here. The resident does not refuse. He/She goes back and forth about having the dressing applied, but will allow staff to do it. The resident will also remove the bandage at times. CMT V had not noticed any changes in the wound in the past three months. The only time he/she had seen it bleed was when the wound nurse was messing with it. They know the resident will remove the bandage and they will come back and do the dressing again. During an interview on 8/8/25 at 8:26 A.M., Assistant Director of Nursing (ADON) A said the resident had a surgical biopsy and it is an aggressive cancer. He/She did not know what kind of cancer. The wound team treats it daily. ADON A will change the bandage if the wound team is not here, if the resident will allow them to. She would expect staff to document if the treatment cannot be completed or if resident refuses. During an interview on 8/8/25 at 8:57 A.M., the Administrator said the wound team is here Monday through Friday and sometimes on the weekend. She would expect staff to follow treatment orders and document if the resident refuses the treatment. If the bandage was taken off, she would expect staff to attempt to change the bandage unless the resident refuses. If the bandage appeared stained or soiled, she would expect staff to attempt to change the bandage. 3. During an interview on 8/7/25 at 8:26 A.M., the Director of Nursing (DON) said physician orders should be followed. The nursing staff are responsible for doing wound care if it is not done by the wound nurse. 4. Review of the facility's Assessment and Management of Resident Weights policy, dated 6/2020, showed:-Purpose: To ensure each resident maintains acceptable parameters of weight and nutrition status;-Weights are obtained upon admission and/or re-admission, then weekly fr four weeks, and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or interdisciplinary team;-Admissions and re-admissions will be weighted on the shift they arrive. Hospital weights will not serve as admission or re-admission weights. Review of Resident #1's care plan, in use during survey, showed:-Focus: The resident has nutritional problem. The resident has orders to meet nutritional needs;-Goal: The resident will comply with recommended diet daily;-Interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Monitor/document/report to physician PRN for signs and symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Refusing to eat. Appears concerned during meals. Monitor/record/report to physician for signs and symptoms of malnutrition. Emaciation, muscle wasting, significant weight loss: 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, greater than 10% in six months. Review of the resident's medical record, showed:-Diagnoses included congestive heart failure, aphasia (loss of ability to speak), dysphasia (difficulty swallowing), and altered mental status.-A hospital progress note, dated 5/17/25: History of Present Illness: Patient states that his/her dry weight is 133 pounds. He/She is 123 pounds today;-admitted to the facility on [DATE];-A weight on 6/5/25, the resident weighed 152.6 lbs. Scale: Wheelchair;-No documentation of additional weights before or after 6/5/25;-No documentation of the resident's weight minus the weight of the wheelchair. Review of the resident's progress notes, showed on 6/24/25 and 6/26/25, resident has a trend of eating <51%. During an interview on 8/8/25 at 8:26 P.M., ADON A said it is the facility's policy to weigh the residents upon admission and then they are weighed weekly for four weeks. She would expect staff to obtain the residents' weight per policy or document the reason why the weight was not obtained. She would expect the weight to be accurate. If the resident was weighed in a wheelchair, the weight of the wheelchair chair should be subtracted. The ADONs are responsible for ensuring the weights are completed. Observation on 8/5/25 at 9:41 A.M., showed the resident was in his/her bed, eyes were open, but he/she did not verbally speak. The meal tray was positioned on the table with biscuits and gravy. The meat was a mechanical soft texture. The biscuits and gravy were untouched. During an observation and interview on 8/6/25 at 12:15 P.M., Registered Nurse (RN) Q reviewed the medical record and confirmed the resident was weighed on 6/5/25 and the weight documented as 152.6 pounds. Certified Nursing Assistant (CNA) T assisted RN Q to weigh the resident using the Hoyer lift (full body mechanical lift). The scale on the Hoyer lift showed the resident's weight measured 103.8 pounds. RN Q confirmed the resident's weight. During an interview on 8/6/25 at 12:30 P.M., CNA T said when the resident was first admitted , he/she ate small portions at first, then he/she ate all his/her food. He/She ate 50% of his/her meal for breakfast. CNA T was asked if the resident looked like he/she lost weight. He/she said the resident looks the same. During an interview on 8/6/25 at 12:30 P.M., RN Q said the residents are weighed once a month unless otherwise ordered by the physician. RN Q was unaware of the resident's weight loss. There were no reports of weight changes or changes with eating. The resident requires assistance with eating. There was no documentation if the dietician was made aware or if the resident was assessed. During an interview on 8/8/25 at 8:57 A.M., the Administrator said staff are expected to weigh the residents upon admission and weekly for four weeks unless the Registered Dietician or physician says differently. She would expect the weight to be accurate and if the weight was not able to be obtained, she would expect staff to document it in the medical record. If the resident was weighed in a wheelchair, she would expect staff to subtract the weight of the wheelchair from the total weight. The resident should have been weighed per policy at admission. The nursing department is responsible for ensuring the weights are completed. She would expect staff to report changes in residents' meal consumption to their ADON and communicate up the chain. They would have a meeting with the Registered Dietician and DON. She would expect staff to notify the dietician. Staff are expected to accurately document the percentage the residents are consuming in the chart.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with acceptable standards of practice, for one resident who had a fall. Staff failed to follow their fall policy and failed to document the circumstances of the fall, assessment of the resident, and/or complete neurological checks on the shift that the fall occurred. In addition, the staff present at the time of the fall failed to report the fall to the physician or the oncoming shift. During the next shift, approximately 8 hours after the fall, the resident was found with significant facial bruising of unknown origin that was only determined to be a fall after interview with the resident and the resident's roommate (Resident #22). The census was 165. The sample was 33. Review of the facility's undated Fall Management Program policy, showed:-Purpose: To prevent resident falls and minimize complications associated with falls through the development of a fall management program;-The facility will provide the highest quality care in the safety environment for the residents residing in the facility. The facility has developed a fall management program that strives to prevent resident halls through meaningful assessments, interventions, education, and reevaluation;-Post-fall: -Following a resident's fall, the licensed nurse will complete an incident report and a post-fall assessment and investigation within 24 hours or as soon as practicable. Review of the facility's Fall Evaluation and Prevention policy, dated 8/2020, showed:-Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents;-Following a fall, the following steps should be undertaken: -Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status; -If there was a loss of conscious or the fall was unwitnessed, neurological signs should be initiated and checked for at least 72 hours (refer to the procedure on neurological checks); -Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of an injury; -Ask the resident what happened prior to the fall or what may have caused the fall. Root cause analysis; -Complete the accident/incident report and notify the physician and responsible party. Document the physician orders and/or response from the physician and responsible party; -If the fall was un-witnessed, initiate the investigation including witness statement from staff and residents. Try to determine who was the last person to see the resident prior to the fall and the resident's condition at that time. Review of the facility's Neurological Assessment policy, dated 2, 2019, showed:-Purpose: To provide guidelines for the performance of neurological assessment on residents;-Nursing staff will perform a neurological assessment in the following circumstances: Following an unwitnessed fall;-Neurological checks will be performed as follows or otherwise as ordered by the attending physician: every 30 minutes x4, then every hour x4, then every 4 hours x4, then every shift for a combined total of 72 hours;-The following information will be documented in the resident's medical record: -The date and time the procedure was performed; -The name and title of the individual(s) who performed the procedures; -All assessment data obtained during the procedure, including: Eye opening, verbal response, motor response, pupillary response, limb response. Review of Resident #22's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/26/25, showed:-Resident is rarely/never understood;-Roll left and right, sit to lying, lying to sitting, sit to stand: Substantial/maximal assistance;-Chair/bed-to-chair transfer: Dependent;-Unable to determine fall history. Review of the resident's medical record, showed diagnoses included generalized weakness, repeated falls, abnormalities of gait and mobility, and dementia. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: At risk for falls related to confusion, incontinence, poor communication/comprehension, repeated fall history;-Goal: Not sustain serious injury;-Interventions included: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of the resident's medical record, showed a progress note dated 8/5/25 at 8:30 A.M., certified nursing assistant (CNA)reported to this nurse that the resident has some bruising noted to the face. Upon assessment, noted resident's face to have a purple bruising. No distress noted. Sitting in a wheelchair at the dining room table eating with assist of one staff member. The physician was notified. New order received for a full facial x-ray. Administrator and the DON made aware. Call placed to the x-ray company. Statements from staff collected at this time regarding this incident. Observation on 8/5/25 at 9:41 A.M., showed the resident in bed on his/her right side. The bed in the low position. Visible bruising to his/her forehead and over both eyes. The bruising extended up to his/her hair line and down below his/her eyes to his/her cheek bones, on both sides of his/her face. The bruising was dark blackish blue in color. There was a slightly elevated lump on the right side of the resident's forehead. The resident appeared to be awake but did not open his/her eyes to verbal stimulation. His/Her eyelids appeared swollen. During an interview on 8/5/25 at 9:42 A.M., Licensed Practical Nurse (LPN) C said the aide noticed today that the resident's face was bruised. He/She was the resident's nurse yesterday and the resident's face was not bruised at that time. He/She first noticed it today. The night shift nurse did not report any fall to him/her at shift change. During an interview on 8/5/25 at 9:44 A.M., CNA D said the last time he/she took care of the resident was a long time ago, so he/she cannot speak as to when the bruising occurred, but he/she is the one who noticed it this morning and reported it to the nurse. He/She is not the resident's CNA, he/she only passed the breakfast tray and saw it. The resident does not speak English and night shift did not say anything about it to his/her knowledge. The resident would not be able to get him/herself up on his/her own if he/she were to fall. During an interview on 8/5/25 at 9:47 A.M., CNA E said he/she was off yesterday. He/She did work over the weekend but did not have the resident's assignment. He/She did not notice any bruising over the weekend, but the bruising is really bad, and he/she thinks that he/she would have noticed it if it had been there at that time. It is very noticeable. During an interview on 8/5/25 at 11:10 A.M., Assistant Director of Nursing (ADON) F said he/she was here yesterday and cannot say that he/she saw the resident. He/She did not work over the weekend. If the resident had a fall, he/she does not believe the resident could get him/herself back into bed on his/her own. Someone would have to help him/her up. The resident could not say what happened. He/She has no idea how the bruising happened. During an interview on 8/5/25 at 11:13 A.M., Certified Medication Technician (CMT) G said he/she speaks Bosnian and the resident speaks Polish. They are not the same language, but many words are similar, so he/she can communicate with the resident and can understand a lot of what he/she said. He/She talked to the resident today when he/she put him/her in bed this morning after breakfast. Yesterday, there was no bruising. This morning when he/she started to pass medications, he/she saw the resident's face and it looked horrible. The resident was more confused this morning as well. He/She asked the resident what happened, and he/she said he/she fell. At first, the resident said he/she fell from the chair and then he/she said from bed, so it is unclear exactly what happened. The resident pointed to his/her head and said pain. CMT G used a translator application on his/her phone to help better communicate with the resident and asked the resident how he/she fell, and he/she said he/she could not remember. He/She nodded when asked if he/she fell from the bed and said it was yesterday evening. The resident would not be able to get him/herself up on his/her own if he/she fell, so he/she is not sure if someone helped him/her up. If staff were to find a resident on the ground, staff are to find the charge nurse. He/She was shocked to see the resident's face and noticed the right side of the head had a bump on it. During an interview on 8/5/25 at 11:21 A.M., the resident's CNA, CNA H said he/she worked yesterday but the resident was not on his/her assignment. He/She did not remember seeing the resident the day prior so he/she cannot say if there was bruising at that time. No staff reported the resident had a fall, so he/she is not aware what happened. During an interview on 8/5/25 at 12:27 P.M., the resident's roommate said last night he/she was sleeping, and he/she woke up to go to the bathroom. The curtain was pulled between the two beds. The bathroom is on Resident #22's side of the room. When he/she went to the door of the bathroom, he/she looked over and saw Resident #22 was on the floor, on his/her side, and wrapped in his/her blanket. The pillow had fallen off the bed too and Resident #22 was laying there awake. He/She asked Resident #22 what happened and turned the call light on to get staff. Staff came in and soon there were 3 or 4 staff in the room. Staff got the resident off the floor and into bed. He/She cannot remember any of the staff names. He/She knows exactly what time it was because he/she looked. It was 12:30 A.M. Resident #22's bed was low when he/she fell. During an interview on 8/5/25 at 3:06 P.M., CMT I said he/she worked the evening shift on 8/4/25 and the resident did not have any falls on his/her shift. He/She arrived at work yesterday and gave the resident his/her medication around 4:30 P.M. At that time, there was no bruising. Review of the resident's medical record, showed: -A progress note dated 8/5/25 at 10:04 A.M., noted resident with facial bruising. No complaints of pain or discomfort. The resident reported that he/she had fallen out of his/her wheelchair. He/She was asked how he/she got to the floor, he/she said I forgot, I'm cuckoo;-A facial x-ray, dated 8/5/25 at 11:30 A.M., showed no fracture seen;-No documentation of the fall, a resident assessment, vital signs, neurological checks, or physician/family notification at or around 12:30 A.M. on 8/5/25. During an interview on 8/6/25 at 9:08 A.M., the Director of Nursing (DON) said the facility concluded their investigation into the bruising and was not able to determine which staff placed the resident back in bed after the fall. At 9:45 A.M., the DON said there is no documentation of the fall completed at the time of the fall, no assessment, and no neurological checks documented on night shift. According to the staff interviewed as part of the investigation, the resident was just put back to bed with no assessment. She is not sure if the doctor was notified prior to the morning shift when staff noticed the bruising. The resident should have been assessed at the time of the fall, neurological checks completed, and physician notified. Neurological checks were started in the morning; at the time the injuries were first noted by day shift. During an interview on 8/6/25 at 11:35 A.M., the Medical Director, who is also the resident's physician, said the facility notified him of the resident's facial bruising due to a fall. He ordered an x-ray. He received lots of calls and cannot recall if the facility called on Monday night or Tuesday morning, but they did notify him of the resident's fall. Staff is expected to follow their policies regarding falls and neurological checks. Observation of the resident on 8/6/25 at 2:41 P.M., showed the resident sat in a wheelchair near the North Hall nurse's station. The bruising extended down the right side of the resident's face, down to his/her neck, and to his/her collar bone. Bruising visible over the lower left outer arm. The resident's right eye appeared swollen, and the eye appeared to be squinting. The resident's entire forehead, both eyes, the right side of the face and cheek, and right side of the neck appeared black and blue. The resident's left eye was blood shot. 1676424

Based on interview and record review, the facility failed to implement their policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for two of five residents sampled for medication review (Residents #3 and #145). The sample was 33. The census was 165.Review of the facility's Documentation and Communication of Consultant Pharmacist Recommendations Policy, dated 8/20, showed:-Policy: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion;-Recommendations: A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team;-Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record;-Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to a recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. If the prescriber that does not respond Is also the Medical Director, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facilitate compliance. 1. Review of Resident #3's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/21/25, showed:-Severe cognitive impairment;-Diagnoses included non-Alzheimer's dementia, depression and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Review of the resident's care plan in use at the time of survey, showed:-Focus: resident requires psychotropic medications;-Goal: will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date;-Interventions: Consult with pharmacy, Medical Doctor (MD) to consider dosage reduction when clinically appropriate. Review of the Consultant Pharmacist Communication to Physician form, dated 1/29/25, showed: -Please note per Centers for Medicare and Medicaid Services (CMS) requirements the use of psychotropic medications is confined to limited duration of use without reassessment of a gradual dose reduction or discontinuation;-This resident has been receiving hydroxyzine (antihistamine, used to relieve itching and treat anxiety and tension) 50 milligrams (mg) three times a day (TID) since 7/24. An evaluation for gradual dose reduction should be documented at this time. If gradual dose reduction is contraindicated, please review the following and check If appropriate:-The resident's target symptoms returned or worsened after the most recent attempt at tapering dose;-Past reduction attempts have resulted in problematic behavior and/or staff Inability to provide care;-Past reduction attempts have resulted in psychiatric instability by exacerbating an underlying medical or psychiatric disorder;-Past reduction attempts have caused the resident to pose danger to self or others;-Physician response to recommendations/finding agree or other;-Physician/Practitioner signature;-The form was blank. Review of the progress notes, dated 1/29/25 through 2/28/29, showed no documentation the MD reviewed the recommendation. Review of the Consultant Pharmacist Communication to Physician, dated 4/24/25, showed: -Please note per CMS requirements the use of psychotropic medications is confined to limited duration of use without reassessment of a gradual dose reduction or discontinuation;-This resident has been receiving trazodone (antidepressant) 50 mg every (q) bedtime (hs) since 6/24. An evaluation for gradual dose reduction should be documented at this time. A second form showed this resident has been receiving quetiapine (antipsychotic) 25 mg twice a day (BID) since 6/24. An evaluation for gradual dose reduction should be documented at this time. If gradual dose reduction Is contraindicated, please review the following and check If appropriate:-The resident's target symptoms returned or worsened after the most recent attempt at tapering dose;-Past reduction attempts have resulted in problematic behavior and/or staff inability to provide care;-Past reduction attempts have resulted in psychiatric instability by exacerbating an underlying medical or psychiatric disorder;-Past reduction attempts have caused the resident to pose danger to self or others;-Physician response to recommendations/finding agree or other;-Physician/Practitioner signature;-Both forms were blank. Review of the progress notes, dated 4/24/25 through 6/30/25, showed no documentation the physician reviewed these consults. 2. Review of Resident #145's annual MDS, dated [DATE], showed:-Short-term and long-term memory problem;-Worse current behavior or other symptoms, care rejection, or wandering compared to prior assessment;-Diagnoses included dementia and depression;-Takes antipsychotic and antidepressant medications. Review of the resident's care plan in use at the time of survey, showed:-Focus: Resident has a mood problem;-Goal: Resident will not experience any increase in signs and symptoms of mood disturbance;-Interventions: Administer medications as ordered, observe and document signs and symptoms of effectiveness and side effects;-Focus: Resident uses antidepressant medication;-Goals: Resident will have decreased episodes of depressed mood, through target date. Resident will be without complications of antidepressant medication's side effects;-Interventions: Observe for side effects of antidepressant medications. Provide the medications per medical provider's orders. Review of the resident's Medication Administration Record (MAR) for the month of August 2025, showed:-Prozac (antidepressant) oral capsule 20 mg, to give 1 capsule by mouth one time a day for depression;-Seroquel (Quetiapine) oral tablet 25 mg, to give 1 tablet by mouth at bedtime related to major depressive disorder. Review of the Consultant Pharmacist Communication to Physician form, dated 1/29/25, showed: -Please note per CMS requirements the use of psychotropic medications is confined to limited duration of use without reassessment of a gradual dose reduction or discontinuation;-The resident has been receiving quetiapine 25 mg twice a day (BID) since 10/24. An evaluation for gradual dose reduction should be documented at this time. If gradual dose reduction is contraindicated, please review the following and check if appropriate;-The resident's target symptoms returned or worsened after the most recent attempt at tapering dose;-Past reduction attempts have resulted in problematic behavior and/or staff Inability to provide care;-Past reduction attempts have resulted in psychiatric instability by exacerbating an underlying medical or psychiatric disorder;-Past reduction attempts have caused the resident to pose danger to self or others;-Physician response to recommendations/finding agree or other;-Physician/Practitioner signature;-The form was blank. Review of the progress notes, dated 1/30/25 through 4/30/25, showed no documentation the MD reviewed the recommendation. Review of the Consultant Pharmacist Communication to Physician form, dated 4/25/25, showed the same reviews and recommendations from 1/29/25. The form was blank. Review of Psychiatric Nurse Practitioner's (NP) assessment notes, dated 5/14/25, showed:-Patient denied any psychotic symptoms;-No staff reports of agitation or restlessness at this time;-We will reduce Seroquel to 25 mg at bedtime only;-If dose reduction is well tolerated, the plan is to discontinue Seroquel at next visit;-Continue Prozac for depression and anxiety. Review of the resident's assessment and progress notes, showed no follow-up documentation after the 5/14/25 NP's visit. No changes in the current dose of Seroquel. 3. During an interview on 8/8/25 at 7:45 A.M. Assistant Director of Nursing (ADON) L said the pharmacy consultant visited the facility. Any recommendations are given to the Director of Nursing (DON). The MD visited the facility twice a week. He will either sign the recommendations or have psych review the recommendation. Then, the DON distributes the recommendations to nursing staff. If there are any changes in the physician's order, the ADON will enter the orders into the computer and notify the resident/resident representative. 4. During an interview on 8/8/25 at 11:00 A.M., the DON said she expected the pharmacy consult recommendation to be reviewed within seven days. The DON said the pharmacy reviews should have been reviewed timely.

Based on observation, interview, and record review, the facility failed to ensure reach resident relieves food choices that accommodate their preferences, for one resident (Resident #171) who preferred chocolate milk with all meals and was not provided with chocolate milk. The census was 165. The sample was 33.Review of the Know Your Rights, resident rights poster, located at the nurse stations, showed residents have the right to participate in their care. Review of Resident #171's medical record, showed:-Diagnoses included: Dysphagia (difficulty swallowing) after a stroke and diabetes;-A nutritional communication form, dated 7/29/25, showed meal location preference: In room. Moderately thick liquids. During an interview on 8/4/25 at 9:18 A.M., the resident said he/she has not had breakfast yet. When he/she gets his/her breakfast he/she wants chocolate milk. It is on his/her ticket for each meal, yet he/she is never given chocolate milk. The resident provided his/her dinner meal ticket, that remained on his/her bedside table from the day prior. Review of the resident's meal ticket dated for dinner 8/3/25, showed beverages: Chocolate milk, 1 cup, nectar thick. Observation and interview on 8/4/25 at 10:08 A.M., showed the resident sat up in bed with his/her breakfast tray. The only drink on the tray was orange juice. No chocolate milk. The resident said he/she did not get chocolate milk served with breakfast. He/She told the nurse, and they just said it was not on the tray. They never provided it. Review of the resident's meal ticket dated for breakfast 8/4/25, showed beverages: Chocolate milk, 1 cup, nectar thick. During an interview on 8/5/25 at 7:47 A.M., the resident said he/she did not get his/her chocolate milk for lunch on 8/4/25. He/She should get it 3 times a day with every meal, and he/she does not. When he/she asks about it, staff just say it is not on there and do not provide it. Observation on 8/5/25 at 8:59 A.M., showed the resident's room door closed as staff passed hall meal trays. At 9:03 A.M., staff brought the resident his/her breakfast. Observation showed the tray had orange juice and no chocolate milk. Staff set the tray down on the resident's bedside table and left the room. Staff did not check the meal ticket for accuracy. The resident said see no milk. I don't know why they don't give me my milk, it is on my ticket. Staff just set it down and leave. Review of the resident's meal ticket dated for breakfast 8/5/25, showed beverages: Chocolate milk, 1 cup, nectar thick. During an interview on 8/6/25 at 1:03 P.M., the resident said he/she did not get his/her chocolate milk for breakfast today. He/She is really hoping he/she gets it for lunch. Observation at 1:05 P.M., showed staff brought the resident's tray to his/her room with no chocolate milk. The resident requested chocolate milk. Another staff member on the hall overheard the request and said oh, yes, the resident loves his/her chocolate milk. The staff person who left the tray told dietary staff who was on the hall, that the resident wanted chocolate milk and then continued to pass trays. At 1:08 P.M., staff entered the resident's room with a cup of thickened chocolate milk. At 1:10 P.M., the resident said he/she should not have to ask for the chocolate milk because it is on his/her meal ticket. Review of the resident's meal ticket dated for lunch 8/6/25, showed beverages: Chocolate milk, 1 cup, nectar thick. During an interview on 8/6/25 at 1:11 P.M., the Dietary/Kitchen Director said dietary staff check the meal tickets on the line in dietary to ensure accuracy. Then nursing staff should be checking it as well when they pass out the trays. Nursing staff should identify if something is missing and bring the tray back. The resident should have been getting his/her chocolate milk with meals. She will tell the dietary staff to make sure he/she gets his/her chocolate milk from now on. The resident should not have to ask for the chocolate milk if it is on the meal ticket, it should already be on the tray.

Based on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #8) when a Certified Medication Technician (CMT) administered a medication without a physician's order. The sample size was 8. The census was 174. Review of the facility's Medication Administration policy, undated, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: Medication will be administered by a licensed nurse per the order of the attending physician or licensed independent practitioner, or as consistent with state law; -Procedure: Compare the licensed practitioner's prescription/order with the medication administration record (MAR); -Compare the licensed practitioner's order with the pharmacy label on the medication package; -Compare the pharmacy label and MAR; -The licensed nurse will chart the drug, time administered, and initial his/her name with each medication administration and sign full name and title on each page of the MAR; -PRN (As needed) medication documentation: When a PRN medication is given, it will be documented on the medication administration record. The nurse will document the date, time, and reason for giving the medication; -The result or effectiveness of the PRN medication will be charted by the responsible nurse on the back of the MAR or in the nursing notes. Review of Resident #8's medical record, showed: -An admitted [DATE]; -Diagnoses included benign neoplasm (non-cancerous mass) of colon, diabetes, depression, and left foot abscess During an interview on 3/26/25 at 11:45 A.M., the resident said he/she had been at the facility since Friday 3/21/25. Since he/she has been at the facility he/she has had bad diarrhea to the point that he/she cannot always make it to the bathroom and had to change his/her clothes. He/She thinks it is related to the intravenous (IV) antibiotic he/she is administered for his/her foot wound. He/She received Imodium (medication used to treat diarrhea) this morning. The CMT told him/her that he/she must ask for it but that he/she can have it twice a day. Once in the morning and once at night. Review of the resident's electronic physician order sheet (ePOS), showed no order for Imodium. Review of the resident's March 2025 MAR, showed no order and no documentation of Imodium administered to the resident. During an interview on 3/26/25 at 2:00 P.M., CMT H said he/she gave the resident Imodium this morning because the resident reported he/she was having bad diarrhea. He/She told the resident that the resident could have one in the morning and one in the evening but the resident needed to ask for it. CMT H was asked about the resident having an order for Imodium. CMT H said everyone has a standing order for Imodium right now and pulled up the resident's electronic MAR. CMT H then said, the resident does not have an order for Imodium. CMT H said he/she informed the nurse this morning and the nurse was supposed to call the physician and put the order in the electronic ePOS. Observation at this time showed the CMT entered the medication room. During an observation and interview on 3/26/25 at 2:10 P.M., CMT H and Registered Nurse (RN) B exited the medication room. RN B said the CMT did not inform him/her about the Imodium this morning. The CMT actually just informed RN B. RN B told the CMT he/she would call the physician and get an order. RN B said he/she expected CMT H to tell the nurse before CMT H gave the medication and not to give a resident mediation if there is no order for it. During an interview on 3/26/25 at 2:15 P.M. the Director of Nursing (DON) said she expected the CMT to notify the nurse before administering medication. Medication should not be given without a physician order, even stock medication like Tylenol or Imodium. The nurse should have been notified immediately and the physician should have been called. MO00251254

Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of residents for one of eight sampled residents (Resident #2). The census was 174. Review of the facility's Refusal of Treatment policy, revised 8/2020, showed: -Purpose: To ensure that residents are able to exercise their right to refuse treatment; -Policy: Facility will honor a resident's request not to receive medical treatment as prescribed by his/her attending physician, as well as care services outlined on the resident's assessment and care plan. treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms; -Procedure: The resident is not forced to accept any medical treatment and may refuse or request to discontinue of a specific treatment even though it is prescribed by his/her attending physician. When a resident refuses or discontinues treatment, the charge nurse or Director of Nursing (DON) interviews the resident to determine what and why the resident is refusing or discontinuing treatment. The charge nurse or DON will attempt to address the resident's concerns and explain the consequences of the refusal or discontinuance of treatment; -The charge nurse or DON will document information relating to the refusal/discontinuance in the resident's medical record. Documentation will include at least the following: --The date and time nursing staff tried to give a medication or treatment was attempted; --The medication or treatment refused/discontinued; --The resident's response and reason(s) for refusal/discontinuance; --The name of the person attempting to administer the treatment; --That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment; --The resident's condition and any adverse effects due to such refusal/discontinuance; --The date and time the Attending Physician was notified and his or her response; --Other pertinent observations; and --The signature and title of the charge nurse or DON documenting the refusal/discontinuance; -The Attending Physician will be notified of refusal or discontinuance of treatment in time frame determined by the resident's condition and potential serious consequences of the refusal or discontinuance; -The interdisciplinary team (IDT) will assess the resident's needs and offer the resident alternative treatments if available while continuing to provide other services in the care plan. -When the resident's refusal or discontinuance brings about a significant change in the resident's condition, a reassessment is made, and new information is incorporated into the resident's care plan. Review of Resident #2's medical record, showed diagnoses included diabetes, stroke, acid reflux, and major depressive disorder. Review of the resident's medical record, showed an after-visit summary dated 12/30/24 at 9:30 A.M., labs ordered calprotectin, fecal (measures the amount of calprotectin, a protein, in a stool sample) and elastase, pancreatic, fecal (stool test that measures the amount of elastase, an enzyme produced by the pancreas, in the stool). Next appointment 3/18/25 at 9:30 A.M. Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR), showed: -An order, dated 12/30/24, for elastase pancreatic fecal to be done at an outside lab; -No order for the calprotectin fecal test noted in the MAR/TAR. Review of the resident's medical record, showed: -A progress note (late entry), dated 12/30/24 at 3:20 P.M. and entered on 2/14/25 at 4:22 P.M., Resident receives orders to have labs done at an outside lab; -An electronic MAR note (late entry), dated 12/30/24 at 3:20 P.M. but entered on 2/14/25, at 4:22 P.M., resident received orders to have labs done at an outside laboratory; -A progress note, dated 2/12/25 at 11:29 A.M., the resident representative calls this nurse today with questions regarding resident's medications and labs which were ordered to be done on 12/30/24. This nurse emailed medication list to resident representative and notified him/her that resident did make this nurse aware that he/she had gone out to an outside lab already and had labs done. Representative asks that follow up be done with the lab to ensure labs were done. Representative also asked about a diagnosis list on resident's chart for stage 3 kidney disease and states that he/she was not aware of that diagnosis. Physician ordered complete blood count (CBC, common blood test that measures various components of the blood) and comprehensive metabolic panel (CMP, blood test that measures various substances in the body to assess overall metabolic health and organ function) which were entered into lab orders to be done tomorrow. -A progress note, dated 2/18/25 at 7:56 A.M., call received from resident representative. Resident had labs done at an outside lab company, but results were inconclusive and must be done over. This nurse tries to encourage resident to allow for the facility lab company to complete lab testing at this time; -A progress note, dated 2/18/25 at 9:02 A.M., resident has refused to give stool specimen for ordered test; -A progress note dated 2/18/25 at 9:03 A.M., Resident refuses to give stool specimen for ordered test. Physician/Resident representative notified at this time; -A progress note, dated 2/24/25 at 3:55 P.M., Lab results received and reported to physician. No new orders at this time. -A progress note, dated 2/25/25 at 4:47 P.M., Resident states he/she would like to go to an outside lab to have his/her lab done that was prescribed by physician at specialist clinic on 12/30. This nurse schedules appointment with the outside lab. Transportation request filled out and turned into BB Transportation. Copy placed in yellow transportation binder at nurse's station. -A progress note, dated 2/27/25 at 4:21 P.M., labs reported to physician with no new orders at this time; -A progress note (late entry), dated 3/3/25 at 9:46 A.M., Resident refused to go to appointment at the outside lab; -A progress note, dated 3/7/25 at 8:46 A.M., Resident noted to have increased aggression. Resident forcefully opens Assistant Director of Nursing (ADON) door and demands paperwork. This nurse lets the resident know that he will receive any requested paperwork after 10 A.M Resident then refuses to close the door and elevates his voice to yelling, demanding that his needs be tended to now. This nurse redirects resident and floor nurse also redirects resident to his/her room, assuring him/her that he/she will receive any paperwork requested. -No progress note dated 3/18/25 related to the missed appointment, reason the appointment was refused, education to the resident or documentation of risk of missing appointment; -A progress note, dated 3/24/25 at 5:06 P.M., Resident has an appointment scheduled for the outside lab on 3/28/25 at 10:30 A.M. Transportation sheet filled out and turned into transportation and copy placed in yellow transportation binder at nurses station; -A progress note, dated 3/24/25 at 5:07 P.M., this is an appointment to go and have stool sample collected for labs ordered on 12/30 at physician clinic. Review of the resident's care plan, dated 3/18/25, showed: -Focus: Resident is non-compliant with getting labs done. The resident makes appointments and does not go. Refuses and reschedules; -Goal: Resident needs will be met during the next 90 days; -Interventions/Tasks: Notify family and physician of behavior/refusal of care. During an interview on 3/26/25 at 9:40 A.M., the resident said the facility will not take him/her to get their physician ordered laboratory test done. The resident has tried to talk to the Social Worker (SW). He/She went to the doctor in December and laboratory tests were ordered to be completed. The resident is worried about his/her diarrhea because he/she has now had the diarrhea for nine months. He/She has tried medications for the diarrhea, but they do not do any good. The transportation is not consistent, and they will just cancel last minute which is hard because some appointments are hard to reschedule. There was an appointment last week that he/she missed. The resident thinks there was some kind of meeting with the manager and SW that may be happening soon but not sure when that will take place. He/She just wants to get the laboratory test done. During an interview on 3/26/25 at 12:25 P.M., the SW said the facility has scheduled and he/she refuses. The resident gives different reasons, sometimes he/she says it is because he/she does not feel like going. Staff have tried to use the facility lab company, but the resident only wants it done at his/her preferred laboratory. Staff are trying to accommodate the resident, and he/she keeps rescheduling. The facility is planning to have an IDT/Care Plan Meeting with the resident. During an interview on 3/26/25 at 1:36 P.M., the DON said she will have to check to see if physician was called on the appointment the resident missed on 3/18/25. She is not sure why the resident missed the appointment. During an interview on 3/26/25 at 1:45 P.M., the medical assistant at the physician office said the resident was a no-show to the clinic appointment scheduled for 3/18/25. The facility or the resident had not called prior to the appointment to cancel and have not called since the missed appointment to reschedule. The office staff is not aware of the facility calling the provider regarding the missed laboratory appointments. The resident was last seen in clinic on 12/30/24. There was a sample dropped off at the lab sometime after that. The sample was not labeled so it was placed in storage. Once they realized that was the sample, the sample was no longer any good. The medical assistant put in a new order for the laboratory tests on 3/6/25 and talked to the resident about the appropriate label. The medical assistant is not sure when the first test was done, it was just dropped off with no label. The medical assistant was not working with the provider at that time so does not know exact date. During an interview on 3/26/25 at 2:15 P.M., the DON said there should have been documentation that the resident did not go to his/her appointment, and she is not sure why he/she did not go. The resident does have an appointment to complete the laboratory test on Friday. MO00250942

Based on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during blood sugar testing and insulin administration for one sampled resident (Residents #5). The census was 174. Review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed: -Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections; -Policy Interpretation and Implementation: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -When hands are visibly soiled; and -After contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after coming on duty; -Before and after direct contact with residents; -Before preparing or handling medications; -Before performing any non-surgical invasive procedures; -Before and after handling an invasive device; -Before donning sterile gloves; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; -After removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. -Single-use disposable gloves should be used: -before aseptic procedures; -when anticipating contact with blood or body fluids; and -when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions; -Applying and Removing Gloves: -Perform hand hygiene before applying non-sterile gloves; -Perform hand hygiene. Review of Resident #5's electronic medical record, showed diagnoses of diabetes, acid reflux, and anxiety. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order dated 2/26/25, for insulin lispro (fast acting insulin). Inject 5 units subcutaneously (layer of tissue beneath the skin) with meals for diabetes. Observation on 3/26/25 at 11:39 A.M., showed Certified Medication Technician (CMT) H in front of the medication cart. CMT H said he/she is going to check Resident #5's blood sugar and entered the resident's room with the blood glucose machine and insulin syringe in his/her hands. CMT H did not perform hand hygiene when he/she entered the resident's room. CMT H did not place on gloves. The CMT walked over to the resident and wiped the resident's finger with an alcohol wipe. He/She stuck the resident's finger and obtained a sample of blood. Blood sugar results measured 257. CMT H drew up 5 units of insulin in a syringe, no hand hygiene performed, and no gloves worn. CMT H raised the resident's shirt and injected the 5 units of insulin into the resident's abdomen. He/She did not perform hand hygiene, place on gloves or wipe the resident's abdomen with an alcohol wipe prior to administering the insulin. CMT H capped the syringe and left the resident's room without performing hand hygiene upon exiting the room. During an interview on 3/26/25 at 1:36 P.M., the Director of Nursing (DON) said she would expect staff to follow facility policy. She would expect nursing staff to perform hand hygiene when entering a resident's room prior to providing care. She would expect staff to place on gloves prior to obtaining a blood sugar level. She would also expect nursing staff to clean the resident's skin prior to injecting medication due to the risk of infection and safety for both the resident and the nursing staff. MO00251254

See Event ID 56TT13. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 7/12/24. Based on observation, interview and record review, the facility failed to ensure staff followed facility policies by failing to ensure nurses assessed and notified the physician of Resident #29's right buttock/right ischium (lower and back part of the hip bone) when Certified Nursing Assistants (CNAs) alerted the nurses of issues for the resident's skin and documented open areas on bath sheets. The resident also requested the facility's former Wound Nurse (WN) assess his/her bottom, but she refused. The resident's request was witnessed by CNA N. The resident was later hospitalized for assessment and treatment of an unstageable pressure injury (slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) to the right ischium that was infected and required intravenous (IV) antibiotics and surgical debridement (a procedure that removes dead, infected, or nonviable tissue from a wound to promote healing). The facility also failed to ensure the wound care company communicated new treatment orders to the facility prior to leaving on the days they made rounds. Two residents (Residents #42 and #35) had treatment order changes that were not implemented timely. One of those residents, Resident #42, was also observed to not have had his/her dressing changed as ordered. In addition, the facility failed to ensure the wound care company provided their progress notes timely to the facility for all three residents. The facility identified 14 residents with pressure ulcers. Six residents were sampled and failures were found with three of the sampled residents. The census was 156.

See Event ID 56TT13. Based on interview and record review, the facility failed to provide appropriate nursing assessments per facility policy for residents with a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), diagnosed with respiratory infection and vomiting. The facility identified seven residents with tracheostomy, three were sampled and failures were found with two (Resident #6 and #44). The census was 156.

See Event ID 56TT13. Based on observation, interview, and record review, the facility failed to follow their policies by failing to promptly assess one resident's right hip wound after a Certified Nursing Assistant (CNA) reported the wound to a Licensed Practical Nurse (LPN) the day before it was assessed and a treatment had been started (Resident #36). Another resident said he/she had reported his/her bottom was sore to staff and no one assessed his/her bottom until two days later when a wound was identified (Resident #39). Both residents complained the facility's largest incontinent briefs were too small and caused the wounds. In addition, staff failed to promptly assess and treat one resident with a right palm laceration. After waiting approximately one hour for staff to treat the laceration, the resident returned to his/her room without receiving treatment (Resident #3). The census was 156.

See Event ID 56TT13. Based on observation, interview and record review, the facility failed to ensure a sufficient number of skilled licensed nurses were on duty each shift to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. The facility failed to ensure a licensed nurse was on duty each shift, for the rehab building. This resulted in four residents (Residents #16, #44, #6, and #45) not receiving tube feedings (enteral nutrition, used to give medicines and liquids, including liquid nutrition, through a small tube placed through abdomen into the stomach) and not receiving medication as ordered. Three residents (Residents #16, #44, and #6) did not receive tracheostomy (trach, a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. The sample was 28. The census was 156.

See Event ID 56TT13. Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to ensure one resident wore a compression suit (applied to reduce edema (swelling) and increase circulation) on the lower extremities every night for one hour (Resident #28). In addition, staff failed to ensure one resident received a glucose monitoring device as ordered (Resident #6). The sample size was 28. The census was 156.

See Event ID 56TT12. Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered by the physician for three residents (Resident #19, #21, and #22). Facility nursing staff documented the treatments as completed, although they were not completed. The facility identified 15 residents with pressure ulcers. Four were sampled and problems were found with three. The census was 164.

Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered by the physician for three residents (Resident #19, #21, and #22). Facility nursing staff documented the treatments as completed, although they were not completed. The facility identified 15 residents with pressure ulcers. Four were sampled and problems were found with three. The census was 164. Review of the facility's undated Skin Care & Wound Management Overview policy and procedure, included the following: -Definitions: Pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction; -Policy: -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions(s) contributing to it and description of impairment to determine appropriate treatment; -Skin care and wound management program includes, but is not limited to: Application of treatment protocols based on clinical best practice standards for promoting wound healing. Daily monitoring of existing wound; -Treatment: Review and select the appropriate treatment for the identified skin impairment. Obtain a physician's order. Communicate interventions to the care giving team. Document treatment on the Treatment Administration Record (TAR). Monitor and document progress. Evaluate effectiveness of interventions during clinical meeting. Communicate changes to the care giving team. 1. Review of Resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/24, showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Diagnoses of paraplegia (impairment in motor or sensory function of the lower extremities), manic depression (bipolar disorder, causes extreme mood swings) and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, and perceives reality); -Unhealed Pressure Ulcer(s): Yes; -Number of Stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) may be present on some parts of the wound bed. Often includes undermining (caused by erosion under the wound edges resulting in a large wound with a small opening) and tunneling (a narrow passageway under the skin in a wound): 4. Review of the resident's care plan located in the electronic healthcare record (EHR), review date of 6/17/24, showed: -Focus: Activities of daily living (ADL) self care performance related to paraplegia. Goal: Will improve current level of function. Intervention/Tasks: Partial/moderate assistance required for toilet hygiene, shower/bathe, and chair/bed to chair transfers; -Focus: Wound infection/osteomyelitis (bone infection). Goal: Will be free of signs/symptoms of complications related to infection. Interventions/Tasks: Administer antibiotics per providers orders. Evaluate for signs/symptoms of skin infection: drainage, heat, redness, swelling and report abnormal findings to medical provider; -Focus: Impaired skin integrity related to Stage 4 pressure ulcer to right heel, sacrum (the area between the bottom of the small of the back and the center upper buttocks) and left ischium (the area between the lower buttock and back of the upper thigh). Review of the resident's Physician's Order Sheet (POS), located in the EHR, showed: -Start Date: 6/12/24 End Date: 7/23/24: Ceftolozane-tazobactam/brand name Zerbaxa (antibiotic for osteomyelitis) 1.5 grams (1500 milligrams (mg) intravenous (IV)); -6/13/24: Right heel. Cleanse with wound cleanser, apply silver alginate (an antimicrobial dressing), cover with bordered dressing daily and as necessary (PRN); -7/10/24: Sacrum. Clean with wound cleanser, apply Dakins (diluted bleach solution) moist gauze, cover with dry dressing. Change daily every day shift; -7/11/24: Left ischium. Clean with wound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily. Review of the resident's TAR, dated 7/1/24 through 7/31/24, showed: -6/13/24: Right heel. Cleanse with wound cleanser, apply silver alginate, cover with bordered dressing daily and PRN; -7/10/24: Sacrum. Clean with sound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily every day shift; -7/11/24: Left ischium. Clean with wound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily. Review of the resident's wound company progress notes, dated 7/10/24, showed: -Wound/Ulcer #2; -Location: Right Heel; -Type: Pressure Ulcer/Injury: Stage 3 (Full thickness tissue loss. Subcutaneous (situated under the skin) fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -Wound Bed Description: 100% pink epithelial tissue (New skin growing in superficial ulcer. It can be light pink and shiny); -Measurements: 1.1 centimeters (cm) (length) x 0.5 cm (width) x 0.2 cm (depth); -Peri-Wound (the area around the wound opening): Normal - No signs of infection noted; -Exudate (drainage): Moderate; -Color: Sero-sanguineous (a thin watery fluid with a light red or pink hue); -Debridement (tissue removal) that has been completed at this site: Mechanical debridement completed via normal saline (NS) and 4x4s (gauze squares); -Goal: Adequate offloading (pressure relief) to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Improved - continue current treatment plan; -Treatment: Cleanse with wound cleanser, apply Silver Alginate, wrap with Kerlix and secure with tape daily and PRN; -Wound/Ulcer #4; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 80% granulation tissue (pink or red tissue with shiny, moist, granular appearance) and 20% slough tissue; -Measurements: 6.0 cm x 7.3 cm x 1.2 cm; -Undermining: 1.3 cm from 3 o'clock to 5 o'clock (undermining and tunneling is associated with a clock face); -Exudate: Moderate; -Color: Sero-sanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Declined; -Treatment: Cleanse with wound cleanser, apply Dakins moist Kerlix, then cover with dry dressing daily and PRN; -Wound/Ulcer #5; -Location: Left ischium; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 90% granulation tissue and 10% slough; -Measurements: 3.6 cm x 3.5 cm x 2.0 cm; -Undermining: 12-12 greatest at 12 o'clock of 5.4 cm; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Sero-sanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Declined; -Treatment: Cleanse with wound cleanser, apply Dakins moist Kerlix, then cover with dry dressing. Change daily and PRN. Observation and interview on 7/11/24 at 10:55 A.M., showed the resident lay in bed. He/She said facility staff change his/her pressure ulcer dressing daily most of the time, but not always. The resident said he/she is receiving IV antibiotics for his/her pressure ulcers; Observation and interview on 7/12/24 at 9:33 A.M., showed the resident lay in bed. The facility Wound Nurse (WN) assisted the resident onto his/her right side and prepared to change the resident's pressure ulcer dressings. The dressings on the resident's sacrum, right heel, and left ischium were intact and dated 7/10/24. The facility WN said all of the pressure ulcers should have been changed yesterday, 7/11/24. He/She was doing paperwork yesterday and had asked the floor nurses to complete the treatments. She measured the resident's pressure ulcers: Sacrum 8.0 cm x 6.3 cm x 3.6 cm. 75% yellow slough and 20% granulation tissue. Right heel 1.2 cm x 0.4 cm x 0.1 cm. 100% granulation tissue. Left ischium 3.7 cm by 4.0 cm x 1.6 cm. 15% yellow slough and 85% granulation tissue. Review of the resident's TAR on 7/12/24, showed the floor nurse had initialed the resident's treatments had been completed as ordered on 7/11/24. 2. Review of Resident #21's admission MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively Intact; -Rejection of Care: Behavior not exhibited; -Diagnoses of paraplegia and diabetes mellitus; -Unhealed Pressure Ulcers: Yes; -Number of Stage 2 pressure ulcers (Partial thickness loss of dermis (middle layer of the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister): 3; -Number of Stage 4 pressure ulcers: 1. Review of the resident's care plan located in the EHR, a review date of 6/19/24, showed: -Focus: ADL self care performance. Goal: Will improve current level of function. Interventions/Tasks: Partial/Moderate assist required for toileting/hygiene, and showers/baths; -Focus: Impaired skin integrity related to Stage 4 pressure ulcer of the sacrum. Goal: Will have improved current skin status. Interventions/Tasks: Encourage resident to turn and reposition. Complete weekly skin assessment. Review of the resident's POS located in the EHR and TAR, dated 7/1/24 through 7/31/24, showed: -6/25/24: Sacrum, clean with Vashe (wound cleanser), gently pack with 1 inch iodoform rope (an antiseptic), cover with pad and secure with dry dressing. Change every shift and PRN. Review of the resident's weekly wound care company progress notes, dated 7/10/24, showed: -Wound/Ulcer #4; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 90% granulation tissue and 10% slough; -Measurements: 4.0 cm x 3.5 cm x 0.9 cm with undermining from 10 to 7 at 3 o'clock of 1.9 cm; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Serosanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing; -Wound Status: Unchanged; -Treatment: Clean with Vashe, gently pack with 1 inch iodoform rope, cover with pad and secure with dry dressing. Change every shift and PRN. Observation and interview on 7/12/24 at 7:55 A.M., showed the resident lay in bed. He/She said he/she could not recall if his/her treatment was done the previous day, but he/she does not think they did. Certified Nursing Assistant (CNA) G and CNA H assisted the resident onto his/her left side. The resident had an intact dressing on his/her sacrum. The dressing was dated 7/10/24. Both CNAs confirmed the date written on the dressing. Observation and interview on 7/12/24 at 11:06 A.M. showed the resident lay in bed. The facility WN assisted the resident onto his/her left side to administer the resident's treatment. The dressing dated 7/10/24, remained on the resident's sacrum. The facility WN said nurses work 12 hour shifts so the resident's treatment should have been done twice on 7/11/24. The sacrum pressure ulcer measured 3.7 cm x 3.6 cm x 1.2 cm and was 10% yellow slough and 90% granulation tissue. Review of the resident's TAR on 7/12/24, showed the floor nurses initialed the treatment had been completed as ordered on the day and night shift on 7/11/24. 3. Review of Resident #22's quarterly MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands - clear comprehension; -Rejection of Care: Behavior not exhibited; -Diagnoses of malnutrition and depression; -Unhealed Pressure Ulcers: Yes; -Number of Stage 4 Pressure Ulcers: 1. Review of the resident's current care plan showed: -Focus: At risk of infection related to wound. Goals: Resident will be free of signs/symptoms of infection. Interventions/Tasks: Administer treatments per medical provider's orders; -Focus: ADL self care performance. Goals: Will maintain current level of function. Interventions/Tasks: Totally dependent for toileting/hygiene and showering/bathing. Review of the resident's TAR, dated 7/1/24 through 7/31/24, showed the following order: -6/26/24: Wound care sacrum. Clean with Vashe, Blastx (wound gel) and collagen powder, cover with calcium alginate, secure with bordered dressing daily and PRN. Review of the resident's weekly wound care company progress notes, dated 7/10/24, showed: -Wound/Ulcer #1; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 100% granulation tissue; -Measurements: 2.8 cm x 1.0 cm x 0.4 cm; -Undermining: None; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Serosanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s and autolytic (uses the body's own enzymes and moisture beneath a dressing to liquefy non-viable tissue); -Goal: Adequate offloading to alleviate pressure for optimal wound healing; -Wound Status: Improved; -Treatment: Clean with Vashe, apply collagen powder (a protein), apply calcium alginate (an absorbent dressing), cover with bordered dressing. Change daily and PRN. During an interview on 7/12/24 at 8:55 A.M., showed the resident said he/she thought staff had completed his/her sacrum treatment the previous day, on 7/11/24. He/She then said, you know, now that he/she thought about it, staff did not do his/her sacrum treatment yesterday; Observation on 7/12/24 at 9:03 A.M. the resident lay in bed. Licensed Practical Nurse (LPN) H assisted the resident onto his/her left side showing a pressure ulcer with no dressing on the resident's sacrum. The pressure ulcer had a red floor and no slough. The LPN said he/she was not aware there was not a dressing on the resident's sacrum and did not know how long the pressure ulcer did not have a dressing. Review of the resident's TAR on 7/12/24, showed the floor nurse initialed the resident's treatment had been completed as ordered on 7/11/24. 4. During an interview on 7/12/24 at 9:00 A.M., Registered Nurse (RN) G said the facility WN is responsible to do the treatments Monday through Friday in both buildings. The floor nurses do the treatments on the weekends or when the facility WN is not here. 5. During an interview on 7/12/24 at 9:14 A.M., the facility WN said she worked the previous day, 7/11/24. She did the treatments in the long term care building, but then she had paperwork to do. She asked the floor nurses in the rehab building, where Residents #19, #21 and #22 reside, to do the treatments. She did not know why they did not do the treatments. 6. During an interview on 7/12/24 at 12:06 P.M., the Director of Nursing said treatments should be completed as ordered. If a treatment cannot be done as ordered, she expected that to be communicated to the next shift so the treatment could be completed. No one told her the previous day the treatments were not completed. She was not aware the facility WN had told the nurses to do the treatments in the rehab building. The floor nurse who worked in the rehab building is not in the facility today, so she did not know if the facility WN told him/her to do the treatments or not. The facility's policy is current and she expected staff to follow that policy. MO00238714

Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered by the physician for three residents (Resident #19, #21, and #22). Facility nursing staff documented the treatments as completed, although they were not completed. The facility identified 15 residents with pressure ulcers. Four were sampled and problems were found with three. The census was 164. Review of the facility's undated Skin Care & Wound Management Overview policy and procedure, included the following: -Definitions: Pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction; -Policy: -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions(s) contributing to it and description of impairment to determine appropriate treatment; -Skin care and wound management program includes, but is not limited to: Application of treatment protocols based on clinical best practice standards for promoting wound healing. Daily monitoring of existing wound; -Treatment: Review and select the appropriate treatment for the identified skin impairment. Obtain a physician's order. Communicate interventions to the care giving team. Document treatment on the Treatment Administration Record (TAR). Monitor and document progress. Evaluate effectiveness of interventions during clinical meeting. Communicate changes to the care giving team. 1. Review of Resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/24, showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Diagnoses of paraplegia (impairment in motor or sensory function of the lower extremities), manic depression (bipolar disorder, causes extreme mood swings) and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, and perceives reality); -Unhealed Pressure Ulcer(s): Yes; -Number of Stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin) may be present on some parts of the wound bed. Often includes undermining (caused by erosion under the wound edges resulting in a large wound with a small opening) and tunneling (a narrow passageway under the skin in a wound): 4. Review of the resident's care plan located in the electronic healthcare record (EHR), review date of 6/17/24, showed: -Focus: Activities of daily living (ADL) self care performance related to paraplegia. Goal: Will improve current level of function. Intervention/Tasks: Partial/moderate assistance required for toilet hygiene, shower/bathe, and chair/bed to chair transfers; -Focus: Wound infection/osteomyelitis (bone infection). Goal: Will be free of signs/symptoms of complications related to infection. Interventions/Tasks: Administer antibiotics per providers orders. Evaluate for signs/symptoms of skin infection: drainage, heat, redness, swelling and report abnormal findings to medical provider; -Focus: Impaired skin integrity related to Stage 4 pressure ulcer to right heel, sacrum (the area between the bottom of the small of the back and the center upper buttocks) and left ischium (the area between the lower buttock and back of the upper thigh). Review of the resident's Physician's Order Sheet (POS), located in the EHR, showed: -Start Date: 6/12/24 End Date: 7/23/24: Ceftolozane-tazobactam/brand name Zerbaxa (antibiotic for osteomyelitis) 1.5 grams (1500 milligrams (mg) intravenous (IV)); -6/13/24: Right heel. Cleanse with wound cleanser, apply silver alginate (an antimicrobial dressing), cover with bordered dressing daily and as necessary (PRN); -7/10/24: Sacrum. Clean with wound cleanser, apply Dakins (diluted bleach solution) moist gauze, cover with dry dressing. Change daily every day shift; -7/11/24: Left ischium. Clean with wound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily. Review of the resident's TAR, dated 7/1/24 through 7/31/24, showed: -6/13/24: Right heel. Cleanse with wound cleanser, apply silver alginate, cover with bordered dressing daily and PRN; -7/10/24: Sacrum. Clean with sound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily every day shift; -7/11/24: Left ischium. Clean with wound cleanser, apply Dakins moist gauze, cover with dry dressing. Change daily. Review of the resident's wound company progress notes, dated 7/10/24, showed: -Wound/Ulcer #2; -Location: Right Heel; -Type: Pressure Ulcer/Injury: Stage 3 (Full thickness tissue loss. Subcutaneous (situated under the skin) fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -Wound Bed Description: 100% pink epithelial tissue (New skin growing in superficial ulcer. It can be light pink and shiny); -Measurements: 1.1 centimeters (cm) (length) x 0.5 cm (width) x 0.2 cm (depth); -Peri-Wound (the area around the wound opening): Normal - No signs of infection noted; -Exudate (drainage): Moderate; -Color: Sero-sanguineous (a thin watery fluid with a light red or pink hue); -Debridement (tissue removal) that has been completed at this site: Mechanical debridement completed via normal saline (NS) and 4x4s (gauze squares); -Goal: Adequate offloading (pressure relief) to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Improved - continue current treatment plan; -Treatment: Cleanse with wound cleanser, apply Silver Alginate, wrap with Kerlix and secure with tape daily and PRN; -Wound/Ulcer #4; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 80% granulation tissue (pink or red tissue with shiny, moist, granular appearance) and 20% slough tissue; -Measurements: 6.0 cm x 7.3 cm x 1.2 cm; -Undermining: 1.3 cm from 3 o'clock to 5 o'clock (undermining and tunneling is associated with a clock face); -Exudate: Moderate; -Color: Sero-sanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Declined; -Treatment: Cleanse with wound cleanser, apply Dakins moist Kerlix, then cover with dry dressing daily and PRN; -Wound/Ulcer #5; -Location: Left ischium; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 90% granulation tissue and 10% slough; -Measurements: 3.6 cm x 3.5 cm x 2.0 cm; -Undermining: 12-12 greatest at 12 o'clock of 5.4 cm; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Sero-sanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing and display healing by reduction in measurement/characteristic every 2 weeks; -Wound Status: Declined; -Treatment: Cleanse with wound cleanser, apply Dakins moist Kerlix, then cover with dry dressing. Change daily and PRN. Observation and interview on 7/11/24 at 10:55 A.M., showed the resident lay in bed. He/She said facility staff change his/her pressure ulcer dressing daily most of the time, but not always. The resident said he/she is receiving IV antibiotics for his/her pressure ulcers; Observation and interview on 7/12/24 at 9:33 A.M., showed the resident lay in bed. The facility Wound Nurse (WN) assisted the resident onto his/her right side and prepared to change the resident's pressure ulcer dressings. The dressings on the resident's sacrum, right heel, and left ischium were intact and dated 7/10/24. The facility WN said all of the pressure ulcers should have been changed yesterday, 7/11/24. He/She was doing paperwork yesterday and had asked the floor nurses to complete the treatments. She measured the resident's pressure ulcers: Sacrum 8.0 cm x 6.3 cm x 3.6 cm. 75% yellow slough and 20% granulation tissue. Right heel 1.2 cm x 0.4 cm x 0.1 cm. 100% granulation tissue. Left ischium 3.7 cm by 4.0 cm x 1.6 cm. 15% yellow slough and 85% granulation tissue. Review of the resident's TAR on 7/12/24, showed the floor nurse had initialed the resident's treatments had been completed as ordered on 7/11/24. 2. Review of Resident #21's admission MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively Intact; -Rejection of Care: Behavior not exhibited; -Diagnoses of paraplegia and diabetes mellitus; -Unhealed Pressure Ulcers: Yes; -Number of Stage 2 pressure ulcers (Partial thickness loss of dermis (middle layer of the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister): 3; -Number of Stage 4 pressure ulcers: 1. Review of the resident's care plan located in the EHR, a review date of 6/19/24, showed: -Focus: ADL self care performance. Goal: Will improve current level of function. Interventions/Tasks: Partial/Moderate assist required for toileting/hygiene, and showers/baths; -Focus: Impaired skin integrity related to Stage 4 pressure ulcer of the sacrum. Goal: Will have improved current skin status. Interventions/Tasks: Encourage resident to turn and reposition. Complete weekly skin assessment. Review of the resident's POS located in the EHR and TAR, dated 7/1/24 through 7/31/24, showed: -6/25/24: Sacrum, clean with Vashe (wound cleanser), gently pack with 1 inch iodoform rope (an antiseptic), cover with pad and secure with dry dressing. Change every shift and PRN. Review of the resident's weekly wound care company progress notes, dated 7/10/24, showed: -Wound/Ulcer #4; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 90% granulation tissue and 10% slough; -Measurements: 4.0 cm x 3.5 cm x 0.9 cm with undermining from 10 to 7 at 3 o'clock of 1.9 cm; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Serosanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s; -Goal: Adequate offloading to alleviate pressure for optimal wound healing; -Wound Status: Unchanged; -Treatment: Clean with Vashe, gently pack with 1 inch iodoform rope, cover with pad and secure with dry dressing. Change every shift and PRN. Observation and interview on 7/12/24 at 7:55 A.M., showed the resident lay in bed. He/She said he/she could not recall if his/her treatment was done the previous day, but he/she does not think they did. Certified Nursing Assistant (CNA) G and CNA H assisted the resident onto his/her left side. The resident had an intact dressing on his/her sacrum. The dressing was dated 7/10/24. Both CNAs confirmed the date written on the dressing. Observation and interview on 7/12/24 at 11:06 A.M. showed the resident lay in bed. The facility WN assisted the resident onto his/her left side to administer the resident's treatment. The dressing dated 7/10/24, remained on the resident's sacrum. The facility WN said nurses work 12 hour shifts so the resident's treatment should have been done twice on 7/11/24. The sacrum pressure ulcer measured 3.7 cm x 3.6 cm x 1.2 cm and was 10% yellow slough and 90% granulation tissue. Review of the resident's TAR on 7/12/24, showed the floor nurses initialed the treatment had been completed as ordered on the day and night shift on 7/11/24. 3. Review of Resident #22's quarterly MDS, dated [DATE], showed: -Adequate hearing; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands - clear comprehension; -Rejection of Care: Behavior not exhibited; -Diagnoses of malnutrition and depression; -Unhealed Pressure Ulcers: Yes; -Number of Stage 4 Pressure Ulcers: 1. Review of the resident's current care plan showed: -Focus: At risk of infection related to wound. Goals: Resident will be free of signs/symptoms of infection. Interventions/Tasks: Administer treatments per medical provider's orders; -Focus: ADL self care performance. Goals: Will maintain current level of function. Interventions/Tasks: Totally dependent for toileting/hygiene and showering/bathing. Review of the resident's TAR, dated 7/1/24 through 7/31/24, showed the following order: -6/26/24: Wound care sacrum. Clean with Vashe, Blastx (wound gel) and collagen powder, cover with calcium alginate, secure with bordered dressing daily and PRN. Review of the resident's weekly wound care company progress notes, dated 7/10/24, showed: -Wound/Ulcer #1; -Location: Sacrum; -Type: Pressure Ulcer/Injury: Stage 4; -Wound Bed Description: 100% granulation tissue; -Measurements: 2.8 cm x 1.0 cm x 0.4 cm; -Undermining: None; -Peri-Wound: Normal - No signs of infection noted; -Exudate: Moderate; -Color: Serosanguineous; -Debridement that has been completed at this site: Mechanical debridement completed via NS and 4x4s and autolytic (uses the body's own enzymes and moisture beneath a dressing to liquefy non-viable tissue); -Goal: Adequate offloading to alleviate pressure for optimal wound healing; -Wound Status: Improved; -Treatment: Clean with Vashe, apply collagen powder (a protein), apply calcium alginate (an absorbent dressing), cover with bordered dressing. Change daily and PRN. During an interview on 7/12/24 at 8:55 A.M., showed the resident said he/she thought staff had completed his/her sacrum treatment the previous day, on 7/11/24. He/She then said, you know, now that he/she thought about it, staff did not do his/her sacrum treatment yesterday; Observation on 7/12/24 at 9:03 A.M. the resident lay in bed. Licensed Practical Nurse (LPN) H assisted the resident onto his/her left side showing a pressure ulcer with no dressing on the resident's sacrum. The pressure ulcer had a red floor and no slough. The LPN said he/she was not aware there was not a dressing on the resident's sacrum and did not know how long the pressure ulcer did not have a dressing. Review of the resident's TAR on 7/12/24, showed the floor nurse initialed the resident's treatment had been completed as ordered on 7/11/24. 4. During an interview on 7/12/24 at 9:00 A.M., Registered Nurse (RN) G said the facility WN is responsible to do the treatments Monday through Friday in both buildings. The floor nurses do the treatments on the weekends or when the facility WN is not here. 5. During an interview on 7/12/24 at 9:14 A.M., the facility WN said she worked the previous day, 7/11/24. She did the treatments in the long term care building, but then she had paperwork to do. She asked the floor nurses in the rehab building, where Residents #19, #21 and #22 reside, to do the treatments. She did not know why they did not do the treatments. 6. During an interview on 7/12/24 at 12:06 P.M., the Director of Nursing said treatments should be completed as ordered. If a treatment cannot be done as ordered, she expected that to be communicated to the next shift so the treatment could be completed. No one told her the previous day the treatments were not completed. She was not aware the facility WN had told the nurses to do the treatments in the rehab building. The floor nurse who worked in the rehab building is not in the facility today, so she did not know if the facility WN told him/her to do the treatments or not. The facility's policy is current and she expected staff to follow that policy. MO00238714

Based on interview and record review, the facility failed to provide appropriate nursing assessments per facility policy for residents with a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), diagnosed with respiratory infection and vomiting. The facility identified seven residents with tracheostomy, three were sampled and failures were found with two (Resident #6 and #44). The census was 156. Review of the facility's Tracheostomy (Trach) Care policy, dated 6/2020, showed: -Tracheostomy care will be performed as ordered by the Attending Physician. -Licensed Nurses or a Respiratory Therapist (RT) may perform tracheostomy care. -Report any unusual observations to the Attending Physician immediately. -Document the care provided, the resident's response, any unusual observations, and physician notification as indicated in the medical record. Monitor vital signs and report abnormal findings to the medical provider. Review of the facility's Change of Condition policy, undated, showed the following: -Policy: An acute change of condition is a sudden, clinically important deviation from the a patient's baseline in physical, cognitive, behavioral or functioning domains. Clinically important means a deviation that, without intervention, may result in complications or death; -Procedure: The licensed nurse will notify the resident's Attending Physician when there is: C. A significant change in the resident's physical, mental psychosocial status, deterioration health, mental or psychosocial status, life threatening conditions or clinical complications; -Documentation: A licensed nurse will document the following: A. Date, time, and pertinent details of the incident and the subsequent assessment in the nurses notes. Review of the facility Documentation Nursing Policy, revised on 6/2020, showed: -Purpose: To provide documentation of resident status and care given by nursing staff; -Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate. Nursing documentation will not contain error-prone abbreviations. See Error -Prone Abbreviations. Abbreviations identified in industry accepted standards such as Steadman's Medical Dictionary or Taber's Cyclopedic Medical Dictionary that are not specifically excluded by the list in Error Prone Abbreviations are acceptable abbreviations. Nursing staff will not falsify or improperly correct nursing documentation; -Procedure: -I. Nursing documentation: -C. The Licensed Nurse will review the Plan of Care on a weekly basis and document the resident's response and progress towards the goal; -D. Any communications with family, durable power of attorney (DPOA), or physician is to be noted in nurse's notes; -F. Nurse's notes are dated, timed, and signed when written; -H. Medication administration records and treatment administration records are completed with each medication or treatment completed; -I. Glucose measuring is documented as per physician's order; -J. Treatments completed and documented as per physician's order; -K. Documentation will be completed by the end of the assigned shift; -II. Alert Charting: -A. Alert charting is documentation done to track a medical event for a period of 72 hours or longer; -B. Alert charting is completed by professional staff rather than non-professional staff; -C. Events may include but are not necessarily limited to: -(a) New physician orders; -(b) Suspected or actual change in condition; -(c) Initiation of new medical treatment; -(d) Fall with or without injury; and/or; -(e) Resident-to-resident event. -D. Alert charted describes what is going on: -(a) Describe the resident's condition, include what you see, hear, smell, feel, etc.; -(b) Use the resident's own words if needed; -(c) Describe what you have done in response to what is going on with the resident; -(d) Describe how the resident responded to the actions; -III. Activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) Documentation: -A. The Certified Nurse Aide (CNA) will document the care provided on the facility's method of documentation, manually or electronic; -B. The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed; -C. Documentation will be completed by the end of the assigned shift. 1. Review of Resident #6's physician orders, showed the following: -Order dated 6/1/24, for trach care every shift and as needed (PRN); -Titrate (adjust or lower amount) oxygen to room air, oxygen at 3 Liters PRN every shift; -No order for Respiratory Therapy Care. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/24, showed the following: -Diagnoses of respiratory failure, seizures, diabetes and seizures; -Totally dependent on staff for all Activities of Daily Living (ADLs); -No antibiotic use; -Oxygen use; -Trach care. Review of the resident's care plan, dated 7/13/24, showed the following: -Problem: Trach Care; -Goal: Will be free of signs/symptoms (s/sx) of complications from trach use. Will have clear and equal breath sounds bilaterally; -Interventions: Administer medications as ordered. Evaluate changes in mental status, agitation, restlessness and confusion. Report abnormal findings to medical provider. Evaluate lung sounds, and respiratory status. Observe for s/sx of pulmonary infection: fever, tachycardia (rapid heartbeat), discolored sputum, foul order, increased secretions, thick secretions, abnormal lung sounds. Report abnormal findings to medical provider, resident/resident representative. Monitor vitals. Review of the progress notes, showed the following: -7/15/24 at 11:38 A.M. completed by the RT: Oxygen Saturation (O2 Sat) 97% (normal 95% to 100%), via 6 liters per minute (LPM) oxygen trach collar mask, heart rate (HR) 80 (normal HR, 60 to 100), respiratory rate (RR) 18 (normal rate, 12 to 18), Breath Sounds (BS) coarse (normal: smooth, soft sound), Suction moderate amount of cream thick mucus (normal secretions, white or clear); -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/16/24; -No documentation staff notified the physician of cream thick secretions; -7/16/24 at 11:01 A.M., completed by the RT: O2 Sat 97%, via 6 LPM per oxygen trach collar mask, HR 88, RR 16, BS coarse. Suction moderate amount of cream thick secretions; -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/17/24; -No documentation staff notified the physician of cream thick secretions -7/17/24 at 11:17 A.M., completed by the RT: O2 Sat 97%, via 5 LPM per oxygen trach collar mask, HR 75, RR 16, BS coarse. Suction moderate amount of thick cream mucus; -No other nurses notes or respiratory assessment notes until 7/22/24; -No documentation whether staff notified the physician of the thick cream colored secretions; -7/22/22 at 11:32 A.M., completed by the RT: O2 Sat 99%, HR 78, RR 18, BS decreased. Suction moderate amount of cream thick mucus; -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/23/24; -No documentation whether staff notified the physician of cream thick secretions; -7/23/24 at 11:21 A.M., completed by RT: O2 Sat 98% via room air, trach capped, HR 78, RR 16, BS decreased. Oral suction clear; -7/24/24 at 11:21 A.M., completed by RT: O2 Sat 98% via room air, trach capped, HR 76, RR 16, BS coarse. Suction moderate amount of thick pale mucus;. -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/29/24; -No documentation whether staff notified the physician of thick pale secretions; -7/29/24 at 11:34 A.M., completed by RT: O2 Sat 98% via room air (RA), trach capped with Heat Moisture Exchanger (HME, special trach cap to help provide moisture to trach) HR 86, RR 18, BS decreased. Suction small amount of thick pale mucus;. -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/30/24; -No documentation whether staff notified the physician of thick pale mucus; -7/30/24 at 11:02 A.M., completed by RT: O2 Sat 99% via room air (RA), trach capped with HME on, HR 80, RR 18, BS coarse. Suction scant amount of thin tan secretions;. -No other nurses notes regarding respiratory status or respiratory assessment notes; -No documentation whether RT notified the nurse of the thin tan secretions; -No documentation whether the physician was notified of the thin tan secretions; -No further documentation regarding the resident's respiratory status until 8/8/24; -8/8/24 at 8:22 P.M., completed by the nurse: [NAME] mucus with a foul smell coming from tracheostomy; -MD notified and ordered Bactrim DS (a combination of two antibiotics) for 7 days; -No further notes of the resident's respiratory status were entered until 8/14/24 at 11:29 P.M. Review of the Medication Administration Record (MAR), showed the following orders: -Bactrim DS, documented as administered from 8/9 through 8/15/24; -Vital signs every shift while on antibiotics every shift for antibiotic monitoring for 7 days (start date 8/9/24). Vital signs not recorded on the second shift for 8/9, 8/10, 8/11, 8/14 and 8/15/24; -Trach Care every shift and as needed: Day shift: Documented as completed: 8/7, 8/8, 8/10 through 8/16/24. Nightshift: 8/6 through 8/16/24. Day shift: Blank 8/1 through 8/6, 8/9/24, Night shift: Blank 8/1 through 8/5/24. Review of the progress notes, showed the following: -8/14/24 at 11:29 A.M., completed by the RT: O2 Sats 98% on room air, HME on, HR 74, RR 18, BS decreased, suctioned small amount of thick tan mucus; -No other nurses notes regarding respiratory status or respiratory assessment notes from 8/14/24 at 11:29 A.M. until 8/16/24; -8/16/24 at 10:22 P.M., (First note of the day) showed staff noted the family said the resident has not responded properly/normally since 8/12 when they visited and demanded hospitalization . Resident's physician notified. New order received to send to the hospital. Review of hospital admission notes, showed the following: -8/16/24 at 9:13 P.M.: the resident presented with altered mental status, green sputum coming from the trach, tachycardia and tachypenia (rapid breathing); -Blood pressure: 106/75, Heart Rate:108, Respirations: 15, Pulse:107, Temperature: 100.6 degrees Fahrenheit (F); -Review of the resident's blood work results showed a white blood count of 10.7, (normal 4.5 to 11.0) blood urea nitrogen (BUN, measures how much urea nitrogen is in the blood) of 80 (normal 7 to 20), Glucose 256 (normal blood sugar (70 to 100); -Workup in the emergency department concerning for sepsis (life threatening complication of an infection), particularly urinary tract infection (UTI); -Started on broad-spectrum antibiotics; -Labs also concerning for dehydration, hypernatremia (high concentration of sodium in the blood); -Diagnosis: Sepsis, UTI, tracheitis (inflammation of the trachea) hypernatremia, dehydration, acute kidney injury; -Computed Tomography (CT) scan of chest and abdomen showed suspected right lower lobe pneumonia; -Plan to admit for additional workup and monitoring. Review of the resident's hospital discharge notes, dated 8/20/24, showed the following: -Discharge diagnoses of Acute Metabolic Encephalopathy (caused by a deficiency of vitamins, oxygen or glucose), pneumonia and sepsis; -Discharge medications: amoxicillin-clavulante (antibiotic) 250-62.5 mg/5 milliliter (ml) 10 ml per gastrostomy (g-tube, flexible tube surgically inserted through the abdomen into the stomach. Used to administer nourishment and medications) every 8 hours for 5 days and doxycycline hyclate (antibiotic) 100 mg every 12 hours for 5 days. Review of the resident's Physician Order Sheet (POS), showed the following: -Doxycycline Hyclate 100 mg via g-tube every 12 hours for pneumonia for 5 days; -Amoxicillin 10 ml via g-tube every 8 hours for pneumonia for 5 days. Review of the MAR, showed the following orders: -Doxycycline Hyclate 100 mg via g-tube every 12 hours for pneumonia for 5 days. Administration not documented for the second dose on 8/25/24 and the last dose 8/26/24. -Amoxicillin 10 ml via g-tube every 8 hours for pneumonia for 5 days. Administration documented three times on 8/22/24, two times on 8/23/24, three times on 8/24/24, two times on 8/25/24 and one time on 8/26/24; -Vital signs every shift for antibiotic use monitoring every shift for 5 days. Vitals were not documented on the day shifts of 8/23/24, 8/24/24 and not documented on either shift of 8/25/24. During an interview on 8/20/24 at 1:37 P.M., CNA E said he/she has taken care of the resident and assisted other CNAs with the resident. The resident required total care. Several days prior to the resident going to the hospital, the resident was very sleepy and had smelly brown mucus coming from his/her trach. This had been going on awhile. CNA E knew the resident was on an antibiotic but the drainage wasn't getting any better. He/She thought the resident's sleepiness was due to him/her being on antibiotics. CNA E would report the trach drainage to the charge nurse. The nurses knew about the drainage and would go in to suction. During early morning rounds, the resident's trach would be full of brown secretions. When Registered Nurse (RN) B was off, the other nurses would not check on the resident. During an interview on 8/27/24 at 10:15 A.M., CNA W said he/she frequently takes care of the resident on the day shift. The resident normally is awake, looking around while up in his/her wheelchair at the nurses station. Prior to the resident going to the hospital, he/she had a lot of thick white, brown and green drainage from his/her trach. CNA W reported the drainage to the charge nurse so he/she could be suctioned. The resident was tired and very sleepy, which was unusual for him/her. CNA W said the CNAs would report their concerns to nursing staff but some nurses, RN L would ignore these concerns so he/she would stop saying anything. During an interview on 8/27/24 at 10:08 A.M., Certified Medication Technician (CMT) V said he/she did the resident's blood glucose fingersticks three times per day. Prior to him/her going to the hospital, the resident was coughing up a lot of slimy mucus. CMT V doesn't recall an odor. The nurse, RN B would hear him/her coughing and go in to suction. CMT V didn't report the drainage because the nurse would hear the resident coughing and go into the room. During an interview on 8/21/24 at 10:34 AM, RN B said he/she could hear from the nursing station if the resident was gurgling and needed suctioning. RT did not report any changes or concerns. On 8/8/24, the physician was notified of foul smelling brown mucus coming from the resident's trach. Orders were obtained for an antibiotic. RN B said staff nurses should assess the resident every shift and document the findings in the progress notes. He/She should have documented his/her assessment in the nurse's notes. During a second interview on 8/27/24 at 10:55 A.M., RN B said trach care included suctioning as needed, breath sounds, O2 Sats, vital signs and changing the trach collar ties. Staff nurses are to document what the secretion color was, consistency and whether their was any odor. RN B said the nurses needed an inservice on what to do because not enough is being documented regarding trach residents' conditions. The change in the resident's secretions should have been reported to the physician and documented in the nurses notes. The RT must report any findings to the charge nurse so that he/she can notify the physician. No one reported any changes in the resident's condition on 8/16/24. The family came in later that evening and requested for the resident to be sent to the hospital. During an interview on 8/20/24 at 10:58 A.M., the RT said he/she must report to the nurse any changes in the resident's condition. This would include breath sounds, color of secretions, decreased O2 saturations and increase in heart rate. He/She reported changes to the charge nurse but was unable to say which charge nurse he/she spoke to. He/She failed to document it because he/she had no access to the electronic record. The RT said he/she documented the changes on paper notes but was unable to produce the documentation. He/She would assess the resident once a shift, usually on Monday, Wednesday and Friday. The charge nurse is responsible to assess the resident during the rest of the shift and on the days he/she is not at the facility. He/She doesn't recall any changes in the resident's condition but he/she was off several days between 7/30/24 and 8/16/24. He/She noted the different consistency of the trach secretions but failed to document that he/she notified the charge nurse. During an interview on 8/27/24 at 1:33 P.M., the Director of Nurses (DON) said trach care consists of lung sounds, appearance of trach secretions, odor if any, changing of trach ties, and should be completed every shift and documented in the nurses notes. If the nurse observes odor, changes in color of secretions and change in mental status, he/she should notify the physician. When receiving antibiotics, the nurse should document the resident's response to the medication. If the resident does not improve or the condition changes, he/she should document and notify the physician. Staff should have administered the antibiotics as ordered. During an interview on 8/20/24 at 12:07 P.M., the resident's physician and Medical Director said he expected staff to follow the facility's policy and assess the resident's condition and document while he/she was receiving antibiotic therapy. The nurses should notify him of any changes in the resident's condition. 2. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for all ADLs; -Received 51% or more of nutrition by tube feeding (used to give medicines and liquids, including liquid nutrition, through a small tube placed through abdomen into the stomach) -Trach care; -Oxygen therapy; -Diagnosis included respiratory failure, tracheostomy, gastrostomy (g-tube, surgical procedure used to insert a tube through the abdomen and into the stomach used for medication, liquids and liquid nutrition), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left and right hand, shortness of breath (SOB), venous thrombosis (blood clots in the veins) and embolism (obstruction or blockage in a blood vessel), sudden cardiac arrest (the heart stops beating suddenly), high blood pressure, muscle weakness, and obstructive sleep apnea (sleep related breathing disorder. The throat muscles relax and block the airway). Review of the resident's care plan, in use during the survey, showed: -Focus: Resident is receiving tracheostomy care; -Goal: -Trach site will remain patent (open and unobstructed) through review date; -Resident will be free of s/sx of complications from tracheostomy, through review date; -Resident will have clear and equal breath sounds bilaterally, through review date; -Interventions: - Administer medications per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident/resident representative (RR); -Administer treatments per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident/RR; -Evaluate lung sounds, and respiratory status. Observe for s/sx of pulmonary infection: fever, tachycardia, discolored sputum, foul order, increased secretions, thick secretions, abnormal lung sounds. Report abnormal findings to medical provider, resident/RR; -Focus: Resident requires, tube feeding; -Goal: Resident will remain free of complications through review date; -Interventions: -Administer medications via tube, per orders; -Administer flushes per medical provider's order; -Check for placement and residuals per policy; -Head of bed elevated 30 degrees or higher; -Monitor intake of enteral tube feeding; -Focus: Resident is at risk of nutritional decline related to: obesity, wound, high blood pressure, hypothyroid (thyroid doesn't create and release enough thyroid hormone into your bloodstream), fluid retention (swelling, edema). Current nothing by mouth (NPO) diet, receives tube feeding of Jevity 1.5 (liquid balanced nutrition) at 65 milliliters (ml) per (/) hour (hr) for 20 hours. Weight loss is desired; -Goal: Receive/tolerate diet as ordered; -Interventions: Observe for s/sx of aspiration (when something enters your lungs by accident), dysphagia (difficulty swallowing) i.e. choking, coughing, pocketing food, loss of liquids, solids from mouth when eating, drinking, difficulty, pain when swallowing. Review of the resident's progress notes, showed: -8/22/24 at 12:54 P.M., Nurses note: resident has vomiting. Primary care physician (PCP) notified, received new order for Zofran (used to prevent nausea and vomiting) three times daily. -8/22/24 at 1:38 P.M., eMAR note: resident had metoclopramide (used to treat nausea and vomiting) scheduled; -8/22/24 at 1:41 P.M., eMAR note: guaifenesin-DM (used to relieve cough and loosen mucus) liquid 100-10 mg/5 ml, give 5 ml via g-tube every six hours as needed for congestion: given for cough; -8/22/24 at 5:38 P.M., eMAR note: clonidine HCL (used to treat high blood pressure) 0.2 mg, give one tablet via g-tube three times a day for high blood pressure, hold for systolic blood pressure (First number of blood pressure, measures the force of the blood flow when blood is pumped out of the heart) of less than 100 or heart rate less than 50: was not given due to low blood pressure and vomiting; -8/23/24 at 7:50 A.M., electronic medication record note: COVID testing as needed: Result negative; During an interview on 8/27/24 at 10:53 A.M., RN B said if he/she has patient with a trach and tube feeding who was vomiting, he/she would make sure the head of the bed was elevated, he/she would stop the tube feeding, wait until the resident stopped vomiting and would take vital signs and do an assessment. The assessment of the resident would consist of how much vomited, what it looked like, how many times the resident vomited, listen to lung sounds, and what the vital signs are. RN B said he/she would then call the doctor and explain the resident assessment to the PCP. RN B said the PCP might want to order a chest x-ray and go from there to ensure the resident did not aspirate while vomiting. RN B said he/she would follow the orders the PCP gave. RN B would the notify the RR of the change in condition and any new orders. The full assessment and notifications to the PCP and RR would be documented in the progress notes. RN B said the facility used to have a change of condition assessment, but it is not available anymore so he/she would document the change of condition and full assessment in a progress note. RN B would automatically ask for an x-ray to make sure the resident did not aspirate. RN B said the resident would need to be assessed each shift for five days. The assessment each shift would be documented in the progress note with vital signs and lung assessments. RN B would pass information about the resident and change of condition to the next nurse during shift-to-shift report. During an interview on 8/26/24 at 2:33 P.M., the DON said if a resident with a trach and tube feeding was vomiting, she expected the nurse to complete an assessment for change of condition. The change of condition assessment includes taking all vital signs, that also includes listening to lung sounds. When the nurse calls the PCP, the nurse should inform the PCP of the change in condition, vital signs, assessment of lungs and describing the vomiting such as color, how much, and how many times the resident vomited and see what orders the PCP gives. The nurse should request an x-ray to ensure the resident did not aspirate. If the PCP gave an order for Zofran for nausea and vomiting and the nurse noticed that the resident was already on a medication for nausea and vomiting, the nurse should call the PCP back and get clarification on the order. She expected the nurse to complete the change of condition assessment, document the orders received in the orders and a progress note, notify the RR and document all notifications and what was said in a progress note. The DON also expected the nurses to complete follow up documentation on that resident each shift for 72 hours in the progress notes, that would include vital signs, lung sounds, and if it was noted the resident was not at baseline, the nurse should be notifying PCP and RR of any changes.

Based on observation, interview, and record review, the facility failed to follow their policies by failing to promptly assess one resident's right hip wound after a Certified Nursing Assistant (CNA) reported the wound to a Licensed Practical Nurse (LPN) the day before it was assessed and a treatment had been started (Resident #36). Another resident said he/she had reported his/her bottom was sore to staff and no one assessed his/her bottom until two days later when a wound was identified (Resident #39). Both residents complained the facility's largest incontinent briefs were too small and caused the wounds. In addition, staff failed to promptly assess and treat one resident with a right palm laceration. After waiting approximately one hour for staff to treat the laceration, the resident returned to his/her room without receiving treatment (Resident #3). The census was 156. Review of the facility Wound Management policy, revised on 6/2020, showed the following: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury (pressure injury, a localized area of skin damage that occurs when there is prolonged pressure on the skin or underlying tissue); -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: Skin Tears, Lacerations, Cuts, and Abrasions: Wounds that usually result from impact (or related incidents) to extremely fragile skin; -Assessment: a Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; upon identification of a new wound the Licensed Nurse will: measure the wound (length, width, depth); initiate a Wound Monitoring Record sheet; a Wound Management Record will be completed for each wound; implement a wound treatment per physician's order; -Wound Management: the attending physician will be notified to advise on appropriate treatment promptly; the Licensed Nurse will notify the responsible party of the presence of a pressure injury; the attending physician and interdisciplinary team (IDT) will be notified of: new pressure injuries or wounds; pressure injuries or wounds that do not respond to treatment; pressure injuries or wounds that worsen or increase in size; complaints of increased pain, discomfort or decrease in mobility by a resident; signs of ulcer sepsis (infections), presence on exudates (drainage), odor or necrosis (necrotic/dead/non-viable tissue), if not already noted by the Attending Physician; residents refusing treatment; -Documentation: new pressure injuries or wounds will be documented on the 24 hour log; wound documentation will occur at a minimum of weekly until the wound is healed; -Documentation will include: location of wound; length, width, and depth measurements recorded in centimeters; direction and length of tunneling and undermining (if applicable); appearance of the wound base; drainage amount and characteristics including color, consistency, and odor; appearance of wound edges; description of the peri-wound (skin around the wound) condition or evaluation of the skin adjacent to the wound; presence or absence of new epithelium at the wound rim; presence of pain; -IDT will document discussion and recommendations for: pressure injury and wounds that do not respond to treatment; pressure injuries and wounds that worsen or increase in size; complaints of increased pain, discomfort or decrease in mobility by a resident; signs of ulcer sepsis, presence on exudates, odor or necrosis; residents refusing treatment; -Licensed Nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Update the resident's care plan as necessary. Review of the facility Documentation Nursing Policy, revised on 6/20, showed: -Purpose: To provide documentation of resident status and care given by nursing staff; -Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate. Nursing staff will not falsify or improperly correct nursing documentation; -Procedure: -I. Nursing documentation: -C. The Licensed Nurse will review the Plan of Care on a weekly basis and document the resident's response and progress towards the goal; -D. Any communications with family, durable power of attorney (DPOA), or physician is to be noted in nurse's notes; -F. Nurse's notes are dated, timed, and signed when written; -H. Medication administration records and treatment administration records are completed with each medication or treatment completed; -I. Glucose measuring is documented as per physician's order; -J. Treatments completed and documented as per physician's order; -K. Documentation will be completed by the end of the assigned shift; -II. Alert Charting: -A. Alert charting is documentation done to track a medical event for a period of 72 hours or longer; -B. Alert charting is completed by professional staff rather than non-professional staff; -C. Events may include but are not necessarily limited to: -(a) New physician orders; -(b) Suspected or actual change in condition; -(c) Initiation of new medical treatment; -(d) Fall with or without injury; and/or; -(e) Resident-to-resident event. -D. Alert charted describes what is going on: -(a) Describe the resident's condition, include what you see, hear, smell, feel, etc.; -(b) Use the resident's own words if needed; -(c) Describe what you have done in response to what is going on with the resident; -(d) Describe how the resident responded to the actions; -III. Activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) Documentation: -A. The CNA will document the care provided on the facility's method of documentation, manually or electronic; -B. The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed; -C. Documentation will be completed by the end of the assigned shift. Review of the facility LPN job description, revised 12/2023, showed: -Position Description: Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Responsible for resident care and direction of nursing care during assigned shift; includes staff assignments, mentoring and educating nursing personnel, working with physicians and other medical professional; -Direct Care Responsibilities: charts progress notes in an informative, factual manner that reflects the care administered as well as the resident's response to care; follows established procedure for charting and reporting all reports on incident/accidents; identifies and reports changes in condition to supervisor, physician, and family; accurately identifies skin changes and follows the company skin management protocols. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/16/24, showed: -Adequate hearing; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; Cognitively intact; -Rejection of Care: Behavior not exhibited; -Other Ulcers, Wounds and Skin Problems: Blank. Review of the resident's care plan, located in the electronic heath record (EHR), showed: -1/14/24: Focus: ADL Self-care performance deficit. Goal: Will maintain current level of function. Interventions: Requires a sit-to-stand lift (a machine that transfers residents capable of bearing weight) with two person support; -1/18/24: Focus: Incontinent of urine. Goal: Will remain free of skin break down due to incontinence. Interventions: Apply barrier creams as needed. Check resident for incontinence. Resident uses XXL disposable briefs, change as needed; -6/21/21: At risk for impaired skin integrity. Goal: Will be without impaired skin integrity. Interventions: Complete weekly skin checks. Review of the resident's weekly skin check, dated 8/16/24, showed: -Does the resident have any skin impairments? Yes. Under bilateral breasts/abdominal folds/groin - redness; -No documentation regarding the resident's right hip. During an interview on 8/19/24 at 8:15 A.M., CNA D said there were a few bariatric residents that needed larger incontinent briefs. They were breaking down between their legs because staff had to squeeze the briefs on the bariatric residents. During an interview on 8/19/24 at 8:23 A.M., the resident said he/she thought he/she had an open area on his/her right hip because the incontinent brief was too tight. During an interview on 8/19/24 at 8:31 A.M., CNA C said the resident had on open area on his/her right hip. He/She noticed it that morning and told LPN O. He/She thought the open area was because the resident's incontinent briefs were too small to fit. Review of the resident's physician's progress notes, physician's order sheets (POS), and treatment administration record (TAR) on 8/19/24 and located in the EHR, showed no documentation or treatment order for an open area on the resident's right hip. Observation on 8/20/24 at 7:00 A.M., showed the resident lay in bed. Unit Manager (UM) M removed the resident's cover and unfastened the resident's incontinent brief, revealing an open area on the resident's right hip that had a small amount of yellow slough (yellow or white layer of dead skin or tissue in a wound that can slow down or prevent healing) with a scant amount of drainage. There was no dressing on the open area. The resident said the open area was there yesterday. He/She thought the Certified Medication Technician (CMT) was aware of it and told the nurse. He/She thought his/her incontinent briefs caused the open area because they were too tight. He/She had been told by staff the facility no longer had his/her size of incontinent briefs. UM M said if the open area was there yesterday and reported to the nurse on duty, that nurse should have assessed the open area, called the physician and obtained a treatment order. It should be documented in the progress notes and added to the POS and TAR. Observations and interviews on 8/20/24 at 7:30 A.M., showed the resident lay in bed. The facility Wound Nurse (WN) measured the open area and said it was 0.8 centimeters (cm) by 1.6 cm by 0.3 cm with 10% yellow slough. The WN also found an open area that measured 0.4 cm by 0.8 cm by 0.2 cm on the resident's left posterior (back) knee, and an open area that measured 3.8 cm by 0.1 cm on the resident's right posterior thigh. She identified all the open area as trauma related, not pressure. If the nurse on duty was told about the open area on the right hip, he/she should have assessed it, called the physician and got a treatment started. The nurse should have filled out the form at the nurse's station so the WN would have known about it today. She did not work yesterday and did not receive a completed form today. Review of the resident's progress note, dated 8/20/24 at 4:45 P.M. and completed by the WN, showed: Reddened area noted to right hip measuring 0.8 cm by 1.6 cm by 0.3 cm. Wound bed with 10% slough noted. Area to right posterior thigh measuring 3.8 cm by 0.1 cm. Area to left posterior knee, red without odor measuring 0.4 cm by 0.8 cm by 0.2 cm. Antifungal cream applied. During an interview on 8/20/24 at 7:40 A.M., LPN O said he/she worked yesterday. He/She did not recall CNA C telling him/her the resident had an open area on the right hip, but he/she was very busy yesterday so it was possible CNA C did tell him/her and he/she forgot. Any new open area should be assessed, the physician should be notified and any new treatment should be documented in the progress notes, POS and TAR. During an interview on 8/20/24 at 9:15 A.M., the Director of Nursing (DON) said she would have expected LPN O to have assessed the resident's right hip when CNA C told him/her about it. The nurse should have notified the resident's physician, and documented any new treatment order in the progress notes, MAR and TAR. LPN O should have let the facility WN know about the new area. During an interview on 8/22/24 at 7:48 A.M., the facility WN said the resident was seen by the wound company on 8/21/24. The open area on the right hip was trauma related caused by the resident's brief. The wound company ordered calcium alginate (dressing which absorbs wound fluid) daily. Review of the resident's POS and TAR, showed an order dated 8/22/24, to cleanse the right hip with wound cleanser, apply a small piece of calcium alginate and cover with a border dressing daily and PRN. 2. Review of Resident #39's annual MDS, dated [DATE], showed: -Adequate hearing; -Makes Self Understood: Usually understood - difficulty communicating some words of finishing thoughts but is able if prompted or given time; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Dependent for toileting hygiene, shower/bathing, upper/lower dressing and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses of diabetes mellitus (high blood glucose/sugar) and renal (kidney) insufficiency; -Other Ulcers, Wounds and Skin Problems: Blank. Review of the resident's care plan, located in the EHR, showed: -11/11/21: Focus: Is at risk for altered skin integrity. Goal: Will be without impaired skin integrity. Interventions: Complete skin assessment upon admission/readmission, quarterly, and as needed; -11/11/21: Focus: ADL self-care performance deficit. Goal: Will maintain current level of function. Interventions: Totally dependent on one staff for lower body dressing, personal hygiene and shower and bathing; -11/29/21: Focus: Incontinent of bladder and bowel. Goal: Will remain free of skin break down due to incontinence. Interventions: Apply barrier creams as needed. Check resident for incontinence. Review of the resident's progress notes, POS and TAR on 8/22/24, showed no documentation or treatment order for the right buttock/ischium (the lower and posterior part of the hip bone). Observations and interviews on 8/22/24 at 11:00 A.M., showed the resident lay in bed wearing an incontinent brief. The resident said it was too small and had been cutting into his/her skin. CNA DD told the resident there were not any larger incontinent briefs. The resident had a sore on his/her buttock for a couple of days. He/She told the nurse yesterday and the day before, but no one had come to look at his/her bottom. The WN said she worked the last two days and no one had told her the resident's bottom was sore. Had she known, she would have assessed the resident. The WN assisted the resident to turn onto his/her side and noted an open area at the top of the posterior right thigh and bottom of the buttock where the resident's incontinent brief fit between the legs. The WN said the open area was 0.5 cm by 2.5 cm by 0.1 cm, was non-pressure and located where the incontinent brief wrapped around the leg. 3. During an interview on 8/20/24 at 8:59 A.M., CNA/Central Supply Clerk DD said the facility had small, medium, large, X-large and XX-large incontinent briefs in stock. Prior to the facility being sold to the new company on 8/1/24, he/she was able to order incontinent briefs that were larger than the XX-large briefs. The new company had an Amazon account that would not allow him/her to purchase the larger incontinent briefs. The larger incontinent briefs were still available, but the system wouldn't allow him/her to purchase more. He/She discussed this with the Administrator a couple of weeks ago, but he/she still could not order those incontinent briefs. Resident #36 and Resident #39 used the larger incontinent briefs he/she could no longer order. During an interview on 8/20/24 at 8:59 A.M., CNA EE said there were about 15 residents, including Resident #36 and Resident #39. who needed the briefs they no longer had. They had not had those incontinent briefs since the facility changed ownership. The residents that need the larger incontinent briefs said the largest ones available were uncomfortable and cut into their skin. During an interview on 8/22/24 at 1:32 P.M., the DON said she started at the facility on 8/12/24. No on had informed her the the largest incontinent briefs the facility had were too small for some of the residents. She was unaware the residents had been complaining the incontinent briefs were too small and cutting into their skin. She would make sure the previous incontinent briefs the resident felt were comfortable were ordered. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Upper and lower extremity impairment on one side; -Toileting: Substantial/maximal assistance; -Transfer: Partial/moderate assistance; -Dressing upper body: Set up or clean up; -Dressing lower body: Partial/moderate assistance; -Diagnosis included diverticulitis (inflammation of the intestine) of large intestine without perforation (a hole in the intestine causing contents to leak into the abdomen) or abscess without bleeding, hemiplegia (severe or complete loss of strength) and hemiparesis (mild or partial weakness on one side of the body) following cerebral infarction (stroke) affecting unspecified side, high blood pressure and weakness. Review of the resident's care plan, in use during the survey, showed: -Focus: ADL self-care performance related to hyperlipidemia (high cholesterol), weakness, iron deficiency, anemia (body does not have enough red blood cells), history of hemiplegia and hemiparesis following cerebral infarction; -Goal: The resident will exhibit improved function at discharge; -Interventions: -Assistance required with ADLs may fluctuate based on time of day, mood, pain, or fatigue. Adjust and document as indicated. Report significant changes to charge nurse; -Chair to bed transfer: Totally dependent of two, two or more helpers do all the effort. Resident does none of the effort; -Identify tasks events that cause frustration. Provide assistance as needed; -Observe and anticipate resident's needs: thirst, food, body positioning, pain toileting needs; -Place call light within reach. Remind resident to call for assistance if cognitively intact; -Focus: Resident has impaired skin integrity, or at risk for altered skin integrity; -Goal: Resident will maintain current skin status through next review date; -Interventions: -Complete skin at risk assessment upon admission, readmission, quarterly, and as needed; -Complete weekly skin checks. Review of the resident's progress notes, dated 8/26/24 through 8/27/24, showed, no progress note related to a laceration on the palm of the right hand. Review of the resident's electronic physician order summary (ePOS), dated 8/27/24 at 12:49 P.M., showed no order for wound care to the palm of right hand. During an observation and interview on 8/26/24 at 6:34 A.M., the resident sat up in his/her wheelchair and propelled up the hall to the nurse's station. When the resident reached the nurse's station, he/she said his/her hand was bleeding. The resident held up his/her right hand that showed a laceration on the right palm between the thumb and index finger. It measured approximately one cm in length and was lightly bleeding. The resident was holding a washcloth in his/her right hand to absorb the bleeding from the laceration. The resident said his/her armrest on the right side of the wheelchair was broken and caused the laceration when he/she was adjusting himself/herself in the wheelchair that morning. The resident showed the area on the right armrest under the padding towards the front of the armrest where the plastic was broken that caused the laceration. The resident said there was no nurse last night and that was why he/she could not get help with the cut on his/her hand. The resident said he/she just needed a Band-Aid so he/she didn't bleed everywhere. The resident was worried about getting blood on his/her clothing. Observation and interview on 8/26/24 at 6:49 A.M., showed the Minimum Data Set Coordinator (MDSC) walked up to the nurse's station and the resident showed her his/her right hand and said it was bleeding and he/she needed help. The MDSC said she would go and find the nurse and left the nurse's station. The MDSC returned to the nurse's station at 7:04 A.M. The resident asked for help again and the MDSC said she did not have keys to the nurse's cart. Around 7:20 A.M. the day shift nurse, Registered Nurse (RN) L walked to the nurse's station and was attempting to make the schedule. The resident continued to ask for assistance with his/her hand to any staff around the nurse's station. The staff at the nurse's station included one CNA, four nursing assistants (NA), one CMT, and one RN. None of the staff assisted the resident when the resident asked. At 7:33 A.M. the resident propelled himself/herself down the hallway to his/her room. He/She said he/she needed to finish getting ready to go to therapy. The resident went to his/her room without receiving any assistance to the laceration to his/her right hand. During an interview on 8/27/24 at 10:21 A.M., CMT V said the resident was at the nurse's station yesterday morning requesting assistance for the cut on his/her right hand. CMT V said the resident came up to the nurse's station again yesterday afternoon and was going off and upset because nobody helped him/her with the cut on his/her hand. CMT V said RN L was sitting at the nurse's station with him/her when the resident came up to the nurse's station. RN L gave CMT V the nurses' keys to the treatment cart and CMT V went to the treatment cart and got wound cleanser and gauze. CMT V said he/she cleaned the cut on the resident's right hand at the nurse's station with wound cleanser and then wrapped the resident's hand with gauze. During an interview on 8/27/24 at 10:31 A.M., the resident said CMT V cleaned his/her hand with wound cleanser and then wrapped it with gauze yesterday afternoon after he/she went to the nurse's station and asked again. The resident's hand did not have a dressing. The resident said he/she removed the gauze wrap from his/her hand this morning because it was getting caught on everything. A nurse did not look at the cut yesterday or today. The resident said he/she and all the other residents did not get enough attention when it was needed; especially without a nurse there. It took all day to get his/her hand taken care of and he/she had to go and request help with it again in the afternoon because he/she could not get help yesterday morning. The resident said he/she showed the broken armrest on his/her wheelchair to therapy, and the therapy person placed black tape around the broken area of the wheelchair. The resident said it was scary that residents could not get care when they need it. The resident then said, What if something worse happened and there wasn't a nurse over here? The resident said it was a very scary thought. The resident said he/she was at the facility to try and get better so he/she could leave and go to an independent living. That was why he/she was working so hard in therapy. During an interview on 8/27/24 at 10:53 A.M., RN W said if a resident reported they had a laceration to the right hand, he/she would first assess the hand and ask how it happened. RN W said if he/she determined the laceration was caused by the resident's wheelchair, RN W would get the resident another wheelchair and give the broken wheelchair to maintenance to repair. RN W would call the physician and get a treatment order and notify the resident representative (RR) if the resident had one. RN W would then enter the treatment order into the Electronic Medical Record (EMR), fill out an incident report in the EMR and make a progress note in the EMR that covered the assessment of the wound and new order. RN W said the resident would be monitored for 72 hours after the incident and a progress note would be entered each shift that would discuss if there were any changes with the resident, how the area looked, if the treatment was in place and vital signs (temperature, blood pressure, oxygen saturation, and pulse). RN W said he/she would not give the nurses' keys for the treatment cart to a CMT and allow a CMT to clean and dress a wound on a resident. During an interview on 8/27/24 at 1:33 P.M., the DON said if a resident reported they had a laceration on their hand, she expected a nurse to assess the laceration and determine how it occurred. If it was determined the laceration was caused by the wheelchair, she expected the nurse to contact therapy and have the wheelchair repaired. The DON expected the nurse to call the physician and get a treatment order and notify the RR. The nurse should document a progress note in the EMR that included the assessment of the laceration, how it happened, any interventions that were put in place, the notifications to the physician and RR, and the new treatment order. Follow up documentation should be completed by a nurse on each shift in a progress note that included assessment of the wound and vital signs for 72 hours. The DON said it was not acceptable for a nurse to give a CMT the treatment cart keys and have a CMT clean and apply a dressing to the wound.

Based on observation, interview, and record review, the facility failed to follow their policies by failing to promptly assess one resident's right hip wound after a Certified Nursing Assistant (CNA) reported the wound to a Licensed Practical Nurse (LPN) the day before it was assessed and a treatment had been started (Resident #36). Another resident said he/she had reported his/her bottom was sore to staff and no one assessed his/her bottom until two days later when a wound was identified (Resident #39). Both residents complained the facility's largest incontinent briefs were too small and caused the wounds. In addition, staff failed to promptly assess and treat one resident with a right palm laceration. After waiting approximately one hour for staff to treat the laceration, the resident returned to his/her room without receiving treatment (Resident #3). The census was 156. Review of the facility Wound Management policy, revised on 6/2020, showed the following: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury (pressure injury, a localized area of skin damage that occurs when there is prolonged pressure on the skin or underlying tissue); -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: Skin Tears, Lacerations, Cuts, and Abrasions: Wounds that usually result from impact (or related incidents) to extremely fragile skin; -Assessment: a Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; upon identification of a new wound the Licensed Nurse will: measure the wound (length, width, depth); initiate a Wound Monitoring Record sheet; a Wound Management Record will be completed for each wound; implement a wound treatment per physician's order; -Wound Management: the attending physician will be notified to advise on appropriate treatment promptly; the Licensed Nurse will notify the responsible party of the presence of a pressure injury; the attending physician and interdisciplinary team (IDT) will be notified of: new pressure injuries or wounds; pressure injuries or wounds that do not respond to treatment; pressure injuries or wounds that worsen or increase in size; complaints of increased pain, discomfort or decrease in mobility by a resident; signs of ulcer sepsis (infections), presence on exudates (drainage), odor or necrosis (necrotic/dead/non-viable tissue), if not already noted by the Attending Physician; residents refusing treatment; -Documentation: new pressure injuries or wounds will be documented on the 24 hour log; wound documentation will occur at a minimum of weekly until the wound is healed; -Documentation will include: location of wound; length, width, and depth measurements recorded in centimeters; direction and length of tunneling and undermining (if applicable); appearance of the wound base; drainage amount and characteristics including color, consistency, and odor; appearance of wound edges; description of the peri-wound (skin around the wound) condition or evaluation of the skin adjacent to the wound; presence or absence of new epithelium at the wound rim; presence of pain; -IDT will document discussion and recommendations for: pressure injury and wounds that do not respond to treatment; pressure injuries and wounds that worsen or increase in size; complaints of increased pain, discomfort or decrease in mobility by a resident; signs of ulcer sepsis, presence on exudates, odor or necrosis; residents refusing treatment; -Licensed Nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Update the resident's care plan as necessary. Review of the facility Documentation Nursing Policy, revised on 6/20, showed: -Purpose: To provide documentation of resident status and care given by nursing staff; -Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate. Nursing staff will not falsify or improperly correct nursing documentation; -Procedure: -I. Nursing documentation: -C. The Licensed Nurse will review the Plan of Care on a weekly basis and document the resident's response and progress towards the goal; -D. Any communications with family, durable power of attorney (DPOA), or physician is to be noted in nurse's notes; -F. Nurse's notes are dated, timed, and signed when written; -H. Medication administration records and treatment administration records are completed with each medication or treatment completed; -I. Glucose measuring is documented as per physician's order; -J. Treatments completed and documented as per physician's order; -K. Documentation will be completed by the end of the assigned shift; -II. Alert Charting: -A. Alert charting is documentation done to track a medical event for a period of 72 hours or longer; -B. Alert charting is completed by professional staff rather than non-professional staff; -C. Events may include but are not necessarily limited to: -(a) New physician orders; -(b) Suspected or actual change in condition; -(c) Initiation of new medical treatment; -(d) Fall with or without injury; and/or; -(e) Resident-to-resident event. -D. Alert charted describes what is going on: -(a) Describe the resident's condition, include what you see, hear, smell, feel, etc.; -(b) Use the resident's own words if needed; -(c) Describe what you have done in response to what is going on with the resident; -(d) Describe how the resident responded to the actions; -III. Activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) Documentation: -A. The CNA will document the care provided on the facility's method of documentation, manually or electronic; -B. The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed; -C. Documentation will be completed by the end of the assigned shift. Review of the facility LPN job description, revised 12/2023, showed: -Position Description: Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Responsible for resident care and direction of nursing care during assigned shift; includes staff assignments, mentoring and educating nursing personnel, working with physicians and other medical professional; -Direct Care Responsibilities: charts progress notes in an informative, factual manner that reflects the care administered as well as the resident's response to care; follows established procedure for charting and reporting all reports on incident/accidents; identifies and reports changes in condition to supervisor, physician, and family; accurately identifies skin changes and follows the company skin management protocols. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/16/24, showed: -Adequate hearing; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; Cognitively intact; -Rejection of Care: Behavior not exhibited; -Other Ulcers, Wounds and Skin Problems: Blank. Review of the resident's care plan, located in the electronic heath record (EHR), showed: -1/14/24: Focus: ADL Self-care performance deficit. Goal: Will maintain current level of function. Interventions: Requires a sit-to-stand lift (a machine that transfers residents capable of bearing weight) with two person support; -1/18/24: Focus: Incontinent of urine. Goal: Will remain free of skin break down due to incontinence. Interventions: Apply barrier creams as needed. Check resident for incontinence. Resident uses XXL disposable briefs, change as needed; -6/21/21: At risk for impaired skin integrity. Goal: Will be without impaired skin integrity. Interventions: Complete weekly skin checks. Review of the resident's weekly skin check, dated 8/16/24, showed: -Does the resident have any skin impairments? Yes. Under bilateral breasts/abdominal folds/groin - redness; -No documentation regarding the resident's right hip. During an interview on 8/19/24 at 8:15 A.M., CNA D said there were a few bariatric residents that needed larger incontinent briefs. They were breaking down between their legs because staff had to squeeze the briefs on the bariatric residents. During an interview on 8/19/24 at 8:23 A.M., the resident said he/she thought he/she had an open area on his/her right hip because the incontinent brief was too tight. During an interview on 8/19/24 at 8:31 A.M., CNA C said the resident had on open area on his/her right hip. He/She noticed it that morning and told LPN O. He/She thought the open area was because the resident's incontinent briefs were too small to fit. Review of the resident's physician's progress notes, physician's order sheets (POS), and treatment administration record (TAR) on 8/19/24 and located in the EHR, showed no documentation or treatment order for an open area on the resident's right hip. Observation on 8/20/24 at 7:00 A.M., showed the resident lay in bed. Unit Manager (UM) M removed the resident's cover and unfastened the resident's incontinent brief, revealing an open area on the resident's right hip that had a small amount of yellow slough (yellow or white layer of dead skin or tissue in a wound that can slow down or prevent healing) with a scant amount of drainage. There was no dressing on the open area. The resident said the open area was there yesterday. He/She thought the Certified Medication Technician (CMT) was aware of it and told the nurse. He/She thought his/her incontinent briefs caused the open area because they were too tight. He/She had been told by staff the facility no longer had his/her size of incontinent briefs. UM M said if the open area was there yesterday and reported to the nurse on duty, that nurse should have assessed the open area, called the physician and obtained a treatment order. It should be documented in the progress notes and added to the POS and TAR. Observations and interviews on 8/20/24 at 7:30 A.M., showed the resident lay in bed. The facility Wound Nurse (WN) measured the open area and said it was 0.8 centimeters (cm) by 1.6 cm by 0.3 cm with 10% yellow slough. The WN also found an open area that measured 0.4 cm by 0.8 cm by 0.2 cm on the resident's left posterior (back) knee, and an open area that measured 3.8 cm by 0.1 cm on the resident's right posterior thigh. She identified all the open area as trauma related, not pressure. If the nurse on duty was told about the open area on the right hip, he/she should have assessed it, called the physician and got a treatment started. The nurse should have filled out the form at the nurse's station so the WN would have known about it today. She did not work yesterday and did not receive a completed form today. Review of the resident's progress note, dated 8/20/24 at 4:45 P.M. and completed by the WN, showed: Reddened area noted to right hip measuring 0.8 cm by 1.6 cm by 0.3 cm. Wound bed with 10% slough noted. Area to right posterior thigh measuring 3.8 cm by 0.1 cm. Area to left posterior knee, red without odor measuring 0.4 cm by 0.8 cm by 0.2 cm. Antifungal cream applied. During an interview on 8/20/24 at 7:40 A.M., LPN O said he/she worked yesterday. He/She did not recall CNA C telling him/her the resident had an open area on the right hip, but he/she was very busy yesterday so it was possible CNA C did tell him/her and he/she forgot. Any new open area should be assessed, the physician should be notified and any new treatment should be documented in the progress notes, POS and TAR. During an interview on 8/20/24 at 9:15 A.M., the Director of Nursing (DON) said she would have expected LPN O to have assessed the resident's right hip when CNA C told him/her about it. The nurse should have notified the resident's physician, and documented any new treatment order in the progress notes, MAR and TAR. LPN O should have let the facility WN know about the new area. During an interview on 8/22/24 at 7:48 A.M., the facility WN said the resident was seen by the wound company on 8/21/24. The open area on the right hip was trauma related caused by the resident's brief. The wound company ordered calcium alginate (dressing which absorbs wound fluid) daily. Review of the resident's POS and TAR, showed an order dated 8/22/24, to cleanse the right hip with wound cleanser, apply a small piece of calcium alginate and cover with a border dressing daily and PRN. 2. Review of Resident #39's annual MDS, dated [DATE], showed: -Adequate hearing; -Makes Self Understood: Usually understood - difficulty communicating some words of finishing thoughts but is able if prompted or given time; -Ability To Understand Others: Understands - clear comprehension; -Cognitively intact; -Rejection of Care: Behavior not exhibited; -Dependent for toileting hygiene, shower/bathing, upper/lower dressing and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses of diabetes mellitus (high blood glucose/sugar) and renal (kidney) insufficiency; -Other Ulcers, Wounds and Skin Problems: Blank. Review of the resident's care plan, located in the EHR, showed: -11/11/21: Focus: Is at risk for altered skin integrity. Goal: Will be without impaired skin integrity. Interventions: Complete skin assessment upon admission/readmission, quarterly, and as needed; -11/11/21: Focus: ADL self-care performance deficit. Goal: Will maintain current level of function. Interventions: Totally dependent on one staff for lower body dressing, personal hygiene and shower and bathing; -11/29/21: Focus: Incontinent of bladder and bowel. Goal: Will remain free of skin break down due to incontinence. Interventions: Apply barrier creams as needed. Check resident for incontinence. Review of the resident's progress notes, POS and TAR on 8/22/24, showed no documentation or treatment order for the right buttock/ischium (the lower and posterior part of the hip bone). Observations and interviews on 8/22/24 at 11:00 A.M., showed the resident lay in bed wearing an incontinent brief. The resident said it was too small and had been cutting into his/her skin. CNA DD told the resident there were not any larger incontinent briefs. The resident had a sore on his/her buttock for a couple of days. He/She told the nurse yesterday and the day before, but no one had come to look at his/her bottom. The WN said she worked the last two days and no one had told her the resident's bottom was sore. Had she known, she would have assessed the resident. The WN assisted the resident to turn onto his/her side and noted an open area at the top of the posterior right thigh and bottom of the buttock where the resident's incontinent brief fit between the legs. The WN said the open area was 0.5 cm by 2.5 cm by 0.1 cm, was non-pressure and located where the incontinent brief wrapped around the leg. 3. During an interview on 8/20/24 at 8:59 A.M., CNA/Central Supply Clerk DD said the facility had small, medium, large, X-large and XX-large incontinent briefs in stock. Prior to the facility being sold to the new company on 8/1/24, he/she was able to order incontinent briefs that were larger than the XX-large briefs. The new company had an Amazon account that would not allow him/her to purchase the larger incontinent briefs. The larger incontinent briefs were still available, but the system wouldn't allow him/her to purchase more. He/She discussed this with the Administrator a couple of weeks ago, but he/she still could not order those incontinent briefs. Resident #36 and Resident #39 used the larger incontinent briefs he/she could no longer order. During an interview on 8/20/24 at 8:59 A.M., CNA EE said there were about 15 residents, including Resident #36 and Resident #39. who needed the briefs they no longer had. They had not had those incontinent briefs since the facility changed ownership. The residents that need the larger incontinent briefs said the largest ones available were uncomfortable and cut into their skin. During an interview on 8/22/24 at 1:32 P.M., the DON said she started at the facility on 8/12/24. No on had informed her the the largest incontinent briefs the facility had were too small for some of the residents. She was unaware the residents had been complaining the incontinent briefs were too small and cutting into their skin. She would make sure the previous incontinent briefs the resident felt were comfortable were ordered. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Upper and lower extremity impairment on one side; -Toileting: Substantial/maximal assistance; -Transfer: Partial/moderate assistance; -Dressing upper body: Set up or clean up; -Dressing lower body: Partial/moderate assistance; -Diagnosis included diverticulitis (inflammation of the intestine) of large intestine without perforation (a hole in the intestine causing contents to leak into the abdomen) or abscess without bleeding, hemiplegia (severe or complete loss of strength) and hemiparesis (mild or partial weakness on one side of the body) following cerebral infarction (stroke) affecting unspecified side, high blood pressure and weakness. Review of the resident's care plan, in use during the survey, showed: -Focus: ADL self-care performance related to hyperlipidemia (high cholesterol), weakness, iron deficiency, anemia (body does not have enough red blood cells), history of hemiplegia and hemiparesis following cerebral infarction; -Goal: The resident will exhibit improved function at discharge; -Interventions: -Assistance required with ADLs may fluctuate based on time of day, mood, pain, or fatigue. Adjust and document as indicated. Report significant changes to charge nurse; -Chair to bed transfer: Totally dependent of two, two or more helpers do all the effort. Resident does none of the effort; -Identify tasks events that cause frustration. Provide assistance as needed; -Observe and anticipate resident's needs: thirst, food, body positioning, pain toileting needs; -Place call light within reach. Remind resident to call for assistance if cognitively intact; -Focus: Resident has impaired skin integrity, or at risk for altered skin integrity; -Goal: Resident will maintain current skin status through next review date; -Interventions: -Complete skin at risk assessment upon admission, readmission, quarterly, and as needed; -Complete weekly skin checks. Review of the resident's progress notes, dated 8/26/24 through 8/27/24, showed, no progress note related to a laceration on the palm of the right hand. Review of the resident's electronic physician order summary (ePOS), dated 8/27/24 at 12:49 P.M., showed no order for wound care to the palm of right hand. During an observation and interview on 8/26/24 at 6:34 A.M., the resident sat up in his/her wheelchair and propelled up the hall to the nurse's station. When the resident reached the nurse's station, he/she said his/her hand was bleeding. The resident held up his/her right hand that showed a laceration on the right palm between the thumb and index finger. It measured approximately one cm in length and was lightly bleeding. The resident was holding a washcloth in his/her right hand to absorb the bleeding from the laceration. The resident said his/her armrest on the right side of the wheelchair was broken and caused the laceration when he/she was adjusting himself/herself in the wheelchair that morning. The resident showed the area on the right armrest under the padding towards the front of the armrest where the plastic was broken that caused the laceration. The resident said there was no nurse last night and that was why he/she could not get help with the cut on his/her hand. The resident said he/she just needed a Band-Aid so he/she didn't bleed everywhere. The resident was worried about getting blood on his/her clothing. Observation and interview on 8/26/24 at 6:49 A.M., showed the Minimum Data Set Coordinator (MDSC) walked up to the nurse's station and the resident showed her his/her right hand and said it was bleeding and he/she needed help. The MDSC said she would go and find the nurse and left the nurse's station. The MDSC returned to the nurse's station at 7:04 A.M. The resident asked for help again and the MDSC said she did not have keys to the nurse's cart. Around 7:20 A.M. the day shift nurse, Registered Nurse (RN) L walked to the nurse's station and was attempting to make the schedule. The resident continued to ask for assistance with his/her hand to any staff around the nurse's station. The staff at the nurse's station included one CNA, four nursing assistants (NA), one CMT, and one RN. None of the staff assisted the resident when the resident asked. At 7:33 A.M. the resident propelled himself/herself down the hallway to his/her room. He/She said he/she needed to finish getting ready to go to therapy. The resident went to his/her room without receiving any assistance to the laceration to his/her right hand. During an interview on 8/27/24 at 10:21 A.M., CMT V said the resident was at the nurse's station yesterday morning requesting assistance for the cut on his/her right hand. CMT V said the resident came up to the nurse's station again yesterday afternoon and was going off and upset because nobody helped him/her with the cut on his/her hand. CMT V said RN L was sitting at the nurse's station with him/her when the resident came up to the nurse's station. RN L gave CMT V the nurses' keys to the treatment cart and CMT V went to the treatment cart and got wound cleanser and gauze. CMT V said he/she cleaned the cut on the resident's right hand at the nurse's station with wound cleanser and then wrapped the resident's hand with gauze. During an interview on 8/27/24 at 10:31 A.M., the resident said CMT V cleaned his/her hand with wound cleanser and then wrapped it with gauze yesterday afternoon after he/she went to the nurse's station and asked again. The resident's hand did not have a dressing. The resident said he/she removed the gauze wrap from his/her hand this morning because it was getting caught on everything. A nurse did not look at the cut yesterday or today. The resident said he/she and all the other residents did not get enough attention when it was needed; especially without a nurse there. It took all day to get his/her hand taken care of and he/she had to go and request help with it again in the afternoon because he/she could not get help yesterday morning. The resident said he/she showed the broken armrest on his/her wheelchair to therapy, and the therapy person placed black tape around the broken area of the wheelchair. The resident said it was scary that residents could not get care when they need it. The resident then said, What if something worse happened and there wasn't a nurse over here? The resident said it was a very scary thought. The resident said he/she was at the facility to try and get better so he/she could leave and go to an independent living. That was why he/she was working so hard in therapy. During an interview on 8/27/24 at 10:53 A.M., RN W said if a resident reported they had a laceration to the right hand, he/she would first assess the hand and ask how it happened. RN W said if he/she determined the laceration was caused by the resident's wheelchair, RN W would get the resident another wheelchair and give the broken wheelchair to maintenance to repair. RN W would call the physician and get a treatment order and notify the resident representative (RR) if the resident had one. RN W would then enter the treatment order into the Electronic Medical Record (EMR), fill out an incident report in the EMR and make a progress note in the EMR that covered the assessment of the wound and new order. RN W said the resident would be monitored for 72 hours after the incident and a progress note would be entered each shift that would discuss if there were any changes with the resident, how the area looked, if the treatment was in place and vital signs (temperature, blood pressure, oxygen saturation, and pulse). RN W said he/she would not give the nurses' keys for the treatment cart to a CMT and allow a CMT to clean and dress a wound on a resident. During an interview on 8/27/24 at 1:33 P.M., the DON said if a resident reported they had a laceration on their hand, she expected a nurse to assess the laceration and determine how it occurred. If it was determined the laceration was caused by the wheelchair, she expected the nurse to contact therapy and have the wheelchair repaired. The DON expected the nurse to call the physician and get a treatment order and notify the RR. The nurse should document a progress note in the EMR that included the assessment of the laceration, how it happened, any interventions that were put in place, the notifications to the physician and RR, and the new treatment order. Follow up documentation should be completed by a nurse on each shift in a progress note that included assessment of the wound and vital signs for 72 hours. The DON said it was not acceptable for a nurse to give a CMT the treatment cart keys and have a CMT clean and apply a dressing to the wound.

Based on interview and record review, the facility failed to provide appropriate nursing assessments per facility policy for residents with a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), diagnosed with respiratory infection and vomiting. The facility identified seven residents with tracheostomy, three were sampled and failures were found with two (Resident #6 and #44). The census was 156. Review of the facility's Tracheostomy (Trach) Care policy, dated 6/2020, showed: -Tracheostomy care will be performed as ordered by the Attending Physician. -Licensed Nurses or a Respiratory Therapist (RT) may perform tracheostomy care. -Report any unusual observations to the Attending Physician immediately. -Document the care provided, the resident's response, any unusual observations, and physician notification as indicated in the medical record. Monitor vital signs and report abnormal findings to the medical provider. Review of the facility's Change of Condition policy, undated, showed the following: -Policy: An acute change of condition is a sudden, clinically important deviation from the a patient's baseline in physical, cognitive, behavioral or functioning domains. Clinically important means a deviation that, without intervention, may result in complications or death; -Procedure: The licensed nurse will notify the resident's Attending Physician when there is: C. A significant change in the resident's physical, mental psychosocial status, deterioration health, mental or psychosocial status, life threatening conditions or clinical complications; -Documentation: A licensed nurse will document the following: A. Date, time, and pertinent details of the incident and the subsequent assessment in the nurses notes. Review of the facility Documentation Nursing Policy, revised on 6/2020, showed: -Purpose: To provide documentation of resident status and care given by nursing staff; -Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate. Nursing documentation will not contain error-prone abbreviations. See Error -Prone Abbreviations. Abbreviations identified in industry accepted standards such as Steadman's Medical Dictionary or Taber's Cyclopedic Medical Dictionary that are not specifically excluded by the list in Error Prone Abbreviations are acceptable abbreviations. Nursing staff will not falsify or improperly correct nursing documentation; -Procedure: -I. Nursing documentation: -C. The Licensed Nurse will review the Plan of Care on a weekly basis and document the resident's response and progress towards the goal; -D. Any communications with family, durable power of attorney (DPOA), or physician is to be noted in nurse's notes; -F. Nurse's notes are dated, timed, and signed when written; -H. Medication administration records and treatment administration records are completed with each medication or treatment completed; -I. Glucose measuring is documented as per physician's order; -J. Treatments completed and documented as per physician's order; -K. Documentation will be completed by the end of the assigned shift; -II. Alert Charting: -A. Alert charting is documentation done to track a medical event for a period of 72 hours or longer; -B. Alert charting is completed by professional staff rather than non-professional staff; -C. Events may include but are not necessarily limited to: -(a) New physician orders; -(b) Suspected or actual change in condition; -(c) Initiation of new medical treatment; -(d) Fall with or without injury; and/or; -(e) Resident-to-resident event. -D. Alert charted describes what is going on: -(a) Describe the resident's condition, include what you see, hear, smell, feel, etc.; -(b) Use the resident's own words if needed; -(c) Describe what you have done in response to what is going on with the resident; -(d) Describe how the resident responded to the actions; -III. Activities of daily living (ADLs, activities related to personal care bathing, toileting, dressing, etc.) Documentation: -A. The Certified Nurse Aide (CNA) will document the care provided on the facility's method of documentation, manually or electronic; -B. The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed; -C. Documentation will be completed by the end of the assigned shift. 1. Review of Resident #6's physician orders, showed the following: -Order dated 6/1/24, for trach care every shift and as needed (PRN); -Titrate (adjust or lower amount) oxygen to room air, oxygen at 3 Liters PRN every shift; -No order for Respiratory Therapy Care. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/24, showed the following: -Diagnoses of respiratory failure, seizures, diabetes and seizures; -Totally dependent on staff for all Activities of Daily Living (ADLs); -No antibiotic use; -Oxygen use; -Trach care. Review of the resident's care plan, dated 7/13/24, showed the following: -Problem: Trach Care; -Goal: Will be free of signs/symptoms (s/sx) of complications from trach use. Will have clear and equal breath sounds bilaterally; -Interventions: Administer medications as ordered. Evaluate changes in mental status, agitation, restlessness and confusion. Report abnormal findings to medical provider. Evaluate lung sounds, and respiratory status. Observe for s/sx of pulmonary infection: fever, tachycardia (rapid heartbeat), discolored sputum, foul order, increased secretions, thick secretions, abnormal lung sounds. Report abnormal findings to medical provider, resident/resident representative. Monitor vitals. Review of the progress notes, showed the following: -7/15/24 at 11:38 A.M. completed by the RT: Oxygen Saturation (O2 Sat) 97% (normal 95% to 100%), via 6 liters per minute (LPM) oxygen trach collar mask, heart rate (HR) 80 (normal HR, 60 to 100), respiratory rate (RR) 18 (normal rate, 12 to 18), Breath Sounds (BS) coarse (normal: smooth, soft sound), Suction moderate amount of cream thick mucus (normal secretions, white or clear); -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/16/24; -No documentation staff notified the physician of cream thick secretions; -7/16/24 at 11:01 A.M., completed by the RT: O2 Sat 97%, via 6 LPM per oxygen trach collar mask, HR 88, RR 16, BS coarse. Suction moderate amount of cream thick secretions; -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/17/24; -No documentation staff notified the physician of cream thick secretions -7/17/24 at 11:17 A.M., completed by the RT: O2 Sat 97%, via 5 LPM per oxygen trach collar mask, HR 75, RR 16, BS coarse. Suction moderate amount of thick cream mucus; -No other nurses notes or respiratory assessment notes until 7/22/24; -No documentation whether staff notified the physician of the thick cream colored secretions; -7/22/22 at 11:32 A.M., completed by the RT: O2 Sat 99%, HR 78, RR 18, BS decreased. Suction moderate amount of cream thick mucus; -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/23/24; -No documentation whether staff notified the physician of cream thick secretions; -7/23/24 at 11:21 A.M., completed by RT: O2 Sat 98% via room air, trach capped, HR 78, RR 16, BS decreased. Oral suction clear; -7/24/24 at 11:21 A.M., completed by RT: O2 Sat 98% via room air, trach capped, HR 76, RR 16, BS coarse. Suction moderate amount of thick pale mucus;. -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/29/24; -No documentation whether staff notified the physician of thick pale secretions; -7/29/24 at 11:34 A.M., completed by RT: O2 Sat 98% via room air (RA), trach capped with Heat Moisture Exchanger (HME, special trach cap to help provide moisture to trach) HR 86, RR 18, BS decreased. Suction small amount of thick pale mucus;. -No other nurses notes regarding respiratory status or respiratory assessment notes until 7/30/24; -No documentation whether staff notified the physician of thick pale mucus; -7/30/24 at 11:02 A.M., completed by RT: O2 Sat 99% via room air (RA), trach capped with HME on, HR 80, RR 18, BS coarse. Suction scant amount of thin tan secretions;. -No other nurses notes regarding respiratory status or respiratory assessment notes; -No documentation whether RT notified the nurse of the thin tan secretions; -No documentation whether the physician was notified of the thin tan secretions; -No further documentation regarding the resident's respiratory status until 8/8/24; -8/8/24 at 8:22 P.M., completed by the nurse: [NAME] mucus with a foul smell coming from tracheostomy; -MD notified and ordered Bactrim DS (a combination of two antibiotics) for 7 days; -No further notes of the resident's respiratory status were entered until 8/14/24 at 11:29 P.M. Review of the Medication Administration Record (MAR), showed the following orders: -Bactrim DS, documented as administered from 8/9 through 8/15/24; -Vital signs every shift while on antibiotics every shift for antibiotic monitoring for 7 days (start date 8/9/24). Vital signs not recorded on the second shift for 8/9, 8/10, 8/11, 8/14 and 8/15/24; -Trach Care every shift and as needed: Day shift: Documented as completed: 8/7, 8/8, 8/10 through 8/16/24. Nightshift: 8/6 through 8/16/24. Day shift: Blank 8/1 through 8/6, 8/9/24, Night shift: Blank 8/1 through 8/5/24. Review of the progress notes, showed the following: -8/14/24 at 11:29 A.M., completed by the RT: O2 Sats 98% on room air, HME on, HR 74, RR 18, BS decreased, suctioned small amount of thick tan mucus; -No other nurses notes regarding respiratory status or respiratory assessment notes from 8/14/24 at 11:29 A.M. until 8/16/24; -8/16/24 at 10:22 P.M., (First note of the day) showed staff noted the family said the resident has not responded properly/normally since 8/12 when they visited and demanded hospitalization. Resident's physician notified. New order received to send to the hospital. Review of hospital admission notes, showed the following: -8/16/24 at 9:13 P.M.: the resident presented with altered mental status, green sputum coming from the trach, tachycardia and tachypenia (rapid breathing); -Blood pressure: 106/75, Heart Rate:108, Respirations: 15, Pulse:107, Temperature: 100.6 degrees Fahrenheit (F); -Review of the resident's blood work results showed a white blood count of 10.7, (normal 4.5 to 11.0) blood urea nitrogen (BUN, measures how much urea nitrogen is in the blood) of 80 (normal 7 to 20), Glucose 256 (normal blood sugar (70 to 100); -Workup in the emergency department concerning for sepsis (life threatening complication of an infection), particularly urinary tract infection (UTI); -Started on broad-spectrum antibiotics; -Labs also concerning for dehydration, hypernatremia (high concentration of sodium in the blood); -Diagnosis: Sepsis, UTI, tracheitis (inflammation of the trachea) hypernatremia, dehydration, acute kidney injury; -Computed Tomography (CT) scan of chest and abdomen showed suspected right lower lobe pneumonia; -Plan to admit for additional workup and monitoring. Review of the resident's hospital discharge notes, dated 8/20/24, showed the following: -Discharge diagnoses of Acute Metabolic Encephalopathy (caused by a deficiency of vitamins, oxygen or glucose), pneumonia and sepsis; -Discharge medications: amoxicillin-clavulante (antibiotic) 250-62.5 mg/5 milliliter (ml) 10 ml per gastrostomy (g-tube, flexible tube surgically inserted through the abdomen into the stomach. Used to administer nourishment and medications) every 8 hours for 5 days and doxycycline hyclate (antibiotic) 100 mg every 12 hours for 5 days. Review of the resident's Physician Order Sheet (POS), showed the following: -Doxycycline Hyclate 100 mg via g-tube every 12 hours for pneumonia for 5 days; -Amoxicillin 10 ml via g-tube every 8 hours for pneumonia for 5 days. Review of the MAR, showed the following orders: -Doxycycline Hyclate 100 mg via g-tube every 12 hours for pneumonia for 5 days. Administration not documented for the second dose on 8/25/24 and the last dose 8/26/24. -Amoxicillin 10 ml via g-tube every 8 hours for pneumonia for 5 days. Administration documented three times on 8/22/24, two times on 8/23/24, three times on 8/24/24, two times on 8/25/24 and one time on 8/26/24; -Vital signs every shift for antibiotic use monitoring every shift for 5 days. Vitals were not documented on the day shifts of 8/23/24, 8/24/24 and not documented on either shift of 8/25/24. During an interview on 8/20/24 at 1:37 P.M., CNA E said he/she has taken care of the resident and assisted other CNAs with the resident. The resident required total care. Several days prior to the resident going to the hospital, the resident was very sleepy and had smelly brown mucus coming from his/her trach. This had been going on awhile. CNA E knew the resident was on an antibiotic but the drainage wasn't getting any better. He/She thought the resident's sleepiness was due to him/her being on antibiotics. CNA E would report the trach drainage to the charge nurse. The nurses knew about the drainage and would go in to suction. During early morning rounds, the resident's trach would be full of brown secretions. When Registered Nurse (RN) B was off, the other nurses would not check on the resident. During an interview on 8/27/24 at 10:15 A.M., CNA W said he/she frequently takes care of the resident on the day shift. The resident normally is awake, looking around while up in his/her wheelchair at the nurses station. Prior to the resident going to the hospital, he/she had a lot of thick white, brown and green drainage from his/her trach. CNA W reported the drainage to the charge nurse so he/she could be suctioned. The resident was tired and very sleepy, which was unusual for him/her. CNA W said the CNAs would report their concerns to nursing staff but some nurses, RN L would ignore these concerns so he/she would stop saying anything. During an interview on 8/27/24 at 10:08 A.M., Certified Medication Technician (CMT) V said he/she did the resident's blood glucose fingersticks three times per day. Prior to him/her going to the hospital, the resident was coughing up a lot of slimy mucus. CMT V doesn't recall an odor. The nurse, RN B would hear him/her coughing and go in to suction. CMT V didn't report the drainage because the nurse would hear the resident coughing and go into the room. During an interview on 8/21/24 at 10:34 AM, RN B said he/she could hear from the nursing station if the resident was gurgling and needed suctioning. RT did not report any changes or concerns. On 8/8/24, the physician was notified of foul smelling brown mucus coming from the resident's trach. Orders were obtained for an antibiotic. RN B said staff nurses should assess the resident every shift and document the findings in the progress notes. He/She should have documented his/her assessment in the nurse's notes. During a second interview on 8/27/24 at 10:55 A.M., RN B said trach care included suctioning as needed, breath sounds, O2 Sats, vital signs and changing the trach collar ties. Staff nurses are to document what the secretion color was, consistency and whether their was any odor. RN B said the nurses needed an inservice on what to do because not enough is being documented regarding trach residents' conditions. The change in the resident's secretions should have been reported to the physician and documented in the nurses notes. The RT must report any findings to the charge nurse so that he/she can notify the physician. No one reported any changes in the resident's condition on 8/16/24. The family came in later that evening and requested for the resident to be sent to the hospital. During an interview on 8/20/24 at 10:58 A.M., the RT said he/she must report to the nurse any changes in the resident's condition. This would include breath sounds, color of secretions, decreased O2 saturations and increase in heart rate. He/She reported changes to the charge nurse but was unable to say which charge nurse he/she spoke to. He/She failed to document it because he/she had no access to the electronic record. The RT said he/she documented the changes on paper notes but was unable to produce the documentation. He/She would assess the resident once a shift, usually on Monday, Wednesday and Friday. The charge nurse is responsible to assess the resident during the rest of the shift and on the days he/she is not at the facility. He/She doesn't recall any changes in the resident's condition but he/she was off several days between 7/30/24 and 8/16/24. He/She noted the different consistency of the trach secretions but failed to document that he/she notified the charge nurse. During an interview on 8/27/24 at 1:33 P.M., the Director of Nurses (DON) said trach care consists of lung sounds, appearance of trach secretions, odor if any, changing of trach ties, and should be completed every shift and documented in the nurses notes. If the nurse observes odor, changes in color of secretions and change in mental status, he/she should notify the physician. When receiving antibiotics, the nurse should document the resident's response to the medication. If the resident does not improve or the condition changes, he/she should document and notify the physician. Staff should have administered the antibiotics as ordered. During an interview on 8/20/24 at 12:07 P.M., the resident's physician and Medical Director said he expected staff to follow the facility's policy and assess the resident's condition and document while he/she was receiving antibiotic therapy. The nurses should notify him of any changes in the resident's condition. 2. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for all ADLs; -Received 51% or more of nutrition by tube feeding (used to give medicines and liquids, including liquid nutrition, through a small tube placed through abdomen into the stomach) -Trach care; -Oxygen therapy; -Diagnosis included respiratory failure, tracheostomy, gastrostomy (g-tube, surgical procedure used to insert a tube through the abdomen and into the stomach used for medication, liquids and liquid nutrition), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left and right hand, shortness of breath (SOB), venous thrombosis (blood clots in the veins) and embolism (obstruction or blockage in a blood vessel), sudden cardiac arrest (the heart stops beating suddenly), high blood pressure, muscle weakness, and obstructive sleep apnea (sleep related breathing disorder. The throat muscles relax and block the airway). Review of the resident's care plan, in use during the survey, showed: -Focus: Resident is receiving tracheostomy care; -Goal: -Trach site will remain patent (open and unobstructed) through review date; -Resident will be free of s/sx of complications from tracheostomy, through review date; -Resident will have clear and equal breath sounds bilaterally, through review date; -Interventions: - Administer medications per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident/resident representative (RR); -Administer treatments per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident/RR; -Evaluate lung sounds, and respiratory status. Observe for s/sx of pulmonary infection: fever, tachycardia, discolored sputum, foul order, increased secretions, thick secretions, abnormal lung sounds. Report abnormal findings to medical provider, resident/RR; -Focus: Resident requires, tube feeding; -Goal: Resident will remain free of complications through review date; -Interventions: -Administer medications via tube, per orders; -Administer flushes per medical provider's order; -Check for placement and residuals per policy; -Head of bed elevated 30 degrees or higher; -Monitor intake of enteral tube feeding; -Focus: Resident is at risk of nutritional decline related to: obesity, wound, high blood pressure, hypothyroid (thyroid doesn't create and release enough thyroid hormone into your bloodstream), fluid retention (swelling, edema). Current nothing by mouth (NPO) diet, receives tube feeding of Jevity 1.5 (liquid balanced nutrition) at 65 milliliters (ml) per (/) hour (hr) for 20 hours. Weight loss is desired; -Goal: Receive/tolerate diet as ordered; -Interventions: Observe for s/sx of aspiration (when something enters your lungs by accident), dysphagia (difficulty swallowing) i.e. choking, coughing, pocketing food, loss of liquids, solids from mouth when eating, drinking, difficulty, pain when swallowing. Review of the resident's progress notes, showed: -8/22/24 at 12:54 P.M., Nurses note: resident has vomiting. Primary care physician (PCP) notified, received new order for Zofran (used to prevent nausea and vomiting) three times daily. -8/22/24 at 1:38 P.M., eMAR note: resident had metoclopramide (used to treat nausea and vomiting) scheduled; -8/22/24 at 1:41 P.M., eMAR note: guaifenesin-DM (used to relieve cough and loosen mucus) liquid 100-10 mg/5 ml, give 5 ml via g-tube every six hours as needed for congestion: given for cough; -8/22/24 at 5:38 P.M., eMAR note: clonidine HCL (used to treat high blood pressure) 0.2 mg, give one tablet via g-tube three times a day for high blood pressure, hold for systolic blood pressure (First number of blood pressure, measures the force of the blood flow when blood is pumped out of the heart) of less than 100 or heart rate less than 50: was not given due to low blood pressure and vomiting; -8/23/24 at 7:50 A.M., electronic medication record note: COVID testing as needed: Result negative; During an interview on 8/27/24 at 10:53 A.M., RN B said if he/she has patient with a trach and tube feeding who was vomiting, he/she would make sure the head of the bed was elevated, he/she would stop the tube feeding, wait until the resident stopped vomiting and would take vital signs and do an assessment. The assessment of the resident would consist of how much vomited, what it looked like, how many times the resident vomited, listen to lung sounds, and what the vital signs are. RN B said he/she would then call the doctor and explain the resident assessment to the PCP. RN B said the PCP might want to order a chest x-ray and go from there to ensure the resident did not aspirate while vomiting. RN B said he/she would follow the orders the PCP gave. RN B would the notify the RR of the change in condition and any new orders. The full assessment and notifications to the PCP and RR would be documented in the progress notes. RN B said the facility used to have a change of condition assessment, but it is not available anymore so he/she would document the change of condition and full assessment in a progress note. RN B would automatically ask for an x-ray to make sure the resident did not aspirate. RN B said the resident would need to be assessed each shift for five days. The assessment each shift would be documented in the progress note with vital signs and lung assessments. RN B would pass information about the resident and change of condition to the next nurse during shift-to-shift report. During an interview on 8/26/24 at 2:33 P.M., the DON said if a resident with a trach and tube feeding was vomiting, she expected the nurse to complete an assessment for change of condition. The change of condition assessment includes taking all vital signs, that also includes listening to lung sounds. When the nurse calls the PCP, the nurse should inform the PCP of the change in condition, vital signs, assessment of lungs and describing the vomiting such as color, how much, and how many times the resident vomited and see what orders the PCP gives. The nurse should request an x-ray to ensure the resident did not aspirate. If the PCP gave an order for Zofran for nausea and vomiting and the nurse noticed that the resident was already on a medication for nausea and vomiting, the nurse should call the PCP back and get clarification on the order. She expected the nurse to complete the change of condition assessment, document the orders received in the orders and a progress note, notify the RR and document all notifications and what was said in a progress note. The DON also expected the nurses to complete follow up documentation on that resident each shift for 72 hours in the progress notes, that would include vital signs, lung sounds, and if it was noted the resident was not at baseline, the nurse should be notifying PCP and RR of any changes.

Based on observation, interview, and record review, the facility failed to ensure one resident was free from abuse when Certified Nursing Assistant (CNA) Y and CNA X confronted and yelled at resident #85 regarding money they thought the resident stole and when CNA X struck the resident at least twice, with one time being in the face. In addition, prior to CNA X striking the resident, the facility's Staffing Coordinator (SC) entered the resident's room with the resident, CNA X, CNA Y and CNA Z. The SC reported the resident appeared terrified, but left the resident in the room with the CNAs without supervision and/or without removing the resident from the room and away from the CNAs. The sample size was six. The census was 137. The administrator was notified on 3/23/23 at 12:08 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 3/19/23. On 3/19/23, the facility's Executive Director/Administrator became aware of the violation. The facility inserviced staff on the abuse policy and procedures. The IJ was corrected on 3/19/23. Review of the facility's Missouri Abuse, Neglect & Misappropriation policy, approved on 1/30/23, included the following: -Scope: This policy is applicable to all adult living centers; -Definitions: -Abuse: Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; -Covered individual is anyone who is an owner, operator, employee, manager, agent or contractor of the facility; -Crime: Examples of situations that would likely be considered crimes in all subdivisions would include: Assault and battery; -Law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including police; -Verbal Abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents; -Physical Abuse: includes hitting, slapping, pinch, kick or flicking with fingers or striking in any manner that is demeaning; -Mental Abuse: includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation; -Willful: as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury; -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents and provide guidance to direct staff to manage any concerns or allegations of abuse. Employees will receive abuse prevention training as required as part of their orientation, as needed/indicated and annually thereafter. In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. The facility will be alert for conspicuous activity that may indicate abuse activities by visitors, contractors, volunteers, or others that may be in the facility and have direct contact with residents regardless of resident voicing such incidents. Such activities may include but is not limited to fearfulness of resident or bruises; -Procedure: -Prevention: The physical environment has been designed to prevent seclusion of residents in areas of the facility which are not easily viewed or within hearing of the supervisory staff. Each resident room is accessed by the resident call system (call light) which allows the resident to call easily if he/she feels uncomfortable with any situation; -An employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the areas of resident care, interviewed by facility leadership for a written statement and not left alone; -If multiple employees are involved, the employees will be separated until individual statements are completed. The employees will not be permitted to be alone in the facility at any time until the investigation is completed; -After completing the statements, the employee(s) will be asked to vacate the facility until further investigation of the incident is completed; -Identification of incidents and allegations: -The accurate and timely identification of any event which would place residents at risk is a primary concern of the facility; -Protection from Abuse: -In the event a staff member has been accused, they will be interviewed by the Executive Director or designee and be immediately escorted from the facility. Review of the facility report to the Department of Health and Senior Services from the facility Administrator, dated 3/19/23 at 10:44 A.M., showed: -The manager on duty walked into the resident's room (Resident #85) and witnessed two or three staff members in the room punching the resident in the face. The police were called. The resident does have some swelling around the eye. Review of the police report, dated 3/19/23 at 8:37 A.M., showed: -Victim Information: Resident #85; -Subject Information: CNA X. Physical State Emotions (CNA X): Angry, crying; -On 3/19/23 at approximately 8:39 A.M., police officer was dispatched to the facility. Upon arrival the Admission Director (AD) stated he witnessed an employee assault a resident who was later identified as Resident #85. The AD advised he was called into the resident's room and as he walked into the room he saw CNA X punch the resident on the right side of the face. The AD separated CNA X from Resident #85; -The police contacted Resident #85. The resident stated he/she returned to the facility at approximately 11:30 P.M. on 3/18/23 and went to his/her room. He/She went to sleep and was awakened by CNA X and an additional staff member (CNA Y). CNA X and CNA Y asked him/her about some missing items and then ransacked his/her room searching for the items they were accusing him/her of taking. The resident said he/she then was punched in the right eye by CNA X while the SC and AD were inside of the room. The resident's right eye was red in color and watery; -He contacted CNA Y. CNA Y said he/she believed the resident heard him/her speaking to CNA X about the car being unlocked. CNA X advised that the resident had disappeared from the facility at the time he/she noticed the money was missing; -CNA X informed the police officer that he/she and CNA Y had entered the resident's room and awakened the resident and ransacked the resident's room. CNA X advised he/she could not locate the resident's bag and he/she punched the resident in the right eye at approximately 7:00 A.M. This concluded the conversation; -CNA X provided the following nonverbatim statements: He/she and CNA Y had arrived at the facility at approximately 7:00 A.M. on 3/19/23. CNA X stated the he/she and CNA X proceeded to the resident's room. CNA X advised he/she tapped the resident's leg and ripped the cover off the resident to awaken the resident. CNA X stated that then he/she pulled on the resident's shirt to locate his/her bag as he/she asked the resident about his/her missing money. CNA X advised that he/she knew the resident had taken the money, because he/she begged for cigarettes prior to his/her disappearance from the facility on 3/18/23. CNA X advised he/she had a total of $2800 inside a bank envelope at the time he/she arrived to the facility on [DATE] with CNA Y. CNA X advised $1000 in $100 dollar denominations was missing from the envelope. CNA X advised that the missing money was his/her money and CNA Y was not missing money. CNA X said that while inside the resident's room he/she blacked out and the AD escorted him/her from the resident's room. CNA X advised that he/she did not assault the resident and only remembered blacking out. CNA X refused to make a written statement. Review of Resident #85's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/8/23, showed: -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Brief Interview for Mental Status (a cognitive assessment) score of 15, indicating the resident is cognitively intact; -Physical, verbal or other behaviors: Behaviors not exhibited; -Setup help only required for bed mobility and transfers; -Walk in room/corridor: Activity did not occur; -Locomotion on/off the unit: Independent; -Mobility Devices: Wheelchair; -Diagnosis of paraplegia (complete paralysis of the lower half of the body). Review of the resident's progress notes, located in the electronic health records showed: -3/19/23 at 9:40 A.M.: Two CNAs entered the resident's room to ask if he knew anything about one of the CNAs missing personal belongings. This was reported and the receptionist immediately called 911 and the AD entered the resident room. Words were exchanged and one CNA made contact with the resident's face. The AD immediately intervened and separated resident and staff. The AD stayed with resident to ensure safety until police arrived. Pain and skin assessment completed with scratch noted to resident's right eye. Resident refused to be sent to emergency department; -3/19/23 at 10:46 A.M.: Social Service met with resident today related to physical altercation with staff. Resident states he/she was in his/her room around 9:00 A.M. when two staff members approached his/her room asking about items they alleged he/she stole from them. He/she states he/she had no idea what they were referring to. Resident states they began to search his/her room, going through his/her drawers and accusing him/her and flipping him/her out of his/her bed. The two staff returned back shortly later with another staff member accusing both him/her and the other staff member of stealing from them. Resident states staff member (CNA X) charged at him/her and punched him/her in the face. AD in room immediately separated staff from resident; -3/19/23 at 10:58 A.M.: Resident right eye noted to be red in color; -3/19/23 at 3:00 P.M.: Social Service follow-up with resident to check on well-being. Resident states he/she is ok, just shocked by the incident from earlier this morning. He/she was given time to vent and express concerns. Resident notified psychiatry will follow-up with him/her and he/she was encouraged to have a behavioral health consult. Resident states he/she is alright and doesn't need that. At this time he/she has no complaints. Resident expressed he/she will go LOA (leave of absence) for a week. Review of the resident's written statement, dated 3/19/23, showed around 7:00 A.M., CNA X and CNA Y claimed I stole some money and other items from their vehicle. They came in very aggressive. In my face, searching my room, flipped me out of the bed, claiming I took a bag and saying where is the bag. My whole room was searched then they left. The two CNAs then came back with a third person (CNA Z) who CNA X and CNA Y thought did it and confronted CNA Z in front of me. CNA X reached out and punched me in the right eye. During an interview on 3/22/23 at 11:20 A.M., the resident said on 3/19/23 around 7:00 A.M., he/she was in bed sleeping. CNA X and CNA Y woke him/her up by yelling in his/her face, pulling on his/her shirt, threatening him/her, saying they were going to beat his/her ass and get the money back in blood. They were asking where the money was that was in CNA X's car. He/She did not know what they were talking about and denied taking any money. They began flipping him/her around in his/her bed, lifting up his/her mattress looking for the money. In the process, he/she fell out of bed. He/She was not injured, but they startled him/her and scared him/her a little bit. They didn't stop to ask if he/she was okay or if he/she needed help. They just kept searching his/her room, tossing everything on the floor. He/She was not hurt and was able to get himself/herself into his/her wheelchair. They both left his/her room and he/she got himself/herself off the floor and into his/her wheelchair. He/She did not tell anyone about what had happened. A short time later, he/she was in his/her room gathering his/her belongings off the floor when CNA X and CNA Y returned with CNA Z. He/She did not know why CNA Z was there. CNA X and CNA Y began screaming and threatening him/her, saying they were going to take it back in blood and beat his/her ass. CNA Z was defending himself/herself from CNA X and CNA Y, because they were accusing him/her of taking the money too. CNA Z made no attempt to defend him/her or tell CNA X and CNA Y to leave the room. CNA Z did not threaten him/her or say much. CNA Z did not do anything to diffuse the situation and allowed the situation to escalate. It was about this time that the Staffing Coordinator (SC) entered the room. Both CNA X and CNA Y were still yelling at him/her. He/She had a phone in his/her hands and CNA X and CNA Y told the SC he/she had stolen the phone from Resident #90 and told the SC to go ask that resident if it was stolen. He/She did not borrow the phone from Resident #90, he/she borrowed it from another resident. The SC left the room for about two or three minutes. He/She was concerned about the SC leaving the room with everything that was going on, but everyone just stood around the room waiting on the SC to return. The SC returned and said Resident #90 said the phone did not belong to him/her, which seemed to upset CNA X and CNA Y. CNA X and CNA Y began yelling at the SC and that is when CNA X hit the resident in the right eye. The SC called for the Admission Director (AD) who came in the room. CNA X had a can of [NAME] in his/her hand. He/She was not sure where it came from and CNA X did not use it or point it at him/her. When the AD entered, CNA X hit him/her again, he/she thinks in the arm. The AD was able to get everyone out of the room and he/she went with the SC to the front office while the AD stayed with all three CNAs. It wasn't long before the police showed up and eventually took CNA X with them. CNA Y and CNA Z left the building as well. When he/she went back to his/her room, the can of [NAME] that CNA X had was on the floor and the Social Service Director (SSD) confiscated it. The entire incident left him/her stressed and shocked and a bit scared and worried. He/She did not want to be there so he/she made arrangements with a friend to leave for a few days. He/She just needed to step away from it all. Later that day, he/she was sitting in the library area across from the front office, waiting for his/her friend. He/She was looking out the window and saw CNA X and CNA Y coming into the facility carrying balloons. CNA X and CNA Y walked right by him/her. They did not say or do anything to him/her but they gave him/her a little side eye as they walked by. He/She went to the office doors and knocked. The SSD came to the door and he/she told her CNA X and CNA Y were back at the facility. The SSD went into an office and called 911. He/She left with his/her friend. As he/she was getting into the car, the SSD came out and asked where the CNAs went and he/she told her they headed down the 400 hall. As he/she was leaving, the police passed him/her and entered the parking lot. Review of CNA Z's typed statement, dated 3/19/23, showed the two CNAs (CNA X and CNA Y) confronted CNA Z at the beginning of our shift regarding someone breaking into their car and stealing their personal items. I told them I didn't know what they were talking about and went about my business. The two CNAs seen me later and demanded I stop by the resident's room (Resident #85) where they again confronted me about someone stealing their personal items. I again told them I didn't know anything about it. While in the room with the resident and the two CNAs, the SC arrived looking for the CNAs. At that time I witnessed CNA X hit the resident and yelled for CNA X to stop. The SC never left and called 911 to report to the police. She (SC) waved down and yelled the AD's name while she was still in the room and on the phone with the police. Upon the AD's arrival into the resident's room, he (AD) witnessed CNA X hit the resident again at which time he intervened and removed the two CNAs from the room escorting them to the break room and I exited the room. During an interview on 3/22/23 at 4:22 P.M., CNA Z said on Sunday 3/19/23, he/she was about 30 minutes late getting to work. It was about 7:30 A.M. when he/she parked in the facility's parking lot. Before he/she could get out of his/her car, CNA X and CNA Y drove up to his/her car and barricaded him/her in so he/she could not leave. CNA X and CNA Y got out of their car. CNA X was holding a crow bar and was walking around his/her car, tapping the crow bar against his/her windows, threatening to bust his/her car up. CNA Y was standing at his/her door trying to open it, screaming and cursing, and saying they had been robbed and he/she (CNA Z) had stolen the money. He/She had no idea what CNA X and CNA Y were saying or what was going on. After a few minutes, he/she got out of his/her car to try to reason with them and to calm them down. They wouldn't listen to anything he/she said. CNA X got into CNA Z's car and began going through everything in his/her car. He/She thought about calling 911, but when CNA X got into his/her car, he/she took his/her phone. Their behavior scared him/her a bit and they were intimidating because, in his/her mind, he/she wondered if they had a gun. He/She opened the trunk of his/her car so they could search it because he/she was afraid if he/she didn't, they would bust his/her car up with the crow bar. CNA X and CNA Y said they were going to the resident's room, he/she better not be lying about taking the money. CNA X and CNA Y entered the building in the back. He/She entered through the front lobby. SC was in the front office, calling him/her, wanting to know why he/she was not at work. He/She spoke to the SC for a moment, but he/she did not tell the SC what had happened in the parking lot or that CNA X and CNA Y were on their way to the resident's room. He/She really did not think of them threatening the resident, because in the past they were all close and he/she did not want them going after his/her car. He/She got to the resident's room and found CNA X and CNA Y standing in the hall outside the resident's room. They were still angry. They all three went into the resident's room. He/She thought they were going to discuss the missing money civilly. CNA X or CNA Y shut the room door. The resident was in his/her room, sitting in his/her wheelchair. The resident's room had all kinds of stuff thrown around on the floor. He/She did not know CNA X and CNA Y had already been in the resident's room that morning. CNA X and CNA Y began yelling at him/her and the resident as well. CNA Y was using his/her body to bump him/her up against the wall. He/She was scared and he/she could tell the resident was scared as well. He/She was not sure if CNA X or CNA Y were threatening the resident at the time, because there was so much commotion going on and CNA X and CNA Y were screaming at both of them. CNA X was searching the resident's room. After a few minutes in the resident's room, the SC came in. CNA X and CNA Y were angry and loud. They were getting in the SC's face. Somehow CNA X came up with a phone that he/she said the resident took from another resident. CNA X told the SC to go and ask the other resident if the phone was his/hers. He/She could not recall if the SC left the room, because there was so much commotion going on at the time. He/She saw CNA X punch the resident in the face. CNA X may have hit the resident more than once, but he/she was not sure because everything was going so fast. Review of the SC's typed statement, dated 3/19/23, showed I went to look for the two CNAs (CNA X and CNA Y), to see why they were not on their assignments yet. I went to the nurse's station to check, but they were not at the nurse's station. I asked one of the CNAs that was sitting at the nurse's station if he/she had seen them and he/she said they're in Resident #85's room. I went to the room and they stated they were confronting the resident, because someone had broken into their car and took their money. I witnessed one of the CNAs (CNA X) hit the resident and I called immediately 911 to report the situation to the police. As I was on the phone with the police, the AD was walking down the hall and I waved him down to come assist with the situation. The AD entered the room and witnessed the CNA (CNA X) hit the resident and he placed himself between the CNAs and the resident to deescalate the situation and protect the resident. The AD then escorted the CNAs to the break room and awaited police arrival. During an interview on 3/20/23 at 9:25 A.M., the SC said on 3/19/23 around 7:30 A.M. or 7:40 A.M., CNA AA came to her and said CNA X and CNA Y were here and walking around mad, but not at their assigned work places. She went looking for the CNAs at that time to tell them to go to their assigned work places. She went to the nurse's station and CNA AA said CNA X and CNA Y were in the resident's room. She did not hear any fighting when she was approaching the resident's room. The door was shut. She knocked and no one said come in. She opened the door and entered the room. CNA X and CNA Y seemed shocked that she had come in. She asked CNA X, CNA Y, and CNA Z why they were not at their assignments. CNA X and CNA Y asked her why she wanted to know. And said, What's it to you? All three of the CNAs were trying to talk to her at the same time. She was telling them to calm down. CNA X and CNA Y were speaking in loud voices when they spoke to her. They were irritated. CNA X and CNA Y told her someone had robbed their car while they were working. They said the resident was always watching their car and he/she knows they leave their car unlocked. The resident was not saying anything about wanting the CNAs out of his/her room, or that CNA X and CNA Y were threatening him/her. The resident did look terrified, like he/she had a wounded face. The resident was holding a phone and CNA Y asked her if she knew if the phone belonged to the resident. CNA Y then accused the resident of stealing the phone from another resident. The resident said the phone did not belong to the resident CNA Y accused him/her of stealing it from, the phone belonged to another resident that loaned it to him/her. She left with the phone to go speak to the resident CNA Y accused Resident #85 stealing it from. Her thinking at the time was to confirm if the phone had been stolen or not. In hindsight, she probably should have not left the room. That resident said the phone did not belong to him/her. She went back to Resident #85's room and told CNA X and CNA Y the phone did not belong to the resident they accused Resident #85 from stealing it from. Then CNA X began to be aggressive with the resident, calling him/her a liar and hit the resident in the right eye. CNA Y was trying to stop CNA X from hitting the resident. The SC had her cell phone and called 911 as soon as CNA X hit the resident. She stepped outside the room, because the 911 operator said she could not hear what she was saying with all the yelling going on. All three CNAs followed her out into the hall. She saw the AD in the hall and motioned for him to come over. The resident came out of his/her room and was behind her. She and the resident went to the front office to get out of the situation, leaving the AD with the CNAs. When they got to the front office, she closed the door and the police arrived about 10 minutes later. During an interview on 3/23/23 at 5:18 P.M., the SC said she remembered CNA Z coming into the facility on [DATE]. CNA Z was late for work that day and she was calling CNA Z to see where he/she was. CNA Z did not tell her anything about about CNA X and CNA Y threatening him/her on the parking lot or that CNA X and CNA Y were on there way to the resident's room to find out about the missing money. Had CNA Z told her, she would have notified the building manager and called the police at that time. Review of the AD's typed statement, undated, showed on 3/19/23 at approximately 8:40 A.M., the SC asked me to come to Resident #85's room. She (the SC) appeared distressed. When entering the room, I witnessed CNA X strike the resident with a closed hand (fist) to the right side of his/her face (his/her right eye). I stepped between the resident and CNA X and removed CNA X from the room. CNA X was accompanied by CNA Y. I proceeded to take CNA X to the break area by the laundry. The police was called and CNA X was arrested. During an interview on 3/20/23 at 10:45 A.M., the AD said on 3/19/23, he was coming from the dining area and walking down the hall. He saw the SC standing in Resident #85's doorway and the SC waved him over to the room. The SC appeared visibly distressed. He got to the doorway and saw CNA X , CNA Y and CNA Z in the resident's room. The resident's room looked completely torn up, not by fighting but by CNA X and CNA Y ransacking the room looking for something. CNA Y was going through the resident's jacket that was on the floor. The resident said CNA X and CNA Y had ransacked his/her room, not CNA Z. CNA X was standing by the resident's bed and the resident was sitting in his/her wheelchair. The resident was not saying much of anything. Then suddenly, CNA X turned around and punched the resident in the face. It happened too quickly for him to stop it. As far as what he saw, CNA X hit the resident one time. The resident acted shocked and surprised that CNA X hit him/her. The resident asked, why did you hit me? He was able to stop CNA X from punching the resident again. He thinks CNA X would have punched the resident more than once as he/she said he/she wanted to see the resident bleed and was swinging, but he stood in between CNA X and the resident, preventing any more punches. He did not see CNA Y or CNA Z attempt to hit the resident, only CNA X. CNA Y was threatening the resident, saying he/she was going to get the resident because he/she stole his/her money. CNA Z was not threatening the resident. He was able to get CNA X, CNA Y, and CNA Z out of the room and he ushered them down the hall toward the administrative offices. As CNA X and CNA Y were screaming and cursing in the hall, he only saw one resident, the same resident the CNA X and CNA Y accused Resident #85 of stealing the phone from. That resident did not seem upset, just wondering what was going on. He was present when the police arrived. The resident was in the administrative offices behind a locked door. The police separated CNA X and CNA Y and questioned them. During observation and interview on 3/20/23 at 11:35 A.M., the SC and AD went to the resident's room to demonstrate where everyone was when the altercation occurred. The SC said she entered the room and the three CNAs and resident were inside the room. The SC walked the distance from the resident's room to Resident #90's, where she asked that resident about the phone. The SC walked 50-60 feet down the hall to the nurse's station then turned right down another hall approximately 40 feet to where the resident's room was located. When she returned to Resident #85's room, she said she was inside the room until CNA X hit the resident, then she moved back to the doorway to call 911. The AD was not in the room when she saw CNA X hit the resident. The AD said he was close to the laundry room doors (approximately 20-30 feet away from the resident's room) when he saw the SC standing in the resident's room doorway and motioning him to there. As the SC stood in the doorway, he moved around her and into the room. That was when he saw CNA X hit the resident. He placed his body between the CNAs and the resident and ushered them all out of the room back toward the laundry room doors away from the resident's room. During an interview on 3/20/23 at 12:10 P.M., CNA AA said yesterday, 3/19/23, he/she and CNA HH were in the hall when the AD, CNA X, CNA Y and CNA Z were in the hall. CNA X and CNA Y were mad, loud and cursing. He/She heard CNA X say he/she was going to get it back in blood, referring to the resident and the missing money. He/She tried to reason with CNA X but there was no reasoning with him/her. CNA Y was not saying too much. Review of the SSD's typed statement, dated 3/19/23, showed message received from SC stating CNA attacked a resident at approximately 8:45 A.M. Spoke with her and AD and instructed them to contact the police immediately. This writer immediately notified the Administrator and Director of Nurses of the incident. Resident reported he/she was on leave from the facility around 5:00 P.M. yesterday and returned around midnight last night. He/She was laying in the bed when CNA X physically assaulted him/her in his/her room. The resident stated CNA X and CNA Y came into his/her room accusing him/her of stealing a bag. CNA searched his/her room, dumping out his/her wallet, closet and drawers. Per resident, staff flipped him/her out of his/her bed. The CNAs left his/her room and he/she got dressed and into his/her chair. Both CNAs returned back to his/her room with CNA Z. The resident said CNA X and CNA Y cornered CNA Z as well accusing CNA Z of stealing as well. They began roughing/holding CNA Z and then CNA X stated it was the resident who did it and began to punch him/her in the right eye. The AD entered the room and separated them while the SC called the police. The resident also said CNA X tried to [NAME] him/her but CNA X dropped the [NAME] on the floor underneath his/her chair. This writer took the [NAME] to the Administrator. During an interview on 3/20/23 at 1:16 P.M., the SSD said she had worked at the facility for about 5 years. She did not know of any previous problems with CNA X, CNA Y or CNA Z prior to yesterday, 3/19/23. She was present yesterday but did not know what was going on until after the police were called and in the building. When CNA X and CNA Y left with the police, the police told them not to return to the facility. Later yesterday evening, around 6:00 P.M., after CNA X and CNA Y were removed from the building by the police, they came back to the facility. The resident was in the library waiting for his/her ride to arrive. The resident told her that CNA X and CNA Y were back in the building. The resident seemed startled at that time. She immediately called 911 and escorted the resident to the parking lot with his/her friend. She went back into the building and located the CNAs and told them they were not allowed on the property. She escorted them out and by that time the police had arrived and told them not to return. During an interview on 3/28/23 at 8:40 A.M., CNA Y said he/she and CNA X went into the resident's room on 3/19/23 around 7:00 A.M. They told the resident about the missing money and he/she denied taking it. The resident gave them permission to search his/her room. They didn't cause the resident to fall out of the bed. They were not threatening or cursing at the resident. The resident said CNA Z took their money. They left the resident's room and found CNA Z on the parking lot as he/she was arriving to work. CNA Z gave them permission to search his/her car. They were not threatening or cursing at CNA Z. When they had finished on the parking lot, they told CNA Z they were going to the resident's room. He/She and CNA X entered the facility through the back. When they got to the resident's room, CNA Z was already in the resident's room. They were all talking over each other when the SC came in. They told the SC the phone the resident had was stolen from another resident and the SC left the room with the phone to ask the other resident if the phone belonged to him/her. A short time later, the SC returned and said she needed to speak to the resident about the phone later. Other than everyone being loud and talking over each other, nothing else happened. Neither he/she nor CNA X were cursing or threatening anyone. CNA Y did not see CNA X hit the resident. The AD came in the room and escorted them all out of the resident's room. Later that day, he/she and CNA X came back to the facility to celebrate another resident's birthday. No one had told him/her they could no

44948 Based on observation, interview and record review, the facility failed to ensure adequate supervision for one resident (Resident #40), who admitted with a history of elopement and voiced a desire to leave the facility. In addition, when the door alarm sounded, the facility failed to follow their elopement policy when staff turned off a door alarm without immediately inspecting the inside and outside of the facility, and immediately accounting for all residents in the facility. The facility also failed to ensure all staff knew the proper procedures related to elopement. The census was 163. Sample was 39. The administrator was informed on 10/11/22 of an Immediate Jeopardy (IJ), which began on 9/10/22. The IJ was removed on 10/17/22 as confirmed by surveyor on-site verification. Review of the facility's elopement management policy, effective on 3/19/19, showed: -Policy: -The facility is to immediately initiate procedures to locate any resident/patient that is unaccounted for. Notification of appropriate parties will comply with state and federal regulations. Following location of the involved resident/patient, the facility leadership will review prevention systems to identify performance opportunities. Failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe area and are unaccounted for, is considered elopement. Residents who are their own person and choose to leave the premises without staff knowledge will be considered an Unauthorized Leave of Absence (LOA) and not elopement; -Procedure: -1. Announce the facility code for missing resident/patient; -a. This facility will use the alert Code GREEN for an elopement; -b. Staff will immediately seek out the source for the alarm; -i. Staff will immediately inspect the inside and outside of the Connections Unit (memory care unit); -ii. Staff will immediately inspect the outside of the facility (building); -c. Staff will begin an accounting of all residents on the Connections Unit; -d. Staff will begin an accounting of all residents for the rest of the facility; -e. Staff will report to the Director of Nursing (DON)/Administrator or nurse supervisor for any unaccounted for residents; -f. The alarm can only be silenced after the nurse on the Connections Unit confirms that all residents are accounted for; -2. Alarms/Alert: -a. All staff will respond to the alarm/alert immediately on their unit; -i. Units are not to be left unattended for safety of the other residents; -3. Unit Supervisor/DON will direct units to form a search team; -a. Verify that staff is available to stay with current resident/patients; -4. Notify the supervisor immediately of any suspected elopement/missing resident/patient; -a. Supervisor notifies the Executive Director (ED) and DON if resident/patient is not quickly located; -b. ED notifies Regional Staff; -5. Conduct a head count to determine any additional missing resident/patients; -6. Search all areas of the facility, opening all doors, entering all rooms. Include all closets, storage areas and under beds; -7. Search the immediate grounds of the facility; continue to [NAME] the radius of the outdoor search; -a. NOTE: If health threatening weather, or nearby external hazard, initiate outdoor search with second team while internal search is underway; -8. Interview staff to determine last known location, clothing description and any indication made by the resident/patient that they were leaving for a certain location; -9. Interview residents/patients as appropriate for any indication made by the resident/patient that they were leaving for a certain location; -10. Notify the resident's/patient's physician; -11. Notify the resident's/patient's family and/or responsible party; -12. Notify law enforcement and state agencies as required by state regulations; -13. Complete and document a physical assessment of the resident/patient upon return to the facility to determine if further treatment is required; -14. Notify all parties of resident's/patient's return to the facility; -15. Review and revise the interventions related to prevention of elopement/missing resident; -16. Communicate the modification of interventions to the caregiving staff, resident/patient and/or family/responsible party. Review of Resident #40's pre-admission medical history, faxed to the facility on [DATE] at 9:03 A.M., and used by the facility to determine if the resident qualified for admission and/or the resident's medical needs required post-admission, showed: -Baseline care plan, showed: -Initial admitted to prior facility 8/24/22; -Initial admission goals - Patient here for wound healing and strength training with physical therapy (PT) and occupational therapy (OT), Return to community; -Level of consciousness/cognition marked as alert and cognitively intact; -Progress notes from prior facility, showed on 8/29/22 at 7:16 P.M., at approximately 5:00 P.M., the certified nursing assistant (CNA) notified this nurse that the resident was outside on the parking lot. Resident was brought back into facility by CNA. CNA stated that the resident was combative and cursing. Physician and DON notified. Resident did have a wander control (electronic monitoring/alert device) on ankle. Review of the admission initial evaluation, dated 9/10/22 at 12:50 P.M., showed; -Date and time of admission was on 9/10/22 at 12:50 P.M.; -Behavior status: -Has the resident exhibited exit seeking since admission, behavior exhibited; -Does the resident have a history of exit seeking, yes; -Does the resident have a history of wandering, yes; -Functional status: -Independent for bed mobility, transfers, and eating, locomotion on unit, personal hygiene, bathing; -Limited assistance for toilet use, walking in room; -Resident is continent of bowel and bladder; -Elopement wandering evaluation: -Does the resident have a history of wandering and/or pattern tied to the resident past, yes; -Is the resident accepting the new admission/readmission situation, no; -Has family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave, yes; -Has the resident expressed anxiety/apprehension to leave the facility, packed personal belonging, pacing with no course of action or direction, or attempted to exit doors, yes; -Does the resident have a history of elopement, yes; -Does the resident wander without a sense of purpose, yes; -Does resident have any additional risk factors for elopement or unsafe wandering, no; -Based on the responses above, is the resident at risk for elopement or unsafe wandering, yes; -Interventions to be implemented to prevent unsafe wandering/elopement: -Apply secured (wander control) device. Check placement every shift, check function and door transmitter daily; -Document in the order the expiration date of the secured device; -Notify staff of elopement risk; -Notify staff of unsafe wandering risk; -Provide diversional or structured activities at times of increased risk. Redirect when appropriate; -Assess for hunger, thirst, ambulation, toileting needs; -Evaluate the need of secured unit, notify medical provider as needed; -Provide education to the resident representative/guardian of the need for secured unit/device to maintain resident safety; -Secured Unit: -Has the resident been placed on a secured unit, yes; -Medical diagnosis, encephalopathy (degenerative brain disease); -Medical symptoms that require a secured unit, resident states he/she does not belong in a facility; -Resident exhibits the following underlying medical factors, gait disturbance, difficulty adjusting to the environment, wandering, other listed: resident has attempted to elope; -Narrative explanation of underlying factors, resident had attempted to elope and expresses that he/she does not belong at facility. During an interview on 9/20/22 at 11:28 A.M., the DON said that the facility does not have a wander control system in place. The admission assessment was completed by an agency nurse. The intervention listed to apply secured device, check placement every shift, check function and door transmitter daily and document in the order the expiration date of the secured device, is not correct. Review of the resident's medical record, showed; -Diagnoses included, alcohol abuse with alcohol induced anxiety, encephalopathy, hypertension (HTN, high blood pressure) and hyperlipidemia (high cholesterol). -Brief Interview for Mental Status (BIMS, used to assess the resident's mental alertness) assessment, completed by the Social Service Director on 9/11/22 at 1:41 P.M., showed a score of 7, which indicates severe cognitive impairment. Review of the resident's care plan, showed: -Focus: Resident has a history of behavior issues and wandering, date initiated 9/10/22; -Goal: Resident will have fewer episodes of behaviors through review date, date initiated 9/11/22; -Intervention: -Monitor behavioral episodes, and attempt to determine underlying causes, date initiated 9/10/22; -Place resident 1:1 pending psychiatric (psych) evaluation, date initiated 9/12/22; -Psych to evaluate resident, date initiated 9/12/22; -Resident picture and information to be placed in elopement risk book, date initiated 9/12/22; -Notify family and seek their assistance if resident becomes combative and attempts to leave, date initiated 9/12/22. Review of psychiatric evaluation, appointment date 9/16/22 at 8:00 A.M., showed the resident stated he/she was living independently prior to coming here. He/she fell in the driveway at home and the police found him/her and brought him/her in. The resident states he/she was trying to get the wheelchair off the porch and it got caught up. Resident is alert and oriented (A&O) x 2 (to person and place). Reminisces appropriately. Has two children and they are both in Missouri. Reports having a good support system, but does not use them appropriately. Irritable with questioning. Reports drinks alcohol, but not every day. Denies drug use. Has been on medications for depression and anxiety in the past. Doesn't remember past medications. Resident has an appetite, but does not like the food here. Not sleeping very well in here. Really wants to go home. Has been in a couple of places, came here from another facility. Resident apparently had an elopement attempt and has been on 1:1 since that time. Review of the resident's progress notes, showed: -On 9/10/22 at 12:50 P.M., Admission note: admitted , receiving wound care. Receiving PT and OT. English is primary language. Activity, walks occasionally. Requires assistance of a wheelchair, ambulates with assist of one or two. At risk for elopement or unsafe wandering. Resident has been oriented to room. Resident has been placed on a secured unit; -On 9/10/22 at 1:05 P.M., Nurses note: Resident arrived to facility by previous facility transportation with two staff. Resident is A&O x 2-3 (person, place and time) and is able to make needs known. Resident is continent of bowel and bladder with incontinent episodes. Resident ambulates using wheelchair and is able to propel self. Resident had wound to right groin per previous facility report. Resident refused assessment of wound. Resident is uncooperative with care and upset about being in this facility stating he/she wants to talk to his/her daughter so he/she can go home. Several calls to resident's daughter to notify of admission and resident's concern were unsuccessful. Messages left, awaiting return call. All medications verified by physician. Resident oriented to room and call light system; -On 9/10/22 at 3:58 P.M., Social services note: Call received from nurse stating alarm was set off and resident exited building. Resident was located on road (in front of facility), walking with his/her wheelchair and was immediately assisted back into the building and placed on locked unit on 1:1. Resident yelling and screaming stating he/she is not supposed to be here. Resident stated he/she wants to return home with his/her daughter and gave an address. Continued to speak with resident in attempt to calm him/her down. Ensured resident social services will work with him/her and contact family related to his/her plan of care. Will continue to monitor for changes in behavior. Nurse will contact physician and psych for consult; -On 9/10/22 at 7:05 P.M., Nurses note: Nurse was informed that resident was outside of the facility. When nurse arrived to resident, he/she was sitting in his/her wheelchair. CNA and the supervisor were standing next to him/her. Staff were able to assist resident back inside the facility. Resident stated he/she did not belong here and doesn't understand why the police brought him/her to this facility. Resident was assisted back to locked down unit. One on one with nurse until relief arrived. Call placed to daughter. Message left. Call placed to physician and received new order for psych consult. During an interview on 9/13/22 at 9:33 A.M., the resident said he/she is locked up here and wants to go home. He/she has a house and said the address. The address matched the address in his/her medical record. He/she has a daughter who would come to the house every day when he/she was at home and would take him/her places if he/she needed to go anywhere. He/she fell in his/her driveway and busted his/her head and was taken to the hospital. He/she goes outside every chance he/she gets. During an observation and interview on 9/14/22 at 8:22 A.M., the maintenance director walked through the resident's path of elopement, which started in the memory care dining room. The maintenance director pressed on the bar to the door leading into the enclosed court yard. The door alarm sounded when he pressed on the bar for approximately 15 seconds and the door opened with alarm still sounding. He said when the door alarm sounds at the door, an alarm at the nurses station also sounds and there is a panel at the nurses station that shows which door alarm has been triggered. He walked across the enclosed court yard to two doors on the other side that were not locked or alarmed. The maintenance director said the enclosed court yard is the resident's smoking area. After the resident passed through the unlocked and unalarmed door out of enclosed court yard, the resident walked down three hallways, then exited the door by therapy that led outside. The maintenance director pressed on the bar across the door and the alarm sounded when he began pressing on the bar for approximately 15 seconds and the door opened with alarm still sounding. The resident exited through the therapy exit and came down a sloped ramp, approximately 40 feet in length, crossed the facility parking lot onto a grassy area and then onto a busy road. The resident was found approximately 200 - 250 feet across the busy road, standing on the side of the road. While outside, observation showed multiple cars driving both ways on the busy road. During an interview on 9/19/22 at 12:36 P.M., CNA EE said on 9/10/22 around 3:20 P.M., he/she entered the memory care unit and the alarm was sounding when he/she entered the unit. CNA EE went to the nurses station and got the key to silence the alarm. He/she then went to the dining room door on the memory care unit and looked out the door, didn't see anyone and put the key in and turned off the door alarm because he/she didn't see anyone. CNA EE went to the charge nurse on the memory care unit and told him/her that the door alarm was going off when he/she entered the unit. CNA EE told the nurse that he/she turned the alarm off because he/she didn't see anyone, but was unsure if anyone got out. The charge nurse was passing medications and said okay. CNA EE put the key back at the nurses station where it hangs. A staff member who was outside in the court yard came to CNA EE and said that a resident from the rehab side said that a resident from the unit was on the rehab side. CNA EE then left the memory care unit to search for the missing resident. CNA EE then heard the alarm at the therapy exit, went to the door and tried to open it, but it wouldn't open; the door had already locked back. CNA EE looked outside and saw the therapy exit led to the parking lot. CNA EE then began walking to the front of the building across the bridge and called the weekend supervisor to let her know that a resident went out the therapy exit and he/she was on the way to the front door. The weekend supervisor said that she would come help look for the resident. CNA EE came out the front, and the weekend supervisor came through the rehab doors. CNA EE saw the resident had stopped cars in the road and was talking to a lady in a car. There was traffic and a bunch of cars were lined up behind him/her. The resident was on the passenger side of the car speaking to the lady, and when CNA EE asked the resident to come inside, he/she began cussing at CNA EE and said he/she wanted to talk to the police or his/her daughter. They had to pretend the facility had the resident's daughter on the phone and pretend to call the police to get the resident back inside the building. The resident kept repeating that he/she did not belong in the facility and he/she was not crazy. CNA EE found the resident around 3:40 P.M. and the alarm was sounding when he/she arrived on the unit at 3:20 P.M. He/she was unsure how long the alarm was sounding before he/she entered the memory care unit, so the resident was unaccounted for at least 20 minutes. CNA EE was unsure what time the resident went back into the building because the resident went into the building with the weekend supervisor and charge nurse for the memory care unit. During an interview on 9/19/22 at 1:08 P.M., Nurse GG said the alarm went off on 9/10/22 and thinks the resident was able to get out of the facility because he/she was a new admission. Nurse GG said CNA EE locked the door and said he/she did not think anyone had got out. Nurse GG said it did not take long to find the resident. During the same interview, Nurse GG said when an alarm goes off, staff look at a board that shows where the alarm is going off, but that it is usually the bridge alarm going off, so he/she was surprised that it was the therapy exit alarm going off. Staff would check the bridge and smoking areas usually first to make sure everyone was there. Nurse GG did not know the facility's policy for turning off the alarm, but he/she would not have turned it off. Nurse GG would have kept looking for the resident until he/she had been found. During an interview on 9/15/22 at 12:09 P.M., Nurse AA said on 9/10/22, he/she was charting at the nurses station and the phone rang. When Nurse AA answered the phone, a woman said she was driving down the road and saw a person who could be a possible resident pushing a wheelchair in the road. The caller wasn't sure if the person/resident belonged to the facility, but was worried the person/resident was going to get hit by a car. Nurse AA did not remember hearing an alarm go off before receiving the phone call. Nurse AA went outside to look. He/she walked across the parking lot, up the hill and stood on top of the hill next to the facility sign and saw CNA EE with the resident and the weekend supervisor. The resident was standing on the far side of the road with his/her wheelchair. CNA EE and the weekend supervisor were attempting to get the resident to move onto the sidewalk and out of the road. The sidewalk is on the far side of the road, across the road, away from the facility. Nurse AA said the resident was yelling and cursing at the weekend supervisor and CNA EE. The resident said he/she was not going back into the building and wanted them to call 911 because he/she did not belong in the facility. The weekend supervisor told the resident he/she would call the resident's family after they went back into the building, and the resident refused to go back in. The weekend supervisor was able to get the resident to sit in his/her wheelchair and move the resident off the road onto the sidewalk. A different nurse then came outside saying the resident's daughter was on the phone and eventually the weekend supervisor and CNA EE were able to get the resident to go back inside the facility. The resident walked between the weekend supervisor and the CNA, pushing his/her wheelchair. The resident stated that they tricked him/her into coming to the facility. Nurse AA said after the elopement, he/she filled out a statement and the weekend supervisor did an in-service on elopement. Nurse AA said the in-service was to watch the doors if an alarm sounded and to check the panel to see which door is alarming. Staff should notify the weekend supervisor on the weekends and to start looking to see which residents are not around. Nurse AA said if an alarm goes off, to call and tell the supervisor and turn off the alarm. Nurse AA said if the facility is unable to locate a resident, then he/she would call 911, call the family and the doctor. Nurse AA also said that when looking for residents, the staff should look in the resident rooms, TV area and outside in the smoking areas. During an interview and observation on 9/19/22 at 9:38 A.M., Nurse AA walked outside the facility up the hill near the facility sign to show where the resident was found on the road. Nurse AA walked to the area across the busy road on the side where the resident was standing with his/her wheelchair. While standing on the side of the road, multiple cars drove by going both ways. Nurse AA said that the resident was probably standing on the side of the road with the CNA and the weekend supervisor for approximately one to two minutes before the resident went to the sidewalk, away from traffic. During an interview on 9/20/22 at 3:35 P.M., the weekend supervisor said CNA EE called her after 3:00 P.M., but was unsure of the exact time. CNA EE said that he/she believed a resident got out. CNA EE said he/she heard one of the alarms going off at the therapy exit door. The weekend supervisor left the rehab side and heard the therapy exit door alarm going off. The weekend supervisor said as she was walking through the rehab side, she asked an agency CNA to please dial zero and make the announcement that a resident had eloped. The weekend supervisor was not sure if the announcement was made, but she made the announcement herself when she was passing through the North nurses station. By the time the weekend supervisor got outside, CNA EE was standing with the resident on the sidewalk. Nurse AA was standing on the grassy area outside on the hill near the facility sign but not standing with the resident and CNA EE. Nurse GG was also approaching the resident at this time. The resident was refusing to come back into the facility and he/she wanted the police to be called. The weekend supervisor had another staff member on the phone and had to trick the resident by saying the resident's daughter was on the phone in the facility. The resident refused for a long time saying he/she was never coming back into the building because he/she didn't belong there. The resident said that nothing was wrong with his/her mind. The weekend supervisor told the resident they could contact his/her family and handle the situation after they got back into the facility. The resident was very upset and didn't want to be at the facility at all. After approximately 30 minutes, they were able to get the resident back into the facility. He/she was immediately placed on 1:1. The weekend supervisor came in and announced the resident was found. CNA EE did not tell her about the alarm going off to the court yard when CNA EE came onto the memory care unit. The weekend supervisor said CNA EE should have immediately called her and told her that the unit door alarm was going off. CNA EE should have started the elopement protocol when the first alarm sounded instead of just turning off the alarm. The weekend supervisor believes if the proper protocol was followed, the resident may not have made it all the way outside and onto the road. The road is busy, and the resident could have been hit by a car. During an interview on 9/19/22 at 3:13 P.M., the Interim DON and the ED they said their expectation for staff when a door alarm sounds, would be for staff to go to that location immediately, unless actively caring for a resident. They expected nurses to be team leaders and direct people to certain locations. They believe the door alarms only sound in each individual building. The long term building would not be alerted to a door alarm from the rehab or memory care unit. The rehab and memory care unit would not be alerted to a door alarm on the long term care side. They would expect all staff to begin searching for the missing resident. If the alarm is set off on the memory care unit, a head count should be conducted immediately on the memory care unit along with the rest of the building. The head count should be conducted with a midnight census sheet and staff should check off the residents as they see them. The ED and Interim DON were unsure where the census sheet goes after the head count, but said from now on it can be kept with the investigation to show the head count was completed. If the resident is not immediately located on the premises, staff would call the DON, ED, and the nurse would contact the police. If they were unable to locate the resident, the nurse would make copies of the resident information to give to the emergency services. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00206826 46104

Based on observation, interview and record review, the facility failed to ensure one resident was treated in a dignified manner when the resident was left to sit in feces. Staff also left the resident visibly exposed to the hallway (Resident #30). The sample size was 39. The census was 163. Review of the facility's Routine Resident Care Policies and Standard Procedures, revised 4/6/16, showed: -Policy: To promote resident-centered care by attending to the physical, emotional, social, and spiritual needs and honor resident lifestyle preference while in the care of this facility; -Provide routine daily care by a certified nursing assistant (CNA) with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including but not limited to: -Implementing and maintaining program for skin care; -Maintaining a bladder and bowel training program; -Assisting and teaching activities of daily living; -Toileting, providing care for incontinence with dignity and maintaining skin integrity; -Providing an environment that contributes to a positive self-image preserves dignity and promotes privacy. Review of Resident #30's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/2/22, showed: -Moderate cognitive impairment; -Exhibited no behaviors; -Highly impaired hearing; -Unclear speech; -Makes self-understood: Usually understood; -Ability to understand: Usually understands; -Required limited assistance with dressing and toilet use; -Required supervision with personal hygiene; -Occasionally incontinent of bladder; -Always incontinent of bowel; -Diagnoses include dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety, depression and arthritis. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Revised 10/6/20, The resident has activities of daily living self-care performance deficit, related to communication deficit, Parkinson's disease; -Goal: The resident will maintain current level of function in (bed mobility, transfers, eating, dressing, toilet use, and personal hygiene) through the review date; -Interventions: Place personal items and assistive devices with reach. Toilet use: Resident is able to (wash hands, hold grab bars, wipe self, adjust clothing) May need supervision at times, Dressing: Resident requires set up and supervision to dress, Personal hygiene: Resident requires staff participation with personal hygiene and oral care. Observation on 9/14/22 at 10:25 A.M., showed the resident in his/her room, by the bathroom. The resident was observed pulling at his/her pants and screaming. At 10:32 A.M., the resident appeared in his/her doorway. The resident sat in his/her wheelchair with pants partially down, pulling at his/her brief. The activity leader walked by the resident's room. She saw the resident and went into the resident's bathroom with the resident. After a few minutes, the activity leader left the resident's room. The resident was in his/her wheelchair by his/her bed. The resident's pants were pulled up and the resident sat quietly in his/her wheelchair. At 10:58 A.M., the resident talked out loud in the hallway. The resident grabbed his/her stomach and then backed up the wheelchair and entered his/her room. The resident grabbed his/her brief, said poop and dirty and tried to get staff to go into his/her bathroom. At 11:00 A.M., observation of the bathroom showed a soiled brief on the floor, bowel movement (BM) in the toilet and a BM stain on the toilet and other high touch areas. The bathroom also had soiled clothes on the floor. During an interview on 9/14/22 at 11:11 A.M., the activity leader said the resident went poop in his/her pants. The resident just needed his/her pants pulled up after he/she went. The activity leader said he/she did not tell anyone the resident had soiled his/her brief with feces. He/she said he/she got busy with other residents and forgot. Observation on 9/16/22 at 9:44 A.M., showed the resident lay in bed. CNA QQ was in the resident's room. CNA QQ stated to the resident, we will help you as soon as we get done passing hall trays. There are only two CNAs right now. CNA PP walked by the resident's room and said there were only two of us right now on the whole floor. CNA PP walked into the resident's room with CNA QQ. CNA PP said to the resident, we will make sure you are ready before family comes. Want to eat breakfast first? CNA PP said to CNA QQ that there are normally four CNAs on this side; -At 9:50 A.M., the resident sat up in bed with his/her nightgown shirt unzipped and wide open. The resident was trying to pull the shirt closed, and his/her stomach and chest were exposed to the hallway. The resident said, me first, me first. The resident continued to say, You call and call and call and no one listens, no nurse comes. Calling, calling, calling, no one listens, please don't leave me because no one will come and help me. The resident repeated the phrase, No one help me as he/she pointed to the hallway. The resident began to pull at his/her brief; -At 9:55 A.M., the CNAs still passed hall trays to residents. The CNAs placed a drink cart outside of the resident's room. The resident was exposed and visible to those outside of the room. The resident was still in bed, crying out for a nurse when a male resident went to the drink cart to get a cup of orange juice. The male resident turned towards Resident #30's doorway and looked in the room at Resident #30. Resident #30 sat on in his/her bed with a shirt still open, no pants, and only wearing a brief; -At 10:02 A.M., Nurse RR walked down the hallway where the CNAs passed trays while multiple call lights were illuminated. The resident continued to cry. CNA PP said, Nurse we just getting the ones that get mad first, it is (CNA QQ's) first day. Nurse RR walked to the drink station outside of the resident's room. The nurse poured coffee while the resident cried loudly. Nurse RR took the coffee and walked down the hall to the nurse's station. At 10:05 A.M., CNA DD walked by the room while the resident was in bed screaming. The CNA did not go into the resident's room; -At 10:10 A.M., CNA PP, CNA QQ, and CNA DD were observed talking to each other. CNA DD stated he/she would get Resident #30. CNA PP said the resident has family coming at 10:30 from out of state. At 10:12 A.M., CNA DD entered the resident's room. He/she came right back out and went around the corner. At 10:15 A.M., CNA DD came down the hallway and passed the resident's room. At 10:17 A.M., Nurse R entered Resident #30's room to complete a skin assessment. CNA DD entered the room after Nurse R. Nurse R removed the resident's brief and revealed the resident had a second brief on under the first one. Nurse R asked CNA DD to change the resident, as the resident was wet. Nurse R left the room and CNA DD performed perineal (the area including and between the buttocks and genitals) care on the resident. The resident's sheet under the resident was wet with urine. The CNA tucked half the brief under the resident then rolled the resident on his/her back. The CNA did not remove the wet sheet. The resident said, pee pee and pointed to his/her genital area then said bathroom. CNA DD said huh and then continued putting a brief on the resident. The resident repeated, try to go to bathroom. CNA DD did not respond. The CNA told the resident, you do not have pants in here. The CNA had the resident roll to his/her back and pulled the gown down to cover the resident. The CNA then zipped the gown. The resident said dress nice, have family coming today. CNA DD said he/she had to find pants for the resident. The CNA took out the trash and left. During an interview on 9/16/22 at 10:38 A.M., CNA DD said he/she was not aware the resident was assigned to him/her today. He/she did not know why the resident was double briefed, but it was probably done to keep the bed from being wet. During an interview on 9/16/22 at 10:45 A.M., Nurse RR says this is his/her first time on this hall. He/she did rounds when he/she arrived. Nurse RR would not double brief a resident because it causes skin injuries. He/she also said if the resident is crying out bathroom, they should be changed and the CNAs should let the nurse know so the nurse can jump in and help. During an interview on 9/16/22 at 10:50 A.M., the Director of Nursing (DON) said it is not appropriate to leave a resident dirty. She expected the resident to be changed. She expected direct care staff to be notified immediately if nondirect care staff realized a resident was dirty. Leaving a resident soiled can cause skin breakdown, urinary tract infection, and is a dignity issue. The DON said the facility is not short staffed. She expected her staff to stop passing trays and wash hands. She then expected staff to tell the nurse immediately if they need help. The resident should not have to yell, scream, and cry. It is undignified. A resident should not have to beg. MO00205171 MO00205450

Based on interview and record review the facility failed to follow acceptable nursing standards to prevent a significant medication error when the facility staff failed to enter a medication order into the computer system for one resident (Resident #56), resulting in the medication not being administered as ordered. The sample was 39. The census was 163. Review of the facility's Medication Administration Policy, dated reviewed 1/5/22, and showed: -Definitions: Medication Administration Record (MAR), the legal documentation for medication administration; -PRN (as needed), use on an as needed basis within the parameters permitted; -Procedure: administer medication only as prescribed by the provider; -Observe the five rights in giving each medication, the right resident, the right time, the right medication, the right dose and the right route; -Read medication label three times before administrating medication: first, when pulling medication from the drawer; second, when comparing label to MAR; third, when preparing to administer the medication; -Report medication errors; -Medications will be signed out when given; -Narcotics (opioid pain relievers) will be signed out when given; -Documentation of medications will follow acceptable standards of nursing practice. Review of the facility's Missed Medication/Medication Error Policy, undated, showed: -Definitions: medication error/incident: any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication. Medication errors/incidents may include medications: given incorrectly (wrong dose, wrong time, wrong route, and wrong drug); and not given within the prescribed timeframe; -The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner; -Failure to administer a prescribed medication as ordered is considered a medication error regardless of the reason or drug category unless the physician has been notified and provided new orders; -Any medication not available during a routine medication pass, the charge nurse will check the E-kit (emergency medication storage) to attempt to offer medications in a timely manner; -The Director of Nursing (DON)/designee is responsible for monitoring undocumented medications to assure residents are receiving their medications as ordered. Review of the facility's Coordination of Care for Hospice Services Policy, dated 2/15/22, showed: -Hospice Care or End of life Care: a distinct service provider with a focus on marinating or improving quality of life for someone who's illness, disease or conditions unlikely to be cured. Hospice provided for comprehensive comfort care provide to those with a terminal illness that is not responding to treatment. Treatment is not the goal but instead comfort and dignity is the goal for end of life choices; -The purpose of this policy is to provide guidance for coordination of services, reduce duplication of services and improve outcomes for resident in the facility; -The facility is responsible for working with hospice care services to provide optimum benefits for end of life care including pain relief; -Communication between the facility staff and the hospice care staff is an integral part of the partnership; -The facility will have a signed contract with each hospice provider that provides services within the facility; -The contract will define services coordination including but not limited to: the hospices responsibilities for determining the hospice plan, a communication process, including how communication will be documented between the long term care facility and hospice; -The hospice's responsibilities for services, including but not limited to: medical direction and management of the resident, nursing, supplies, durable medical equipment and drugs; -The facility will designate a member of the facility's interdisciplinary team (IDT) who is responsible for working with hospice representative to coordinate care to the resident by the facility and hospice staff; -The IDT facility member will be responsible for communicating with the hospice representative; obtaining the following information from the hospice provider: hospice medication information specific to each resident; -Staff communication and Coordinated Services: the facility and hospice services must have a method to communicate changes and updates regarding the residents care needs; -Coordinated Care needs may include but not limited to: pain management including breakthrough pain assessment and treatment; -Coordinated Resident Centered Plan of Care; the facility and hospice will develop a coordinated clinical plan of care that is specific for each resident receiving hospice services with the facility. Review of Resident #56's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/14/22, showed the following: -readmitted : 9/1/22 from an acute care hospital; -Cognitively intact; -Had an ostomy (a surgically created opening from an area inside the body to the outside of the body); -Diagnoses included cardiorespiratory (heart and lungs) debility, atrial fibrillation (irregular heart beat), coronary artery disease (damage or disease of the heart's major blood vessels usually caused by plaque build-up), high blood pressure, diabetes, malnutrition and respiratory failure (the lungs fail to get enough oxygen to the blood); -Was on a scheduled pain medication regimen; -Received PRN (as needed) pain medications; -Had pain present; -Numeric pain scale rating was nine, on a scale of 0 to 10 (where 0 would be no pain and 10 being the worse pain); -Received hospice care while a resident. Review of the resident's care plan, in use at the time of survey, showed: -Problem: has pain secondary to abdominal wall opening, chest pain on breathing; -Goal: will be able to verbalize relief of pain through target date; -Interventions: provide medications per order. Review of the resident's progress notes, dated 9/1/22 at 2:23 P.M., showed the resident readmitted to the facility. He/she is on hospice services. Medications verified with Medical Doctor (MD) and hospice nurse. Review of the resident's hospice's plan of care, dated 9/1/22 through 9/6/22, showed on 9/2/22, adding morphine 10 mg every four hours scheduled for pain. Review of the resident's MAR, reviewed for the dates of 9/1/22 through 9/7/22, showed the order for morphine 10 mg every four hours not documented as ordered or administered until 9/7/22. During an interview on 10/11/22 at 7:00 P.M., Nurse WW, a contracted nurse, said if a resident had a new order for medication or if a medication was changed, whoever got the order is responsible for entering the order into the computer. Nurse WW said he/she thought when the hospice nurse comes into the facility and medications are ordered or adjusted, the hospice nurse can enter the medication/changes into the computer. During an interview on 10/13/22 at 12:35 P.M., the Hospice Case Manager said the facility was not giving the resident his/her routine pain medication as ordered. In addition, the orders for the medications were not getting entered into the computer. The hospice nurses do not enter the orders into the computer. The facility is responsible for entering the medications into the computer. The hospice nurse would write down the orders on paper and give them to the facility nurse. The facility's agency staff would not or did not know how to put orders into the computer. Once, while she was at the facility, she found the paper with the orders wrote on it shoved into a drawer. During an interview on 10/14/22 at 9:55 A.M., Nurse TT said when hospice gets new orders and/or changes an order, they will give the order to the facility nurse to enter into the computer. Sometimes the hospice nurse gave orders to the agency nurse and they do not always follow through with them. On 9/2/22, Nurse TT was working but he/she was not assigned to the resident and he/she did not receive any orders from the hospice nurse, that day. Review of hospice progress notes, dated 9/7/22 through 9/14/22, showed: -On 9/7/22 at 8:30 A.M., the resident rated their pain 7/10 and asked for morphine. Orders for Morphine every four hours was rewritten as they were not in the system; -On 9/13/22 at 9:11 A.M., added orders for morphine extended release 30 mg every eight hours, orders written down for the facility nurse. He/she was instructed to keep all prn orders in place. The facility nurse called the office shortly after the visit asking if short acting morphine should be discontinued. Registered Nurse (RN) manager clarified that all orders should be continued. Review of the MAR, dated 9/8/22 through 9/14/22, showed the order for Morphine 10 mg every four hours was discontinued on 9/14/22. Review of the facility' progress notes dated 9/7/22 through 9/14/22, showed no documentation showing why the morphine 10 mg every four hours was discontinued. During an interview on 10/11/22 at 4:00 P.M. and 10/14/22 at 11:11 A.M., Nurse GG said he/she received an order from the hospice nurse for morphine extended release 30 mg every eight hours. After hospice left he/she was thinking about all the morphine the resident was receiving and called hospice back to clarify the order. Nurse GG said hospice never called back before the shift ended. When he/she came back to work, he/she was told nothing had changed. When the resident received his/her morphine it did help the resident's pain and he/she was able to rest more and was less agitated. During an interview on 10/14/22 at 9:55 A.M., Nurse TT said he/she did not know why morphine every four hours was discontinued on 9/14/22. During an interview on 10/14/22 at 11:26 A.M., Nurse K said the resident would occasionally request pain medicine and would rate pain between 6 and 8, a lot of times. The resident did not have signs of pain. He/she recalled the resident and might have received orders for him/her. He/she cannot recall putting in specific morphine orders because he/she was agency staff and had put in so many orders since working with the resident. He/she knew the resident always had a PRN (as needed) order for morphine. Then the resident had a routine order for morphine. He/she did not recall the PRN order for morphine being discontinued and was not aware of the routine morphine order being discontinued. During an interview on 10/14/22 at approximately 12:18 P.M., the hospice supervisor said when the hospice manager received an order for morphine extended release 30 mg, the facility took it upon themselves to discontinue morphine 10 mg every four hours. During an interview on 10/14/22 at 1:15 P.M., the hospice RN manager said the order for routine morphine 10 mg was ordered on 9/2/22 and the resident was not receiving it until 9/7/22. It should not have been discontinued on 9/14/22. Review of the resident's hospice progress notes, dated 9/15/22 through 9/22/22, showed: -On 9/15/22 showed, had to rewrite the order for morphine 10 mg every four hours scheduled for pain. Staff confused about orders. They were clarified in writing; -On 9/16/22, resident states he/she is not getting his/her scheduled morphine 10 mg every four hours. Order rewritten for morphine 10 mg every four hours. Orders clarified and given to facility nurse. The resident did not have orders for every four hours morphine scheduled. -On 9/20/22 at 9:08 A.M., medication ordered clarified again this visit, watched Nurse visibly enter in morphine 10 mg every four hours scheduled due to orders not being entered once they've been written. Review of the resident's MAR, dated 9/15/22 through 9/20/22, showed the order for Morphine 10 mg every four hours for pain. The order was rewritten on 9/15/22, but was not started until 9/20/22. During an interview on 10/13/22 at 1:17 P.M., the Director of Nursing (DON) said when the hospice nurse received orders for a new medication or a change in a medication, that information is communicated to the facility floor nurse and the facility nurse will enter the information into the computer. If the hospice nurse gave the facility nurse an order, the DON would expect the order to be entered into the computer the same day. During a telephone interview on 10/14/22 at 12:15 P.M., the resident said he/she had pain in his/her abdomen, hands and feet. The pain was severe, most days the pain was a 9 to 10/10. The scheduled morphine was not given on time and he/she had to remind staff to give the medications. If he/she asked for a prn pain medication it would take hours to get it. He/she did ask to speak to someone at the facility about it and was told they were shorthanded and stuff like that. During an interview on 10/15/22 at 9:06 A.M., the DON said she did not know why the orders for morphine received on 9/2/22 were not entered into the computer until 9/7/22. She did not know why the morphine order was then discontinued on 9/14/22, then rewritten on 9/15/22 and not entered into the computer until 9/20/22. An increase in the resident's pain level would be a possible consequence of not receiving pain medications as ordered. It would be considered a medication error if the medication was not administered as ordered. The DON would expect for staff to follow physician orders and administer medications as ordered and would expect for staff to follow the facility's policies and procedures. MO00207355

Based on interview and record review, the facility failed to ensure pain management was provided to one resident (Resident #56) who received hospice care (care that focuses on end of life comfort) when pain medications were not administered to the resident as ordered, which resulted in uncontrolled pain. The sample was 39. The census was 163. Review of the facility's Pain Management and Assessment policy, dated 7/25/18, showed the following: -It is the policy of this facility to provide resident centered care that meets psychosocial and emotional needs and concerns of the residents; -The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, the resident's choices, related to pain management; -The clinician must accept the resident's report of pain; -The nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pain. Review of the facility's Coordination of Care for Hospice Services policy dated 2/15/22, showed the following: -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents; -Hospice Care or End of life Care: a distinct service provider with a focus on maintaining or improving quality of life for someone who's illness, disease or conditions unlikely to be cured. Hospice provided for comprehensive comfort care provide to those with a terminal illness that is not responding to treatment. Treatment is not the goal but instead comfort and dignity is the goal for end of life choices; -The purpose of this policy is to provide guidance for coordination of services, reduce duplication of services and improve outcomes for resident in the facility that elects to use hospice services; -The facility is responsible for working with hospice care services to provide the optimum benefits for end-of-life care including pain relief, custodial care, and resident preferences to the extent possible; -Communication between facility staff and the hospice care staff is an integral part of this partnership; -The facility clinical team will coordinate services and care with the hospice team for comfort, care, and therapeutic measures as appropriate; -The facility and the hospice service must have a method to communicate changes and updates regarding the residents care needs; -Coordinated care needs may include pain management including breakthrough pain and treatment. Review of Resident #56's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/14/22, showed the following: -readmitted : 9/1/22 from an acute care hospital; -Cognitively intact; -Had an ostomy (a surgically created opening from an area inside the body to the outside of the body); -Diagnoses included cardiorespiratory (heart and lungs) debility, atrial fibrillation (irregular heart beat), coronary artery disease (damage or disease of the heart's major blood vessels usually caused by plaque build-up), high blood pressure, diabetes, malnutrition and respiratory failure (the lungs fail to get enough oxygen to the blood); -Was on a scheduled pain medication regimen; -Received as needed (PRN) pain medications; -Had pain present; -Pain was rated a nine on the numeric pain rating scale (a scale used to measure pain intensity, where zero is no pain and ten is the worst pain imaginable); -Received hospice care while a resident. Review of the resident's medical record, showed a diagnosis of chronic pain (persistent pain that carries on longer than 12 weeks despite medication or treatment). Review of the resident's care plan, in use at the time of the survey, showed the following: -Pain secondary to abdominal wall opening and chest pain on breathing; -Interventions included administering non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice/heat, music therapy, relaxation techniques, imagery), assessing and monitoring for pain, providing medications as ordered and notifying the medical provider of unsuccessful interventions. Review of the resident's September 2022 progress notes, showed on 9/1/22 at 2:23 P.M., the resident readmitted to the facility on hospice services. Medications were verified with the medical director and hospice nurse. Review of the resident's hospice plan of care, effective 9/1/22 through 9/6/22, showed the following: -An order dated 9/1/22, for morphine (an opioid medication used to alleviate pain) 10 milligram (mg) every one hour PRN for pain; -An order dated 9/2/22, for Morphine 10 mg every four hours scheduled for pain; -Patient's pain/physical discomfort will be reduced to the level of the patient's stated goal or patient does not demonstrate signs and symptoms of physical discomfort; -Patient/caregiver will verbalize understanding of the pain management plan. Review of the resident's September 2022 physician order sheet (POS), showed the following: -An order dated 9/1/22, to monitor pain every shift; -An order dated 9/1/22, for morphine 2 mg every one hour as needed for pain; -No order dated 9/2/22, for morphine 10 mg every four hours scheduled per the hospice plan of care. Review of the hospice care progress notes, showed the following: -9/1/22 at 9:10 A.M., hospice and facility developed a coordinated plan of care that guides both providers. Plan of care coordination completed with facility nurse; -9/1/22 at 2:01 P.M., the resident had increased abdominal pain rated 10 out of 10, medications were reconciled with the provider and the nurse verbalized understanding of the medication regimen; -9/2/22 at 10:04 A.M., the resident rated his/her pain at a 10, appeared very uncomfortable and his/her heart rate was elevated. Hospice nurse spoke to the facility nurse, who was unaware resident was in the facility or that he/she had pain medications. Morphine 10 mg every hour PRN was kept and morphine 10 mg every four hours scheduled was added. The resident received morphine 10 mg at 8:30 A.M. and 9:40 A.M. and then appeared comfortable; -9/3/22 at 10:00 A.M., the resident denied receiving morphine pain medication. Hospice made the nurse and certified medication technician (CMT) aware that a new order was written for morphine every four hours. Staff brought the resident his/her pain medication. Review of the resident's September 2022 medication administration record (MAR), reviewed for the dates of 9/1/22 through 9/5/22, showed the following: -Monitor for pain every shift: Staff initials documented but no pain levels recorded; -Morphine sulfate solution 20 mg per 5 milliliters (ml), administer 0.5 ml to equal 2 mg every one hour as needed for moderate pain: -Not administered on 9/1/22 when the resident reported 10 out of 10 pain; -On 9/2/22 at 9:42 A.M., administered for pain of 8; -On 9/3/22 at 11:02 A.M., administered for pain of 3; -No further doses documented as administered; -No order for morphine 10 mg every four hours scheduled. Review of the resident's hospice plan of care update, effective 9/6/22 through 9/20/22, showed the following: -An order dated 9/1/22, for Morphine 10 mg every one hour PRN for pain; -An order dated 9/2/22, for Morphine 10 mg every four hours scheduled for pain; -Current complaints/new problems: Increased pain, shortness of breath (SOB) with pain, high blood pressure and rapid heart rate with increased pain. Review of the resident's September 2022 POS, showed the following: -An order dated 9/1/22, to monitor pain every shift; -An order dated 9/1/22, for morphine 2 mg every one hour as needed for pain; -An order dated 9/7/22 and discontinued 9/14/22, for morphine sulfate 10 mg every 4 hours for pain: -No order for the morphine sulfate 10 mg every 4 hours for pain prior to 9/7/22, as ordered by hospice on 9/2/22 and no order between the dates of 9/14/22 through 9/20/22; -An order dated 9/14/22, for morphine sulfate extended release (ER, long acting) 30 mg every 8 hours for pain; -An order dated 9/20/22, for morphine sulfate 10 mg every 4 hours for pain. During an interview on 10/14/22 at approximately 12:18 P.M., the hospice supervisor said when the hospice registered nurse (RN) manager received an order for and added morphine extended release, the facility, without an order, discontinued the morphine 10 mg every four hours. Further review of the hospice care progress notes, showed the following: -9/7/22 at 12:15 P.M., the resident appeared moderately uncomfortable and rated pain as a seven out of ten. He/she requested Morphine and uncontrolled pain was noted. The facility nurse was unaware that hospice ordered Morphine 10 mg every 4 hours scheduled and every one hour PRN. Order for Morphine 10 mg every four hours was rewritten because they were not in the system. The facility nurse reported that the resident requested morphine every six hours and the resident reported requesting morphine more often and not receiving it; -9/8/22 at 9:51 P.M., the resident stated he/she was in pain and the facility nurse administered morphine; -9/9/22 at 9:20 A.M., the resident rated his/her pain five out of ten and it was noted that he/she had received morphine every four hours and PRN; -9/13/22 at 9:11 A.M., the resident grabbed at his/her abdomen and appeared to be in pain. He/she reported his/her pain to be an eight out of ten. Morphine extended release 30 mg every eight hours was added. All Morphine orders were to remain in place. The facility nurse called the hospice office shortly after the visit asking if short acting morphine should be discontinued and the hospice RN manager clarified that all orders should be continued; -9/16/22 at 8:32 A.M., the resident complained that he/she had not received his/her scheduled morphine concentrate. Hospice rewrote the order for morphine 10 mg every four hours scheduled for pain. Morphine extended release 30 mg every eight hours, morphine concentrate 10 mg every four hours scheduled and morphine 10 mg every one hour as needed were clarified with the facility nurse; -9/18/22 at 4:00 P.M., the resident reported not getting pain medications as ordered and denied receiving pain medication until 1:15 P.M. The facility nurse reported that the resident received pain medication in the morning. Morphine concentrate was administered while hospice was in the facility. The nurse was aware that morphine 30 mg was scheduled every eight hours and Morphine concentrate was scheduled every 4 hours; -9/20/22 at 9:08 A.M., the resident complained about his/her medications and pain continued to be an issue since the last visit. Medication orders were clarified again and the nurse was watched when inputting morphine 10 mg every 4 hours. The facility nurse voiced understanding of comfort medication orders. Review of the resident's September 2022 MAR, reviewed for the dates of 9/6/22 through 9/22/22, showed the following: -Monitor for pain every shift: Staff initials documented but no pain levels recorded; -Morphine sulfate solution 20 mg per 5 ml, administer 0.5 ml to equal 2 mg every one hour as needed for moderate pain: -On 9/5/22 at 10:04 A.M., administered for pain of 6 at 6:13 P.M., administered for pain of 8; -On 9/6/22 at 6:04 P.M., administered for pain of 8; -On 9/7/22 at 8:49 A.M., administered for pain of 8; -On 9/16/22 at 9:36 A.M., administered for pain of 7; -No further documentation of as needed morphine sulfate administered; -An order dated 9/7/22 and discontinued 9/14/22, for morphine sulfate 10 mg every 4 hours for pain: -Documented as not administered on 9/13/22 for the 12:00 A.M. dose; -Documented as not administered on 9/14/22 for the 12:00 P.M. dose; -No order for morphine sulfate 10 mg every 4 hours for pain between the dates of 9/14/22 through 9/20/22; -An order dated 9/20/22, for morphine sulfate 10 mg every 4 hours for pain. Review of the resident's September 2022 progress notes, showed: -No documentation to show why the 9/13/22 12:00 A.M., morphine sulfate 10 mg every 4 hours for pain was not given; -On 9/14/22 at 1:55 P.M., morphine sulfate every 4 hours for pain not given. No further rationale why the medicine was not given. Review of the resident's narcotic count sheets, showed: -Morphine sulfate solution 100 mg/5 ml (10 mg) give 10 mg every hour as needed for pain, date on the label was 9/1/22; -Morphine 30 mg, date received 9/13/22; -No narcotic count sheet was provided for morphine 2 mg every hour PRN. Review of the resident's September 2022 progress notes, showed: -No documentation of non-pharmacological intervention implemented for complaints of pain; -No documentation that the physician was notified the resident complained of pain; -On 9/22/22 at 11:09 A.M., the resident discharged to a new facility via emergency medical services. During an interview on 10/11/22 at 4:00 P.M., Nurse GG said when the resident received his/her morphine it did help the resident's pain and he/she was resting more and was less agitated. On 10/14/22 at 11:11 A.M., Nurse GG said he/she never thought the resident was in pain. He/she always looked comfortable. The resident did not complain of pain unless you asked him/her about their pain and he/she knew their medications and what time they were to be administered. The resident always got their medications as ordered and the resident would make sure he/she got it. During an interview on 10/14/22 at 9:55 A.M., Nurse TT said when he/she saw the resident, he/she did not appear to be in pain. The resident knew his/her medications and if the pain medication was not there he/she would ask for the pain medication. When his/her routine morphine every four hours was discontinued, Nurse TT did not notice any increase in complaints of pain During an interview on 10/14/22 at 11:26 A.M., Nurse K said the resident would occasionally request pain medicine and would rate pain between 6 and 8, a lot of times. The resident did not have signs of pain. During a telephone interview on 10/14/22 at 12:15 P.M., the resident said when he/she was as the facility, he/she was in severe pain. He/she had pain in his/her abdomen, hands and legs and rated his/her pain level at 9 to 10 most days. The morphine was not given on time and he/she would have to remind staff to give him/her his/her medication. The morphine would relieve the pain briefly. During an interview on 10/14/22 at 12:17 P.M., the hospice social worker said it was consistently reported to the facility nurses that the resident's pain was not well controlled. The resident was not consistently receiving his/her pain medication. During an interview on 10/14/22 at 1:15 P.M., the hospice RN manager said the resident was tearful, anxious and shaky the day after he/she admitted to the facility because he/she had not received morphine on the first day he/she was admitted and he/she had a PRN order for morphine 10 mg. The routine morphine 10 mg was ordered on 9/2/22 and the resident was not receiving it until 9/7/22. It should not have been discontinued on 9/14/22. The resident was always in pain and his/her quality of life would have been better if he/she received his/her pain medication regularly. During an interview on 10/13/22 at 1:17 P.M., the Director of Nursing (DON) said an increase in the resident's pain level would be a possible consequence of not receiving pain medications as ordered. The DON would expect for staff to follow physician orders and administer medications as ordered and expected for staff to follow the facility's policies and procedures. During an interview on 10/25/22 at 2:00 P.M., the resident's physician said when hospice wrote an order for medications, he/she expected facility staff to follow it, if the medications were available. He/she expected facility staff to start hospice orders on the same day hospice wrote the orders, if it had been communicated to the nurses. The resident was a sick person and was in the hospital 10-15 times. He/she received pain medication before receiving hospice services. Morphine 2 mg would have been a med error and is not a morphine order. The usual morphine dose is 10 mg. Morphine 2 mg would not make a difference for the resident. The resident was known to get pain medication. MO00207355

Based on interview and record review, the facility failed to ensure all residents were free from physical abuse when one staff member, certified nurse aide (CNA) A, held one resident's (Resident #12) arms behind his/her back. The staff member was observed wrestling the resident and falling to the floor which resulted in the resident sustaining bruises and abrasions. The sample was 21. The census was 161. The administrator was informed on 5/25/22 of an Immediate Jeopardy (IJ), which began on 5/16/22. The IJ was removed on 5/27/22 as confirmed by surveyor on-site verification. Review of the facility's Abuse, Neglect and Misappropriation Policies and Standard Procedures, revised 10/27/21, showed: -Definitions: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, or good or services that are necessary to attain or maintain physical, mental and psychosocial well-being; -Physical Abuse: Includes hitting, slapping, pinch, kick or flicking with fingers or striking in any manner that is demeaning. It also includes controlling behavior through corporal punishment. 1. Review of the Resident #12's medical record, showed: -admitted on [DATE]; -Diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, difficulty in walking, personal history of self harm, anxiety and schizoaffective disorder (a combination of schizophrenia, a disorder that affects a person's ability to think, feel and behave clearly and mood disorder, such as depression or bipolar disorder). Review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff dated 4/9/22, showed: -Cognitively intact; -Exhibited no behaviors; -Independent with locomotion on and off the unit. Review of the resident's care plan showed: -Focus: Revised 4/4/22. The resident is receiving ECT, related to frequent behaviors; -Goal: The resident will attend all ECT treatments to completion; -Interventions: ECT treatments at the hospital. Pick up at 6:45 A.M. via hospital transportation; -Focus: Revised 4/4/22. The resident has potential to demonstrate physical behaviors related to poor impulse control, bipolar disorder and anxiety; -Goal: The resident will demonstrate effective coping skills through the review date. The resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalates behaviors and document. Assess and address for contributing sensory deficits, assess and anticipate needs. Provide physical and verbal cues to alleviate anxiety, give positive feedback, and assist verbalization of source of agitation. Assist to set goals for more pleasant behavior. Encourage seeking out staff member when agitated. If 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. Monitor, document and report to MD of danger to self and others. Provide as many choices as possible about care and activities; -Focus: Revised 4/12/22. The resident often exhibits agitation towards staff. The resident was noted to push the medicine cart at a nurse due to his/her agitation; -Goal: The resident will remain free of agitation related behaviors; -Intervention: Administer medications as ordered. Observe and document signs and symptoms of effectiveness and side effects. Allow resident one on one time to vent his/her frustrations; -Focus: Revised 2/13/22. The resident has shown non-redirectable behaviors. He/she easily becomes fixated on a person or thing. The resident has been noted to attack a staff member with a fork; -Goal: The resident will remain free of non-redirectable behaviors through the next review date; -Interventions: Allow the resident to vent his/her frustrations and feelings. Educate the resident on respecting personal/physical/emotional boundaries. Provide education about positive behaviors and behavior management. Review of Resident #12's hospital record, dated 5/16/22, showed: -Chief Complaint: Social Problem; -History of present illness: The resident presents to the emergency department from same day surgery, earlier from the nursing home. Reportedly, he/she was here getting electroconvulsive therapy (ECT, a psychiatric treatment where a generalized seizure is electronically induced to manage refractory mental disorders) when he/she told the nurses here that he/she was abused at the nursing home. He/she was evaluated by our nurses who were suspicious of possible abuse so he/she was sent to the emergency department. According to the patient, he/she got into a fight with an orderly. It sounds like he/she was ultimately escorted back to his/her room with his/her arms behind his/her back by the orderly, according to the resident. The patient states he/she was hit and kicked by the orderly. When asked where and how he/she was kicked or hit, the patient states, I'm not aware of him/her hitting me. Patient clearly characterized how he/she was kicked, other than describing a way of being tripped and let down to the ground by the orderly. He/she states he/she was fighting back. I was hitting and kicking him/her. He/she denies loss of consciousness. He/she does have bruises and abrasions; -Wound Type: -Abrasion (the surface layers of the skin (epidermis) has been broken) below the knee; -Abrasion/scratches on right shoulder, superficial; -Abrasion on right calf; -Abrasion on left eye, orbit, eyebrow and left forehead. Bruised lower eye and nose. Some abrasions on side of nose and forehead (left); -Abrasion on right eyebrow and forehead; -Small scattered abrasion on right elbow and right lower arm; -Abrasion on right inner forearm; -Abrasion on right lateral forearm. Review of the resident's progress notes, showed: -5/16/22 at 12:44 P.M., Staff at the hospital notified this facility of this resident stating a staff member abused him/her. Per allegations, the resident stated to hospital staff a facility staff member hit and kicked him/her. Immediate investigation started. Police notified. Department of Health and Senior Services (DHSS) in building and notified. Legal guardian aware and stated this resident will not return to the facility. Primary care physician and psychiatrist notified. During an interview on 5/16/22 at 12:31 P.M., the DON said Resident #12 reported to hospital staff a heavy set, medium height staff member beat him/her up and gave him/her a black eye. The description was of CNA A. CNA A was suspended pending an investigation. The facility started their investigation and began in-servicing staff. Review of the resident's care plan, updated on 5/16/22, showed: -Focus: Revised 5/16/22. The resident has behavior problems. The resident often states false allegations; -Goal: The resident will have fewer behaviors through the review date; -Interventions: Approach and speak in a calm manner, behavioral health consults as needed, communicate with resident/resident representative regarding behaviors and treatment. Encourage to maintain as much independence and control/decision making as possible. During an interview on 5/17/22 at 8:32 A.M., CNA A said he/she worked at the facility for over a year and was not assigned to the resident, but worked on the south hall. On 5/16/22 around 6:30 A.M., he/she was completing his/her assignments when Resident #12 came to the nurse's station and said he/she had to go to an appointment. Nurse B asked CNA A if the resident had an appointment. CNA A told Nurse B the only appointments were for residents going to dialysis and he/she did not know of any appointment for the resident. Nurse B told the resident he/she would check to see if the resident had an appointment. The resident became upset and started cussing and said he/she had to leave. The resident became irate. CNA A gave the resident a hug from behind with his/her arms over the resident's arms to calm the resident down. The CNA walked the resident back to his/her room while the nurse left to check on the appointment. He/she continued to hug the resident as they walked back to the resident's room and told the resident to calm down. CNA A denied hitting the resident. CNA A said he/she held the resident like the police and held the resident's hands behind his/her back until the resident calmed down. The resident was upset, then calmed down. CNA A left the room and then the resident ran out of the room towards CNA A with a belt in his/her hand. A linen cart was in the hallway, so CNA A grabbed the linen cart and moved it between him/herself and the resident to create a barrier. Nurse B then returned and was able to calm the resident down. CNA A completed his/her rounds with other residents and left the facility. During a telephone interview on 5/24/22 at 11:51 A.M., Resident #12 said he/she was waiting at the front entrance for transportation to his/her ECT treatment at the hospital when the orderly (identified as CNA A) told him/her to go back to his/her room. He/she told CNA A he/she had an appointment. The nurse came to the front entrance and told the resident he/she would check to see if the resident had an appointment. The nurse then left. CNA A told him/her to go to his/her room and pushed the resident. CNA A then put the resident's arms behind his/her back and pushed the resident back to his/her room. When they got to the room, the resident tried to free his/her hands, but could not. CNA A and the resident went to the ground and the resident's head was down. CNA A hit the resident in the eyeball. CNA A continued to have the resident's hand behind his/her back. The resident said CNA A beat me up and pushed me around a little bit. The nurse came in while the resident's arms were behind his/her back and said he/she would take over from there and watch the resident. CNA A left and the nurse gave the resident his/her medication. The nurse left the room and then returned shortly to tell him/her the transportation had arrived. The resident denied leaving his/her room with a belt or that a linen cart was pushed in his/her direction. The resident has since returned to the facility and feels safe because CNA A was fired. During an interview on 5/17/22 at 9:30 A.M., Nurse B said Resident #12 was at the nurse's station and upset because he/she had an appointment. Nurse B told the resident he/she did not see an appointment for the resident. He/she checked the Treatment Administration Record (TAR) and saw where the resident received ECT. He/she told the resident he/she was going to assist another resident and would return to check on the appointment. He/she left to check on the other resident and left Resident #12 at the nurse's station with CNA A. He/she did not see anything out of the ordinary. After returning from the other resident's room, Nurse B saw the linen cart in the middle of the hallway on Resident #12's unit. The phone rang at the nurse's station and it was the resident's transportation for ECT. He/she then knocked on the resident's door to inform him/her of the appointment. The resident was in his/her room. The nurse denied seeing any bruising on the resident. The resident's room seemed to be in shambles. The resident's night stand was knocked over and items were on the floor. He/she denied seeing any interaction between CNA A and the resident. During an interview on 5/17/22 at 11:11 A.M., Resident #21, who the facility identified as alert and oriented said he/she was in bed asleep when his/her roommate (Resident #12) and CNA A came in the room wrestling. They ended up on Resident #21's bed, then on the floor. CNA A held the resident down from behind and told the resident to calm down, or he/she would strangle him/her. He/she denied seeing CNA A hit the resident. During an interview on 5/17/22 at 12:57 A.M., Resident #16, who the facility identified as alert and oriented, said about two nights ago he/she overheard residents fighting. He/she overheard the commotion as his/her room was next door to Resident #12's. He/she overheard commotion and things being thrown. He/she also overheard CNA A say, Are you done? Did you get it out of your system? During an interview on 5/17/22 at 1:02 P.M., Resident #17, who the facility identified as alert and oriented said he/she overheard commotion from next door. He/she overheard a voice saying, Calm down. He/she denied seeing or overhearing anything else. During an interview on 5/17/22 at 1:16 P.M., Resident #20, who the facility identified as alert and oriented, said he/she overheard a commotion from next door. Resident #12 was saying he/she needed to go to the hospital and was arguing with a male nurse. He/she denied hearing any fighting, only Resident #12 saying he/she wanted to go to the hospital. During an interview on 5/17/22 at 12:00 P.M., the DON said when she spoke with CNA A, he/she did not mention taking the resident to his/her room or that the incident became physical. During an interview on 5/19/22 at 11:50 A.M., the administrator and DON said the CNA's actions were not appropriate. The CNA should have reported the incident and involved the nurse to de-escalate the situation. The CNA will be terminated from the facility. During an interview on 5/25/22 at 11:29 A.M., the resident's physician said staff should not have held the resident down if he/she was not a danger to him/herself. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00201332 MO00201251 MO00201231

Based on observation, interview and record review, the facility failed to ensure pain management is provided to residents who require such services, consistent with professional standards of practice by failing to adequately assess and treat pain for one of three residents investigated for pain concerns. The resident fell and suffered a broken hip, ankle and knee; experienced severe pain and was not provided pain management for three weeks (Resident #82). The sample was 32. The census was 162. Review of Resident #82's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/6/18, showed: -[DIAGNOSES REDACTED]. -Functional limitation of range of motion: No impairment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance of two or more staff needed for bed mobility including moving to and from lying position, turning side to side and positioning body; -Functional limitation in range of motion due to impairment on one side; -On a scheduled pain medication regimen; -Received as needed (PRN) medications for pain; -Pain assessment interviews should be conducted. Review of the resident's physician order [REDACTED]. -An order dated for 6/26/18, for [MEDICATION NAME] Patch (used to treat pain) 25 micrograms (mcg) every 72 hours. Apply one patch [MEDICATION NAME] (on the skin), in the afternoon every three days for pain; -An order dated 12/1/16, for [MEDICATION NAME] tablet (combination of narcotic pain medication and Tylenol) 5-325 milligram (mg). Give one tablet every four hours as needed for pain; -Monitor for pain every shift. Review of the resident's nurse's notes: -On 11/6/18 at 8:00 P.M., showed a late entry: Staff observed the resident on the floor. Staff assessed the resident and returned him/her to bed. The resident had a laceration (cut or break in the skin) to his/her nose; -On 11/9/18 at 1:27 P.M., the next note after 11/6/18, the resident complained of 10 out of 10 pain to his/her lower right extremity. He/she had bruising to the back of his/her leg. The resident told staff he/she had a fall two days before but was not in pain at the time of the fall. Staff called the resident's physician's exchange about the change in condition and left a message; -At 6:53 P.M., the nurse assessed the resident due to the earlier complaint of pain. The resident stated he/she felt fine and his/her nose was not broken. Staff administered PRN narcotic; -No documentation the physician returned the call or if staff followed through on the call to the physician. Further review of the resident's MAR, dated 11/1/18 through 11/30/18, showed the following: -Monitor for pain every shift: -On 11/6/18 through 11/13/18, pain level not documented as assessed on day, evening or night shift; -On 11/13/18, pain level not documented as assessed on day or night shift. Evening shift documented pain level at 3 (on a scale of 0-10, 0 indicates no pain, 10 indicates the most severe pain); -On 11/14/18 through 11/19/18, pain level not documented as assessed on day, evening or night shift; -On 11/20/18, pain level not documented as assessed on evening or night shift. Day shift documented pain level at 5; -On 11/21/18 through 11/24/18, pain level not documented as assessed on day, evening or night shift; -On 11/25/18, pain level not documented as assessed on day or night shift. Evening shift documented pain level at 2; -On 11/26/18, pain level not documented on evening or night shift. Day shift documented a pain level at 0; -[MEDICATION NAME] Patch 25 mcg every 72 hours for pain: -On 11/8/18, [MEDICATION NAME] applied, pain level at 0; -On 11/11/18, [MEDICATION NAME] not documented as applied, pain level not documented. See nurses notes; -On 11/14/18, [MEDICATION NAME] not documented as applied, pain level not documented. See nurses notes; -On 11/17/18, no documentation if [MEDICATION NAME] applied or pain level recorded; -On 11/20/18, [MEDICATION NAME] applied, pain level 5; -On 11/23/18, [MEDICATION NAME] applied, pain level at 0; -On 11/26/18, [MEDICATION NAME] applied, pain level at 0; -[MEDICATION NAME] 5-325 mg, one tablet by mouth two times a day for pain. Scheduled administration times of 8:00 A.M. and 4:00 P.M.: -Documented as administered on 11/10/18 at 2:40 P.M., 11/17/18 at 11:51 P.M. and 11/30/18 at 9:30 A.M. only. Further review of the resident's POS, showed: -An order dated 11/29/18, for [MEDICATION NAME] 5-325 mg, give one tablet by mouth two times a day for pain; -An order dated 12/5/18, for [MEDICATION NAME] sulfate (narcotic pain medication), 5 mg every three hours as needed for pain. Further review of the resident's MAR, showed no documentation of PRN [MEDICATION NAME] administered after 11/17/18 for pain. During an interview on 5/15/19 at 8:20 A.M., the corporate vice president said she entered the late entry on 11/28/18 after staff realized the resident had a broken hip, ankle and knee. Further review of the resident's nurse's notes, showed the following: -On 11/14/18 at 11:30 A.M., the next note after 11/9/18, the resident complained of right hip and leg pain. Staff placed a call to the resident's physician who gave an order for [REDACTED]. At 5:44 P.M., the interdisciplinary team met to discuss the resident's additional dependence on staff and requested an order for [REDACTED].>-No documentation of whether the x-ray was done or results; -On 11/27/18 at 2:04 P.M., staff ordered an x-ray on 11/14/18 for the resident's right hip, pelvis, femur (long bone of the upper leg), tibia/fibula (bones of the lower leg) and ankle. The x-ray technician was unable to straighten the resident's leg and had to send another technician over later that day. The x-ray technician who came out later x-rayed the wrong hip and leg. The nurse reordered another x-ray on 11/27/18. At 8:10 P.M., staff called the x-ray service to inquire about the results of the x-ray. The x-ray staff said the resident showed positive for a right distal femur fracture, a recent right [MEDICAL CONDITION], a right ankle fracture with healing present, a right recent knee fracture as well as a tibia/fibula recent right fracture. Staff notified the resident's physician who ordered him/her sent to the hospital. Review of the resident's discharge MDS, dated [DATE], showed unplanned discharge, return anticipated, to an acute care hospital. Review of the resident's radiology report dated 11/27/18, showed the following: -There is a fracture involving distal tibia and fibula (ankle) with no displacement. There is associate soft tissue swelling; -There is a fracture involving right distal femur with displacement (bone is not aligned). There is associated joint effusion (abnormal accumulation of fluid); -There is a fracture involving the right femoral neck with displacement. Recent right [MEDICAL CONDITION] as described above. Proximal and distal right femur (knee) fracture as described. Review of the resident's hospital records, dated 11/28/18, showed the following: -Resident presented with a fall (rolled out of bed a few weeks ago, normally bed bound). Resident complained of pain of right side since, so physician ordered x-rays and found he/she had right hip, right femur, right tibia/fibula and right ankle fractures and sent resident to the hospital. The resident has dementia and is reportedly bed bound. He/she stated he/she fell out of bed but did not recall when. According to charts he/she either fell out of bed a few weeks ago or on 11/27/18. Due to complaints of pain since falling, x-rays were performed. Observation on 5/14/19 at 12:28 P.M., showed the resident lay in bed and had facial grimacing. The resident said he/she stays in bed all day. He/she gets lonely and wished someone would come talk to him/her. On 5/16/19 at 8:09 A.M., the resident sat up in bed and staff assisted the resident with breakfast. He/she does have pain at times. During an interview on 5/14/19 at 4:00 P.M., Licensed Practical Nurse (LPN) V said he/she thought the resident needed an x-ray on 11/14/18 because he/she continued to complain of pain on his/her right side. The X-ray company sent out someone on his/her shift but the resident could not straighten his/her right leg to get the X-ray so they left until another technician could come out. The x-ray company did not come back until after the LPN had left for the day. An agency nurse actually sent the order in and LPN V thought he/she passed the information along to the next shift. He/she did not work directly with the resident again until 11/17/18, so he/she did not realize the x-ray company x-rayed the wrong leg. When he/she came to work on 11/17/18, Certified Nurse's Aide (CNA) W told him/her the resident had been in pain all weekend. He/she would cry out in pain whenever touched. He/she told the nurse on duty but the nurse did not go in and assess the resident or call the physician. LPN V reviewed the resident's chart to find out the results of the x-ray and realized the results were not there. He/she called the x-ray company to find out the results and realized the company had x-rayed the wrong side. He/she immediately called the resident's physician to reorder an x-ray on the correct side. During an interview with a staff member at the x-ray company on 5/14/19 at 2:00 P.M., he/she said the original x-ray on 11/14/18 had the right side listed but it looked like someone scratched out right and wrote left on the original order that came from the facility. During an interview on 5/15/19 at 1:10 P.M., CNA W said the resident was in pain on the weekend of 11/24 and 11/25/18. He/she would cry out No, no when touched and his/her face was grimaced with pain. He/she would scream out in pain. The resident regularly yelled out but this yelling was different. The CNA told the nurse something was wrong with the resident but the nurse only said ok but never went in and looked at the resident. It was not until LPN V came in on 11/17/18 that the resident was assessed and the physician was called. During an interview on 5/15/19 at 1:15 P.M., assistant Director of Nursing (ADON) U said staff should have called the resident's physician after the fall if there was an injury to his/her face. There should have been some documentation to alert the next shift after the incident occurred. The person who ordered the x-ray should have documented if the x-ray company came and the results of the x-ray. If it was a STAT (increased urgency) order, staff should have called for the results before the shift was over. Staff should have called the physician if the resident continued to complain of pain and all of this should have been documented. During an interview on 5/16/19 at 2:15 P.M., the administrator said staff should have notified the resident's physician when he/she complained of pain after the fall and should have followed through on getting the results from the x-ray. During an interview on 5/14/19 at 3:45 P.M., the resident's physician said he remembered ordering the first x-ray but did not remember staff contacting him again before the second x-ray. If the resident continued to complain of pain, staff should have contacted him again. He was always available and the resident should not have had to be in pain for three weeks. They should have followed up on the first x-ray.

Based on observation, interview and record review, the facility failed to provide protective oversight for one sampled resident (Resident #3) who was at risk for elopement. The facility had recently assessed the resident had short and long term memory problems, wandering behaviors and a [DIAGNOSES REDACTED]. On 1/28/19, the resident left the building without staff's knowledge and was outside of the facility for an undetermined amount of time wearing a thin [NAME]et, long sleeved shirt and pajama pants. The temperature at that time was approximately 30 degrees Fahrenheit. An undetermined amount of time passed before staff were aware the resident was missing, a code was called and a search was begun. The facility did not alert the police that the resident was missing. Facility staff did not follow their policy and procedure for locating the resident. The census was 169. Review of the facility's elopement prevention and management overview, dated 7/1/2016, showed: -Definitions: -Elopement is defined as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at harm or injury; -Unsafe wandering is defined as when a resident enters an area that is physically hazardous or contains potential safety hazards; -Leave of absence (LOA) is defined as when a cognitively intact resident who is capable of independent decision making completes the facility sign out procedure prior to leaving the facility; -Policy: The interdisciplinary team plans the least restrictive interventions to promote mobility and safety and to meet the individualized needs and goal of the resident. Components of the elopement prevention and management program include, but are not limited to, the following: -Elopement drills; -Environmental modifications to promote safe mobility with monitoring for effectiveness; -Protected list of names and photographs of those residents identified as being at risk for elopement; -Regular rounds; -Structured group activities. -Procedure: -Identify residents who are at risk for elopement; -Determine elopement risk factors which may include, but are not limited to: -Acute or chronic confusion/disorientation; -Anxiety; -Dementia, or dementia related disease; -History of purposeful wandering and/or elopement; -New admission with adjustment difficulties, or a desire to return to previous living situation; -Restless, irritable; -Document risk factors; -Develop and document individualized interventions to manage risk factors; -Discuss interventions and goals with resident and/or family/responsible party; -Communicate risk factors to caregiving staff; -Monitor and document resident response to elopement risk reduction interventions; -Evaluate effectiveness of interventions during clinical meetings; -Modify goals and interventions as indicated and communicate changes to the caregiving team, resident and/or family/responsible party. Review of the facility's elopement management policy, dated 7/1/2016, showed: -Definitions: -Centers for Medicare and Medicaid Services (CMS); -Elopement: CMS defines elopement as when a resident leaves the premises or a safe area without the authorization and/or necessary supervision. Each state may define elopement by a set of criteria for self-reporting. -Policy: The facility is to immediately initiate procedures to locate any resident that is unaccounted for. Notification of appropriate parties will comply with state and federal regulations. Following location of the involved resident the facility leadership will review prevention systems to identity performance opportunities. Failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe area and are unaccounted for is considered elopement. Residents who are their own person and choose to leave the premises without staff knowledge will be considered an Unauthorized Leave of Absence (LOA) and not elopement. -Procedure: -Announce the facility code for missing resident; -Form a search team. Verify that staff is available to stay with current residents; -Notify the supervisor immediately of any suspected elopement/missing resident: -Supervisor notifies the Executive Director (ED) and Director of Nursing (DON) if resident is not quickly located; -ED notifies regional staff; -Conduct a head count to determine any additional missing residents; -Search all areas of the facility, opening all doors, entering all rooms. Include all closets, storage areas and under beds; -Search the immediate grounds of the facility; continue to broaden the radius of the outdoor search; -Note: If health threatening weather, or nearby external hazard, initiate outdoor search with second team while internal search is underway; -Interview staff to determine last known location, clothing description and any indication made by the resident that they were leaving for a certain location; -Interview residents as appropriate for any indication made by the resident that they were leaving for a certain location; -Notify the resident's physician; -Notify the resident's family and/or responsible party; -Notify law enforcement and state agencies as required by state regulations; -Note: Notification of law enforcement and state agency will be completed by the ED or designee; -Missouri: -The reporting facility will contact the Complaint Registry Unit (CRU) in Jefferson City to report incidents that meet self-reporting criteria; -Inform CRU this is a self-report; -Elopement as defined by CRU criteria: -Elopement does not include a resident who is witnessed walking out of a door and the staff follows behind the resident; -An elopement is when a resident leaves the facility without anyone's knowledge; -The amount of time a resident is gone or the distance in which the resident traveled is not relevant. This includes incidents in which the resident remained on the facility's property; -Facilities should report elopements when staff was not aware the resident left; -Documentation for Missouri self-report investigation: -Facility self-report form; -Specific description of the incident (date, time, location); -Resident face sheet; -Description of resident injury (if injury - measurements, location) and if possible photographs for the state agency; -Names, addresses, home telephone numbers, date of birth, social security number and employee position; -Written statements by employees - signed and dated - with specific details; no general statements. Interviews must be conducted with staff that have some knowledge of the event or were in the area or covering the shift at the time of the incident; -Correct action to prevent recurrence; -Other supporting information including nurse's notes, care plan, physician's notes, etc.; -Police reports and police contact information; -Complete and document a physical assessment of the resident upon return to the facility to determine if further treatment is required; -Notify all parties of resident's return to the facility; -Review and revise the interventions related to prevention of elopement for the resident; -Communicate the modification of interventions to the caregiving staff, resident and/or family/responsible party. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/18, showed: -Admission: 4/19/18; -[DIAGNOSES REDACTED]. -Rarely/never understood/understands; -Severe cognitive impairment; -Long and short term memory problems; -No behavior symptoms exhibited; -No wandering; -Required total assistance with personal hygiene, toileting and dressing; -Required extensive assistance with bed mobility; -Required supervision with eating; -Required one person assistance with transfers and locomotion in room, corridor and on and off the unit, the activity only occurred once or twice; -No mobility devices used. Review of the resident's physician's orders [REDACTED]. -Diagnoses: [REDACTED].) -An order dated 4/20/18: transfer resident to the special care unit. Review of the resident's care plan, dated 4/23/18, showed the following: -Focus: At risk for elopement due to attempted to open exit doors. Placed on a secure unit for his/her safety and [DIAGNOSES REDACTED]. -Goal: Will remain safely within the facility unless accompanied by staff or family member through next review; -Interventions/tasks: Assess for hunger, thirst, ambulation or toileting needs when found attempting to exit. Assess for need for secure unit. Notify physician as needed. Complete elopement risk assessment upon admission, quarterly and as needed (PRN). Monitor Wanderguard in place every two hours. Check function every shift. Change battery monthly. Notify physician and family of behavior changes; -Added on 5/23/18: Activities to provide diversionary activities. Review of the resident's quarterly MDS, dated [DATE], showed: -No behaviors; -No wandering; -Required no staff assistance to walk in corridor, occurred once or twice -Wheelchair used for mobility. Review of the resident's Wandering Observation Tool, dated 10/19/18 at 11:00 P.M., showed: Potential risk factors: -Does the resident have a [DIAGNOSES REDACTED].? Yes; -Does the resident ambulate independently, with or without the use of an assistive device (including a wheelchair)? Yes; -Does the resident have any hearing, vision, or communication problems? No; -Does the resident have a history of wandering and/or is there a pattern tied to the resident's past? Yes; -Has the resident recently admitted or readmitted (within the past 30 days) and not accepting of the situation? No; Definitive Risk Factors: -Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? Yes; -Has the resident expressed anxiety/apprehension to leave the facility, pack personal belongings, pacing with no course of action or direction, or attempted to exit doors? Yes; -Does the resident have a history of elopement? Yes; -Does the resident wander without a sense of purpose? (i.e. confused, may enter others' rooms and explore others' belongings? Yes; -Does the resident have risk factors for elopement or unsafe wandering? Yes; -If risk factors are present proceed to care plan; -Signed by the Assistant Director of Nurses (ADON) and dated 1/28/19. Review of the resident's quarterly MDS, dated [DATE], showed: -No behaviors; -Wandering behavior occurred 1 to 3 of the last 7 days; -Required one person assist to walk in corridor, occurred once or twice; -Wheelchair used for mobility. Review of the resident's quarterly MDS, dated [DATE], showed: -Behavioral symptoms: -No physical behavior exhibited; -Verbal behavior symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred 1 to 3 of the last 7 days; -Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting, or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) behavior of this type occurred 1 to 3 of the last 7 days; -Wandering behavior occurred 1 to 3 of the last 7 days; -Walked in corridor independently with no help or staff oversight at any time; -Wheelchair used for mobility. During an interview on 2/5/19 at 9:00 A.M., the DON said there was an emergency care plan meeting with the resident and Family Members J and K on 1/25/19 at 10:30 A.M., due to staff reporting Family Member J removed the resident's Wanderguard. A Wanderguard was reapplied immediately. The resident and Family Member J's primary language was not English and they did not understand the English language. Family Member K understood and spoke English and translated messages from the staff to the resident and Family Member J. After the emergency care plan meeting, the resident was placed on two hour face checks starting at 11:00 A.M. Review of the resident's progress notes, showed the DON documented an entry, labeled late entry (no date or time entered) with an effective date of 1/25/19 at 10:30 A.M., that an emergency care conference was initiated due to Family Member J was observed by staff removing the resident's Wanderguard. A new Wanderguard was applied. Family Members K and L were in attendance. Explained to Family Member K that the resident was at risk for elopement due to a strong desire to leave the facility with Family Member J each time he/she visits. Further explained that staff have observed Family Member J remove the resident's Wanderguard. If any future attempts of removal of the Wanderguard are noted by staff, all visits will be supervised by staff during the entire visit to ensure the resident's safety. Family Member K verbalized an understanding and stated he/she would make sure Family Member J understood the importance of keeping the Wanderguard in place. The resident's physician was made aware. Review of the resident's care plan, showed staff revised the care plan interventions/tasks on 1/25/19, adding staff will monitor the resident's Wanderguard every two hours and PRN (as needed) related to Family Member J and resident removing it. Review of the resident's two hour face checks, showed staff documented two hour face checks were completed starting 1/25/19 at 11:00 A.M. through 1/28/19 at 5:00 A.M. Review of the facility staffing pattern, for the special care unit, dated 1/28/19 for day shift, 7:00 A.M. through 3:00 P.M., showed: -The scheduled nurse's name was circled and WNBI (will not be in) was written by her name; -The ADON's name was written above that nurse's name; -Certified Medication Technician (CMT) O; -Certified Nurse Aide (CNA) P. Review of the facility's census/resident roster, dated 1/28/19, showed there were 26 residents on the special care unit. During an interview on 2/7/19 at 9:52 P.M., CMT R said he/she floated to the special care unit often and knew the resident was an elopement risk. When Family Member J was not at the facility, the resident would get agitated and would exit seek. The resident had a history of [REDACTED]. The resident set the egress door alarm off multiple times in the past and CMT R ran down the hall and redirected the resident back to the dining room area with activities and snacks. He/she did not report the resident was exit seeking and setting off the egress door alarm, because all staff were aware he/she was doing it. The resident knew the egress door on the special care unit went outside and he/she was fast on his/her feet. CMT R never saw the resident or Family Member J remove the Wanderguard. He/she worked the night shift on 1/27/19 from 11:00 P.M. through 7:00 A.M. on 1/28/19. The resident alarmed the egress door that morning at approximately 6:00 A.M. He/she told the day shift CMT O and CNA P to keep an eye on the resident, because he/she attempted to go out the egress door earlier that morning. He/she left the facility after 9:00 A.M. on 1/28/19, after giving report to CMT O. The resident was on the special care unit at that time. During an interview on 2/6/19 at 10:30 A.M., CMT O said he/she worked the day shift, from 6:00 A.M. through 2:00 P.M., on 1/28/19. His/her usual assignment was on the rehabilitation unit, but he/she was pulled to administer medications on the special care unit at approximately 9:30 A.M. - 10:00 A.M. CMT R told him/her what residents to crush medications for, no other resident report was given. CMT O did not know the residents and did not know which residents were an elopement risk. CNA P was the only other staff member on the special care unit that shift. CMT O helped CNA P as much as he/she could, but he/she was administering medications to residents. CMT O recalled several door alarms went off that day. One resident (name unknown) alarmed the door down the long hall and went outside. CMT O ran after the resident and redirected him/her to the dining room. He/she did not know how to turn the door alarms off or which residents were setting the door alarms off. CMT O went to lunch between 1:10 P.M. and 1:41 P.M. He/she could not remember if the door alarms were sounding when she left the special care unit for lunch. The resident was in the dining room when he/she left for lunch. When he/she got back from lunch, he/she wrote down the names of all of the residents that had Wanderguards so he/she could keep track of them. He/she was not aware the resident was on two hour face checks. CMT O and CNA P were the only staff assigned to the special care unit that day shift. When he/she left the facility at 2:00 P.M., CNA P was the only staff member on the special care unit and the resident was in the dining room. CMT O gave the ADON report at the reception desk on the rehabilitation side of the facility. He/she did not report multiple door alarms went off or that the unknown resident got out the long hall door, because he/she got the resident back inside and it was no big deal. During an interview on 2/6/19 at 12:45 P.M., CNA P said he/she worked the day shift on 1/28/19, from 6:30 A.M. through 3:00 P.M., as the only day shift CNA assigned to the special care unit. CMT R gave him/her report and left the unit when CMT O got there. CNA P did not know the residents and was not aware which residents wandered and/or were an elopement risk. Multiple residents wandered around the special care unit that day and set off the door alarms multiple times. He/she did not know how to turn the door alarms off, so the alarms stayed on for a long time. He/she redirected the residents back to the dining room area with the other residents at least 10-15 times that day. Family Member U, another resident's family member, showed him/her where the door key was to turn the door alarms off and explained that green meant the door was locked and red meant the door was open. The door alarm key was hanging at the nurse's station. The only staff assigned to the special care unit that day was him/her and CMT O. CMT O was administering medications, so he/she tried to keep the residents in one area. He/she did not take a lunch break that day, because there was no one to relieve him/her. Family Member J visited that day and the resident was agitated. He/she was screaming, but CNA P could not understand the resident, because he/she did not speak English. Family Member J left the special care unit at approximately 12:00 P.M., while the resident ate lunch. At approximately 1:50 P.M., he/she took a smoke break. When he/she got back to the special care unit at 2:00 P.M., Family Member U helped figure out which door alarm was sounding, it was the long hall, egress door. He/she turned the alarm off and made sure the door was locked again. CNA P counted the residents and made sure everyone was in the special care unit at that time. CMT O left the special care unit at 2:00 P.M. and CNA P was the only staff member on the special care unit from 2:00 P.M., until the evening shift CNAs got there at approximately 3:15 P.M. He/she gave report to CNA S at approximately 3:15 P.M. He/she told CNA S multiple residents were exit seeking and setting off the alarms all day. When he/she left the special care unit the resident was in the activity closet on the unit. During an interview on 2/7/19 at 9:52 P.M., CMT R said he/she was late to work on 1/28/19. He/she was scheduled to work the evening shift, 2:00 P.M. through 10:00 P.M. He/she got to the facility between 2:15 P.M. and 2:20 P.M. and the ADON stopped him/her at the reception desk and gave him/her report. When he/she got to the special care unit, day shift CNA P was the only staff member on the unit. He/she recalled not seeing the resident on the special care unit at that time. He/she assisted CNA P to toilet a resident and then looked for the resident. CMT R asked CNA P where the resident was, and was told, Family Member J. CMT R assumed he/she meant the resident was with his/her family member. CNA S and CNA T were the evening shift CNAs. They got to the special care unit after 3:00 P.M. and he/she gave them report. CMT R left the special care unit to get supplies after he/she gave the evening shift CNAs report. At approximately 3:30 P.M. - 3:40 P.M., he/she got back to the special care unit and CNA S and CNA T reported the resident was missing. CMT R, CNA S and CNA T looked for the resident. CMT R called the ADON at approximately 4:40 P.M., and reported the resident was missing. An elopement code white was announced overhead immediately. CMT R clarified he/she did not see the resident on the special care when he/she got to the facility on [DATE], between 2:15 P.M. and 2:20 P.M. He/she did not document the resident was at the nurse's station at 3:00 P.M., because he/she could not find the resident at that time. During an interview on 2/13/19 at 10:50 A.M., Family Member U, (family member of another resident) said he/she was visiting his/her family member at the facility on 1/28/19. He/she got to the special care unit at approximately 12:30 P.M. and a door alarm sounded right around that time. The door alarm sounded for a long time and he/she went to the hallway to find out what was going on. There was a staff member at the nurse's station with no name tag on, he/she thought it was the CMT. The staff member walked from behind the nurse's station and said, I don't have to work here, and left the special care unit. Family Member U did not see this staff member again the rest of the time he/she was on the special care unit. One CNA (name unknown) was working on the special care unit that day shift. He/she did not recognize the staff that worked that day. They did not know the residents or how to respond when the door alarms sounded. He/she showed the CNA how to turn the door alarm off and told him/her to check to make sure all the residents were accounted for. They found out it was the long hall (egress) door alarm sounding. He/she was concerned a resident got out of the facility through the long hall (egress) door. Family Member U did not know if the CNA counted to make sure all the residents were there. He/she left the facility between 2:30 P.M. and 3:00 P.M. Before he/she left, the nurse (name unknown) pointed to the resident's room and said, he/she got out today. The ADON interviewed Family Member U on 1/29/19, to see what he/she knew about the elopement. He/she told the ADON the above information. During an interview on 2/6/19 at 11:00 A.M., the ADON said she was the oversight nurse for the special care unit on 1/28/19, day shift. The scheduled nurse called off, so CMT O was floated to the special care unit to administer medication on the day shift. CMT R, worked the night shift of 1/27/19 into 1/28/19, and stayed late until CMT O got there and gave CMT O report. CMT O and CNA P were the staff assigned to the special care unit, for the day shift. CMT O was the charge CMT. The ADON said she was not on the special care unit the entire day. She did rounds on the unit at 11:00 A.M. and 1:00 P.M. She did not hear door alarms sounding at those times. CMT O left the facility after giving the ADON report at 2:00 P.M. The ADON then gave CMT R, who came back to the facility to work the evening shift, report when he/she got to the facility on [DATE]. CMT R was running late that evening and the ADON gave him/her report a little bit before 3:00 P.M. Approximately 30-40 minutes later, an announcement was made overhead that a resident was missing. The ADON said the resident wanders around the special care unit, but she was not aware the resident was exit seeking. She expected staff to report when a door alarm went off on the unit. During an interview on 2/13/19 at 8:15 A.M., CNA S said he/she worked on 1/28/19, from 2:45 P.M. through 10:00 P.M. and was assigned to the special care unit. When he/she got to the special care unit that day, CNA P was the only CNA working. No door alarms were sounding at that time. CNA P asked him/her to not be mad, because CNA P did the best he/she could to care for the residents, being the only CNA working. CNA P said the residents had been getting out. CNA S thought CNA P meant the residents were getting out of the circle, which was the dining room/television area, not out of the facility. CNA S said he/she did not know the residents on the special care unit well, because he/she was PRN and was usually assigned to the long term care side. After getting report from CNA P, CNA T told him/her the resident was missing. He/she asked charge CMT R where the resident was and he/she thought the resident was with Family Member J. They looked in every room and closet on the special care unit. CNA S and CNA T went to the reception desk at the rehabilitation entrance and asked if the resident left with Family Member J. Administrative Assistant W told them Family Member J left the facility and the resident was not with him/her. CNA S told CMT R that the resident was missing at approximately 3:40 P.M. - 4:00 P.M. CMT R left the unit to report the resident was missing, then came back to the special care unit and told him/her and CNA T to keep looking for the resident, because management did not want to jump the gun in calling an elopement code. CNA S said CNAs do not report to the DON they have to go through the chain of command, which is through the CMT. During an interview on 2/7/19 at 8:05 A.M., CNA T said he/she worked on the special care unit often and was familiar with the residents, but was not aware which residents were an elopement risk. He/she knew the resident had a Wanderguard. He/she never saw the resident or Family Member J remove the Wanderguard. He/she worked the evening shift on 1/28/19, but was running late and got to the special care unit between 3:05 P.M. and 3:15 P.M. No door alarms were sounding at that time. When he/she got to work that day, CNA T did normal room to room rounds as he/she always did and did not see the resident. He/she started to count the residents but CNA S stopped him/her, because they needed to get report from CNA P because he/she was leaving. CNA P said he/she was the only CNA assigned to the unit that day and he/she told CNA T and CNA S, that he/she did the best he/she could to keep the residents safe. Both CNA T and CNA S looked for the resident after CNA P left and they could not find him/her. CMT R was off the unit getting supplies. He/she left the unit to find CMT R to report the resident was missing. CNA T found CMT R and reported the resident was missing. They went to the reception desk at the rehabilitation entrance and asked Administrative Assistant W if the resident left with Family Member J. Administrative Assistant W told them Family Member J left the facility at approximately 1:00 P.M., by himself/herself. CMT R called the ADON at approximately 3:30 P.M. and reported the resident was missing. The elopement code was not announced until approximately 4:30 P.M. After the elopement code white was announced the DON and the administrator came to the special care unit and asked staff if they were sure the resident was missing. The police escorted the resident back into the facility after 5:00 P.M. The resident was shivering and said he/she was cold. CNA T did not know why there was such a long delay in announcing the elopement code. CNA T said the DON told him/her to tell the state surveyor Family Member J removed the resident's Wanderguard, but that was not true, it was the resident removing the Wanderguard. The DON also told him/her to tell CNA S that they saw the resident when they got to the facility that day. CNA T said he/she could not lie, he/she did not see the resident when he/she arrived to work on 1/28/19, and he/she reported it to CMT R immediately. CNA T was concerned for the resident's safety. During an interview on 2/13/19 at 9:15 A.M., Administrative Assistant W said he/she worked on 1/28/19, from 8:30 A.M. through 5:30 P.M., at the reception desk on the rehabilitation entrance. Staff came over (time unknown) and asked if Family Member J left the facility by himself/herself. He/she told them yes, but could not recall what time he/she left. Administrative Assistant W clocked out early that day, at approximately 4:45 P.M. A few seconds later a code green, the elopement code, was announced, so he/she stayed at the facility to help out, because it was cold outside and he/she was concerned about the resident. When he/she left the facility between 5:15 P.M. and 5:30 P.M., emergency medical services (EMS) were escorting the resident back into the facility. During an interview on 2/5/19 at 9:00 A.M., the DON and Administrator said a CMT reported the resident was missing on 1/28/19 at 4:50 P.M. The receptionist announced the elopement code and everyone started looking for the resident immediately. Social Worker M notified the DON, a few minutes after the elopement code was called, the police called the facility and the resident was found in a subdivision behind the facility. As soon as Social Worker M reported that to her, the police escorted the resident back in the facility. The resident was wearing a [NAME]et, long sleeve shirt, pajama pants, socks and shoes. A licensed nurse assessed the resident immediately and found no injuries were sustained. The resident's vital signs were stable, his/her temperature was 97 degrees. The Wanderguard was not on the resident when he/she arrived back to the facility. The DON called Family Member K when the resident got back to the facility. The DON said Family Member J visited the resident that day and she thought he/she removed the Wanderguard again. After the resident returned to the facility, he/she was placed on 1:1 observation and one hour Wanderguard checks. Neither the DON nor the Administrator knew how the resident eloped from the facility or what time. The facility did not have cameras. There are three doors on the special care unit, two of them are corridor doors, which lead into the facility and the door down the long hall is an egress door (an emergency evacuation door). When you push on the egress door a beeping alarm sounds, then when you push on the door for 15 seconds, the door opens and the alarm sound changes to a solid tone. The egress door goes outside, it leads to a parking lot and a neighborhood. None of the doors on the special care unit were Wanderguard doors, because they are already locked doors. The DON and Administrator said the only doors that are Wanderguard doors are the doors at the entrance to the rehabilitation entrance and the long term care entrance to the facility. The DON said the resident was observed at the nurse's station at 3:00 P.M. that day. Police found him/her walking around a neighborhood behind the facility at 4:11 P.M. Per the DON and Administrator there were no alarms going off that day in the special care unit and all staff including the ADON, CMT O and CNA P were on the special care unit the entire day shift. After the resident was back in the facility, the DON inserviced staff on elopement prevention, elopement management and occurrence incident reporting policies after the resident returned the facility. Revi

Based on interview and record review, the facility failed to thoroughly and accurately assess, document and notify the physician of a change in condition sustained by two of four sampled residents. When one resident experienced respiratory distress, the nurse did not reassess the resident after multiple staff reported the resident's respiratory status was worsening and failed to ensure the resident was sent to the hospital timely. Additionally, staff failed to assess and document another resident's change in medical condition; the resident sustained [REDACTED]. (Residents #1 and #2) The census was 165. Review of Resident #1's face sheet, showed an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's admission nurse's note, dated [DATE] at 6:24 P.M., showed staff documented the resident arrived to the facility at 4:45 P.M., and was alert, oriented, cooperative and sociable. Mucous membranes were pink and moist, skin dry and warm and his/her right lower extremity was wrapped with an ACE bandage (an elastic bandage used to create localized pressure) due to right fibula fracture. Lung sounds clear, respirations even and unlabored and a regular pulse assessed. All medications were verified by the resident's physician. Review of the resident's admission observation tool, dated [DATE] at 4:20 P.M., showed staff documented the following: -Vital signs: Blood pressure (B/P): ,[DATE] (normal ,[DATE]), Pulse (P): 69 (normal 60 to 100), Respirations (R): 16 (normal ,[DATE]), Temperature (T): 97.0 (normal 98.6), oxygen saturation (O2 sat, percentage of oxygen in the blood): 97% (normal ,[DATE]%), on room air; -No shortness of breath or trouble breathing with exertion, sitting at rest or when lying flat; -Respirations: Unlabored; -Lung sounds: Clear; -No cough assessed; -No supplemental oxygen; -No respiratory appliance; -No hallucinations, delusions, physical or verbal behaviors exhibited; -No medical history of [REDACTED]. -[MEDICAL CONDITION] (opening for portion of the colon through the abdominal wall to the outside surface to excrete feces). Review of the resident's baseline care plan, dated [DATE], showed the following: -Initial goal: discharge to the community; -Cognition: Alert/cognitively intact; -Communication: Verbal; -Vision impaired: Glasses; -Safety: History of falls at home due to black outs; -Dietary order: Regular; -Behavior concerns: Depression; -Therapy services: Physical therapy (PT) and occupational therapy (OT); -Other comments/interventions: Right ankle fracture from fall at home; -Equipment: Wheelchair; -The care plan did not address and respiratory concerns or issues. Review of the resident's admission physician's orders [REDACTED]. -Full code; -[MEDICATION NAME] (combination inhaler containing a steroid to reduce inflammation and a [MEDICATION NAME][MEDICATION NAME] to relax airway muscles to improve breathing) inhale two puffs orally two times a day (BID) for asthma; -[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME], an inhaled medication used to open the lung airways) 0.5 milliliters (ml) inhale orally every six hours as needed (PRN) for asthma; -No orders for scheduled or PRN oxygen. Review of the resident's vital signs summary, dated [DATE] at 11:24 A.M., showed staff documented the following: B/P: ,[DATE], P: 18, R: 18, T: 98.0 and oxygen saturation: 95% on room air. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Understood/understands; -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 13 of 15 (a score of ,[DATE] indicates moderately impaired cognition); -No behaviors; -No anxiety; -Limited assistance with bed mobility, dressing, transfers and toileting; -Supervision with personal hygiene and eating; -Occasionally incontinent of bladder; -[MEDICAL CONDITION]; -Non-ambulatory; -No shortness of breath. Review of the resident's progress note, dated [DATE] at 10:44 A.M., showed the activity director documented the resident was admitted to the facility for skilled nursing care on [DATE]. [DIAGNOSES REDACTED]. The resident's goal was to return home. Review of the resident's nurse's note, dated [DATE], showed Nurse A documented the following: -At 1:41 P.M., the resident performed activities of daily living (ADLs) with staff assistance, needed the assistance of two staff for transfers, was alert and able to make his/her needs known and had even and unlabored breathing. Will continue to monitor; -At 9:20 P.M., the resident consumed a bowl of soup for dinner and was able to make his/her needs known. Will continue to monitor. During further interview on [DATE] at 11:30 A.M., Nurse A said he/she worked on [DATE], from 6:30 A.M. through 9:30 P.M., and was assigned to the resident. Between 6:00 P.M. and 7:00 P.M., the resident had a panic attack and was concerned the cast on his/her right lower extremity was too tight. The resident's family was there and calmed him/her down. The resident did not have respiratory issues on [DATE]. Nurse A did not recall if he/she took the resident's vital signs when he/she had the panic attack. The resident's family calmed the resident down so Nurse A was not concerned about the resident. Review of the resident's medical record, showed no documentation of an assessment of the resident, on [DATE], when he/she had a panic attack or of the right lower extremity when he/she complained the ACE bandage/cast was too tight. During an interview on [DATE] at 11:30 A.M., Nurse A said he/she worked on [DATE], from 6:30 A.M. through 11:00 P.M., and was assigned to the resident. At approximately 7:15 A.M., the resident was alert and talking, sitting in his/her room in his/her wheelchair. He/she ate 100% of breakfast. At approximately 10:30 A.M., the resident lay in bed, watching television and talking on the phone. Between 3:00 P.M. and 3:30 P.M., the resident self propelled his/her wheelchair down the hall and talked to other residents. During an interview on [DATE] at 12:45 P.M., Certified Nurse Aide (CNA) F said he/she worked on [DATE], from 7:00 A.M. through 3:00 P.M., and was assigned to the resident. He/she was not familiar with the resident because he/she usually worked a different assignment. The resident was in bed, with the head elevated 45 degrees when he/she entered the room at approximately 7:40 A.M. The resident was alert, could make his/her needs known and was on oxygen per nasal cannula (NC, a device that consists of a plastic tube that fits around the ears and a set of two prongs that fit in the nose to deliver supplemental oxygen to a person in need of respiratory help) the entire shift. There was an oxygen concentrator in the resident's room and an oxygen tank on the back of the resident's wheelchair. At approximately 8:15 A.M., he/she assisted the resident into his/her wheelchair and the resident self propelled to the dining room for breakfast. The resident ate 50% of breakfast and ate lunch in the dining room as well. Between 1:00 P.M. and 1:30 P.M., CNA F assisted the resident to bed. At approximately 2:45 P.M., the resident lay in bed with the head elevated 45 degrees, sleeping with oxygen on via NC. CNA F takes all the residents' vital signs on his/her normal assignment, but did not take any vital signs that day because no one told him/her to. CNA F could not recall how many liters (L) of oxygen the resident used, but verified by looking at the resident's picture, that he/she had oxygen on during the entire shift and had no signs or symptoms of breathing difficulty. During an interview on [DATE] at 2:00 P.M., CNA C said he/she worked on [DATE], from 2:45 P.M. through 11:00 P.M., and was assigned to the resident. He/she saw the resident in his/her room at approximately 3:00 P.M., and the resident said he/she was hot and had the air conditioner on. The resident was breathing normally and his/her color was normal. Between 4:00 P.M. and 4:30 P.M., the resident complained he/she could not breathe. Nurse A and Nurse D were in the resident's room assisting him/her. CNA C got an oxygen tank for the resident and the nurses administered it. CNA C thought the resident was having a panic attack. He/she was breathing heavily and the nurses attempted to calm the resident. CNA C, Nurse D and Nurse A attempted to get the resident's O2 sat but his/her hands were freezing. CNA C turned the air conditioner off and closed the window. The resident was upset because he/she was hot and sat in his/her wheelchair sweating. Nurse D and Nurse A transferred the resident to bed. They tried to take the resident's blood pressure with the electronic blood pressure machine but it kept beeping and read ,[DATE]. The nurses kept taking the resident's blood pressure with the machine, it kept beeping and giving weird blood pressure numbers. While the nurses were trying to get the resident's blood pressure, he/she complained of chest pain. A few minutes later Nurse D and Nurse A left the resident's room, and the resident was still breathing heavily. Nurse D told him/her to check on the resident frequently, but did not give a timeframe of how often to check on the resident. CNA C was worried about the resident because he/she knew something was not right. The resident kept complaining he/she was hot when it was cold in the room. He/she checked on the resident between 5:00 P.M. and 5:20 P.M., and the resident had slid to the foot of the bed. CNA H helped pull the resident up in bed and left the room. The resident had slurred speech and told CNA C he/she could not feel his/her tongue. CNA C reported this to Nurse A who was passing medications to other residents down the hall. During an interview on [DATE] at 2:40 P.M., CNA E said he/she worked on [DATE], from 7:00 A.M. through 11:00 P.M., and was not assigned to the resident. At approximately 5:30 P.M., CNA E was passing dinner hall trays and saw the resident up in his/her wheelchair in the hallway. When CNA E asked the resident if he/she was ok, the resident said, no, he/she could hardly breathe. Nurse A and Nurse D were walking down the hall at the time, assessed the resident immediately and CNA C got an oxygen tank for the resident. The resident's color was normal at that time and he/she was mouth breathing, as if he/she could not catch his/her breath. During further interview on [DATE] at 2:00 P.M., CNA C said he/she checked on the resident at 6:20 P.M. The resident lay in bed, with the head of the bed elevated 30 degrees. The resident was hard to understand because his/her speech was slurred and his/her breathing sounded like heavy wet wheezing. He/she could tell the resident was having difficulty breathing at that time. The resident refused to eat dinner. He/she reported the information to Nurse A. When CNA C checked on the resident at 6:50 P.M., he/she lay in bed, with the head of the bed elevated 30 degrees, his/her eyes closed and appeared to be asleep. The resident was still breathing heavily and CNA C kept reporting the resident's breathing difficulties to Nurse A. A few minutes later CNA C saw Nurse A go into the resident's room and administered an inhaler. The CNA took the resident's vital signs at that time with a manual blood pressure cuff and got the following: B/P: ,[DATE], P: 100s and O2 sat was bouncing around 60% - 80%. CNA C told CNA H he/she was worried about the resident and CNA H agreed the resident did not look good. During an interview on [DATE] at 1:10 P.M., CNA H said he/she worked on [DATE], from 7:00 A.M. through 11:00 P.M., and was not assigned to the resident. After dinner, between 6:00 P.M. and 6:30 P.M., CNA C asked him/her to help pull the resident up in bed. CNA H, CNA C and CNA I entered the resident's room. The resident had oxygen on via NC at 4 L, his/her speech was slurred and the resident said he/she could not feel his/her tongue. The resident was clammy and his/her fingers were blue and very cold. Between 10 and 15 minutes after CNA H left the resident's room, he/she told Nurse A the resident had blue fingers, was having difficulty talking, was breathing heavily and using accessory muscles (muscles other than the diaphragm and intercostal muscles (those running between the ribs and help form and move the chest wall), the main respiratory muscles, and utilized by people with respiratory distress to help the flow of air in and out of the lungs) to breathe. Nurse A said he/she was aware and waiting for the physician to call back. CNA H told CNA C to check on the resident every 15 minutes to ensure the resident did not code (go into [MEDICAL CONDITION]) and to keep an eye on him/her until the physician called back. During an interview on [DATE] at 1:30 P.M., CNA I said he/she worked on [DATE], from 7:00 A.M. through 11:00 P.M., and was not assigned to the resident. Between 5:00 P.M. and 6:00 P.M., the resident was in the hallway complaining he/she could not breathe. The resident's color was pale. Nurse A propelled the resident to his/her room and both Nurse A and Nurse D assessed the resident. CNA I saw staff put oxygen on the resident a few minutes later. Later he/she saw the resident slouched in bed and told CNA C the resident needed to be pulled up so he/she could breathe better. When they entered the room to reposition him/her, CNA I could tell something was wrong. Although the resident had oxygen on he/she was pale and using his/her chest muscles to breathe. After the resident was repositioned CNA I reported the resident's abnormal breathing to Nurse A. During interviews on [DATE] at 10:00 A.M. and 12:15 P.M., Nurse D said he/she worked on [DATE], from 10:45 A.M. through 6:30 P.M., and was the manager on duty. He/she was familiar with the resident. At approximately 5:00 P.M., he/she and Nurse A overheard the resident tell staff he/she was having difficulty breathing. Nurse A propelled the resident to his/her room and Nurse D followed. The resident was very anxious, moving his/her feet around and would stand up and sit down constantly. Nurse A told CNA C to get an oxygen tank for the resident. Nurse D, CNA C and Nurse A stayed in the resident's room during the assessment. CNA C administered 2 L of oxygen via NC within minutes and Nurse D and Nurse A transferred the resident to bed. The resident's room was cold but the resident complained he/she was hot. Both Nurse D and Nurse A rubbed the resident's fingers to warm them up because they could not get a reading on Nurse A's personal (not facility owned) pulse oximeter (a device placed on a finger to noninvasively monitor the O2 sat). The resident was a little discolored around his/her mouth and his/her initial oxygen saturation was 75%. Staff attempted to obtain the resident's vital signs but he/she was so anxious they could not get a blood pressure reading. A few minutes later the resident calmed down and they got a blood pressure of approximately ,[DATE] and a pulse in the 90s. Nurse D and Nurse A kept warming up the resident's fingers. Nurse A's pulse oximeter read 88%. The resident was on 3 L via NC at that time. The color around the resident's mouth improved after the oxygen was administered. Nurse D left the room between 6:15 P.M. and 6:30 P.M. Review of the resident's nurse's note, dated [DATE] at 6:56 P.M., showed Nurse A documented the resident came out into the hallway stating he/she was having a hard time breathing. His/her O2 sat was between 70% and 81%, then dropped to 65%. The resident continued to state that he/she had [MEDICAL CONDITION]. He/she was in a state of panic and having an anxiety attack. Oxygen administered via NC. Skin cold, room colder than outside, but the resident said he/she was hot. When reassessed, vital signs were; B/P: ,[DATE], P: 94, R: 34, T: 97.1 and O2 sat: 90% on 3 L of oxygen. Resting calmly in his/her room at that time. Will continue to monitor. Oxygen was initially administered at 5 L then decreased to 3 L, once the resident's O2 sat began to rise. During further interview on [DATE] at 11:30 A.M., Nurse A said between 6:45 P.M. and 6:50 P.M., the resident self propelled into the hallway and told CNA E that he/she could not breathe. Nurse A and Nurse D, who was the manager on duty, overheard what the resident said and assessed him/her immediately. Nurse A propelled the resident to his/her room. The room was really cold because the air conditioner was on and the window was open. The resident's fingers were really cold so he/she rubbed them to warm them up. Nurse A and Nurse D attempted to assess the resident's O2 sat using a pulse oximeter. The resident's O2 sat was bouncing between 71% and 84%. Nurse A administered oxygen per NC at 2 L and the resident's O2 sat level increased to 88%. The resident calmed down and Nurse A assisted the resident to bed. After the resident got into bed he/she had another anxiety attack. Nurse A and Nurse D attempted to assess the resident's blood pressure and pulse at that time but the resident would not sit still. The resident calmed down a few minutes later and staff obtained the following vital signs: B/P: ,[DATE], P: 94, R: ,[DATE], T: 97.0 and O2 sat: 90%. Nurse A instructed the resident to calm down and rest. He/she reassessed the resident at approximately 7:15 P.M., and he/she was sitting on the side of the bed having a full blown panic attack. The resident was on 3 L of oxygen and his/her O2 sat bounced between 86% and 88%. Nurse A reassessed the resident's vital signs at that time but did not remember if he/she documented them in the resident's medical record. The resident's color was normal and a few minutes later he/she had calmed down. Nurse A reassessed the resident between 7:30 P.M. and 7:45 P.M., and he/she had labored breathing, was using accessory muscles and pursed lip breathing (a breathing technique that consists of exhaling through tightly pressed (pursed) lips) and inhaling through the nose with the mouth closed). Review of the resident's nurse's notes, dated [DATE] at 7:43 P.M., showed Nurse A documented the resident's physician was notified of the resident's breathing using accessory muscles and pursed lip breathing and the inability to get his/her O2 sat above 90%. The resident was clammy at that time. The physician called back and gave orders to send the resident to the emergency room (ER). During further on [DATE] at 11:30 A.M. and on [DATE] at 11:10 A.M., Nurse A said he/she called the resident's physician's exchange at approximately 7:43 P.M. on [DATE], and the physician called back 20 or 30 minutes later. Nurse A reported the resident's O2 sat was not over 90%. The physician said to send the him/her to the ER for further evaluation and treatment. Nurse A did not recall if he/she told the physician about the accessory muscle or pursed lip breathing. He/she called the physician, not because the resident was in respiratory distress, but because the resident's O2 sat was low and he/she was concerned about the resident. Nurse A said he/she called the resident's physician's exchange non-urgent because the resident's respiratory condition was stable and he/she was alert and talking. During an interview on [DATE] at 9:24 A.M., Nurse K said he/she worked on [DATE], from 3:00 P.M. through 11:00 P.M., and was not assigned to the resident. At approximately 8:00 P.M., Nurse A called and asked for the ambulance company's phone number so he/she could call and get the resident sent to the hospital. Nurse A said the resident's O2 sat was bouncing around, but the resident's respiratory status was stable. Nurse A did not ask him/her to assess the resident. Nurse K told Nurse A he/she would notify Nurse J, the on call nursing supervisor, that the resident was sent to the hospital due to a change in respiratory condition. Review of the resident's nurse's note, dated [DATE] at 8:12 P.M., showed Nurse A documented the ambulance company was called and gave a wait time of 10 minutes. Will continue to monitor. During further interview on [DATE] at 11:30 A.M., Nurse A said he/she called a non-urgent ambulance at approximately 8:12 P.M. He/she told the ambulance dispatch person the resident's O2 sat was in the 80s and was told an ambulance would be at the facility in 10 minutes. Nurse A ordered the ambulance non-urgent because the resident's respiratory condition was stable. The ambulance was at the facility at 8:25 P.M. During an interview on [DATE] at 12:30 P.M., Nurse B said he/she worked on [DATE] from 2:30 P.M. through 11:00 P.M., and was not assigned to the resident. Between 8:00 P.M. and 8:30 P.M., Nurse A told him/her a resident was being sent to the hospital due to decreased O2 sat. Nurse A did not ask Nurse B to assess the resident or for assistance with the resident until EMS arrived at the facility and Nurse A yelled to Nurse B to come STAT (immediately). Nurse B entered the resident's room and assessed the resident immediately. The resident was foaming at the mouth, his/her pupils were fixed and dilated and his/her face was blue. EMS was also in the room and hooked the resident up to a cardiac monitor. When EMS transferred the resident from his/her bed to a stretcher the resident's heart rhythm showed asystole (flat line, no heart beat) on the monitor. EMS started cardiopulmonary resuscitation (CPR) in route to the ambulance. Nurse A told Nurse B the resident's respiratory condition was stable until EMS got there. Nurse B said he/she would have assessed the resident earlier if Nurse A asked him/her to. When a resident was having difficulty breathing he/she would administer oxygen, assess the resident's vital signs every 15 minutes, including blood pressure, pulse, respirations and oxygen saturation to ensure the resident was not in respiratory distress. Nurse B spoke with EMS in the parking lot and found out the ambulance was called as a non-urgent transport. Nurse B said a resident in respiratory distress was a medical emergency and did not understand why Nurse A did not call 911. When Nurse B walked back into the facility CNA C was very upset and told Nurse B he/she reported the resident was not right to Nurse A multiple times but that Nurse A did not nothing. During further interview on [DATE] at 2:00 P.M., CNA C said after Nurse A called EMS, CNA C checked on the resident who appeared to be sleeping again. The color around the resident's mouth was pale and he/she was using accessory muscles to breathe. CNA C told Nurse A what he/she saw. Review of the resident's nurse's note, dated [DATE] at 8:25 P.M., showed Nurse A documented EMS was at the facility to transport the resident to the hospital. The resident had a change in respiratory condition, his/her breathing was deep and labored and he/she was unresponsive to name. The resident's O2 sat was 45% on 3 L of oxygen. Review of the resident's nurse's note, dated [DATE] at 10:51 P.M., showed Nurse B documented at approximately 8:30 P.M., the resident was being transferred to the hospital due to shortness of breath and an O2 sat of 88%. He/she agreed with Nurse A that the resident needed to be sent out. A few minutes later Nurse A yelled for Nurse B to come STAT. When Nurse B entered the resident's room, EMS was there and the resident was unresponsive and foaming at the mouth. The resident's pupils were fixed and dilated and appeared to have a short episode of focal (partial) [MEDICAL CONDITION] that subsided. EMS applied a cardiac monitor on the resident and transferred him/her to the stretcher. The resident immediately went into asystole. EMS started CPR immediately on the way to the ambulance. EMS called 911 to get additional backup assistance and worked on the resident in the parking lot. EMS told Nurse B the ambulance was called as a non-urgent pick up with a stable resident. CNA C told Nurse A multiple times the resident was not right. Nurse B was informed the resident was short of breath all afternoon and that Nurse A asked Nurse D to assess the resident. Nurse B was not aware the resident had difficulty breathing. During further interviews on [DATE] at 11:30 A.M. and 2:42 P.M., Nurse A said when EMS arrived he/she entered the resident's room to assist. The resident's respiratory condition had declined. The resident was no longer alert or talking, his/her breathing was labored, he/she was using accessory muscles to breathe and was very pale. The resident was on 3 L of oxygen per NC and the head of the bed was up 45 degrees. He/she called Nurse B to come to the resident's room. EMS transferred the resident to a stretcher and placed a cardiac monitor on him/her. The resident went into [MEDICAL CONDITION] as EMS propelled the stretcher down the hall. EMS started CPR on the way out to the ambulance. No staff reported the resident had slurred speech or chest pain. No staff told Nurse A the resident was having difficulty breathing prior to 6:45 P.M. If staff would have told him/her the resident was in respiratory distress he/she would have called 911. Nurse A confirmed no other vital signs were documented in the resident's medical record. There were two sets of vital signs documented on the nurse report sheet, but that was not part of the resident's medical record. Nurse A said he/she did not notify the house supervisor because he/she spoke to Nurse D regarding the resident's respiratory status. Nurse A said he/she initially administered oxygen at 5 L per NC then decreased it to 3 L once the resident's O2 sat increased. The resident's respirations were never 34, they were 24 and if 34 was documented it was a misprint. The resident's lungs were assessed at that time and they were clear. He/she did not remember if the assessment was documented in the resident's medical record. At 7:43 P.M., the resident's use of accessory muscles and pursed lip breathing lasted a few minutes and then the resident calmed down. The resident was talking at that time and was alert. Nurse A attempted to get the resident's vital signs at that time, but the resident's blood pressure would not read on the electronic vital sign machine or manual blood pressure cuff. O2 sats are normally in the 90s. When the resident's O2 sat was in the 80s he/she was not flipping out because the resident was alert, talking and did not complain of pain. During an interview on [DATE] at 2:30 P.M., the rehabilitation unit nurse manager said she expected staff to assess and document each resident's vital signs in the nurse's notes in the residents' medical record, every day. Review of the south rehabilitation (unit where the resident resided) nurse report sheet, dated [DATE], showed the following vital signs were documented by the resident's name: -7:07 P.M., B/P: ,[DATE], P: 91, R: 24, T: 98.0 and O2 sat: 81%; -7:26 P.M., B/P: ,[DATE], P: 98, R: 24, T: 97.1 and O2 sat: 85%. Review of EMS #1's run sheet, dated [DATE], showed the following: -Ambulance called at 8:19 P.M.; -Ambulance dispatched at 8:21 P.M.; -Enroute at 8:22 P.M.; -On scene at 8:43 P.M.; -At the resident's bedside at 8:45 P.M.; -In transport to the hospital at 9:38 P.M.; -Arrived to the hospital at 9:46 P.M.; -Transferred care to hospital staff at 9:48 P.M.; -Narrative: The ambulance staff responded non-urgent per dispatch instruction to a 911 call for respiratory distress. Arrived on scene to find a [AGE] year old resident laying in bed with oxygen via NC at 3 L. The resident was unresponsive to painful stimuli, pupils dilated and nonreactive to light. The resident was breathing eight times per minute with gasping irregular respirations and was secreting white foam from his/her mouth. The resident's nurse said the resident had a low O2 sat all day and the last time the resident was assessed he/she was alert and orientated. The nurse was not able to state what time that was. Vital signs were obtained and the resident was transferred from bed to stretcher. The resident became pulseless and apneic (a pause in breathing) as he/she was transported from the facility to the ambulance. Chest compressions were initiated and ambulance dispatch was notified to send additional advanced cardiac life support (ACLS) units. The resident was secured in the ambulance where placement of defibrillator pads and initial rhythm check showed asystole. ACLS protocol was initiated as chest compressions continued. Another ambulance arrived on scene to assist in ACLS. Approximately 45 minutes after the initial [MEDICAL CONDITION] the decision was made to transport the resident to the nearest hospital. ACLS was continued in route to the hospital; -EMS documented the following vital signs: -8:48 P.M., B/P: not taken (NT), P: 76, R: 10, O2 sat 74%; -8:49 P.M., B/P: NT, O2 sat 78%; -8:55 P.M., resident in asystole; -9:15 P.M., O2 sat 76%; -9:27 P.M., P: 98. Review of EMS #2's run sheet, dated [DATE], showed the following: -No arrival time documented; -Responded to a 911 call for [MEDICAL CONDITION] at the facility per another ambulance company. There were two ambulances on the scene when this ambulance arrived; -Upon arrival the resident was in the back of an ambulance. EMS was providing ACLS. The resident's heart rhythm was in asystole. All EMS staff assisted with ACLS. The resident remained in asystole during the code and transport to the hospital. Review of the resident's hospital record, dated [DATE], showed he/she got to the hospital at 9:50 P.M., via EMS from a nursing home. EMS was called non-urgent by nursing home staff for shortness of breath. Per nursing home staff, the resident complained of shortness of breath and was found to have O2 sat in the low 70s. Nursing home staff administered oxygen 3 L via NC, which improved the resident's O2 sat to 81%. Nursing home staff notified the resident's physician who gave orders to send the resident to the ER. Upon arrival to the nursing home the resident was assessed to have gasping breaths and dilated, fixed pupils, agonal breathing (gasping/labored breathing, accompanied by strange vocalizations and jerking/twitching movements) and frothy sputum around his/her mouth. During transport to the ambulance, the resident lost his/her pulses and became apneic. EMS began CPR and the resident was in asystole. The resident had been down for approximately one hour upon arrival to the ER. During an interview on [DATE] at 1:00 P.M., the EMS paramedic that initially arrived to the facility at 8:43 P.M., said when he/she and the emergency medical technician (EMT) got to the resident's room, there were no staff in the room. The resident was agonally breathing and had irregular jerking movements as well. The resident's color was pale and his/her fingers were cyanic (blue). He/she called out the resident's name and did a sternal rub (a painful test to determine level of consciousness by using the knuckles to rub on the sternum (breast bone)) on the resident. The resident did not respond to either verbal or painful stimuli, his/her pupils were fixed and dilated and 30 seconds later foam started to come from his/her mouth. EMS applied a cardiac monitor and transferred the resident from bed to stretcher. The resident coded on the way to the ambulance. The only vital sign EMS was able to obtain prior to the resident coding was a oxygen saturation of 74%. The EMT called dispatch and requested ACLS backup due to the resident being in [MEDICAL CONDITION]. Two other ambulances reported to the facility and assisted with ACLS on the ambulance. EMS prov

Based on observation, interview, and record review, the facility failed to have a system in place to ensure residents were admitted /readmitted to the facility when the computer system was not working correctly for one of one random sampled resident, resulting in the resident not receiving medications or treatments from 7/7/16 through 7/9/16. The resident was to receive medications including a [MEDICAL CONDITION] medication, had a [MEDICAL CONDITION] episode on 7/9/16 and was sent to the hospital and admitted to the intensive care unit (Resident #27). The facility also failed to ensure communication and documentation existed between the facility and the hospice agency for one of six sampled residents seen by hospice (Resident #8). The sample was 23 with an additional six random residents. The census was 169. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/20/15, showed the following: -Originally admitted to the facility on [DATE]; -[AGE] years old; -[DIAGNOSES REDACTED]. -Cognitive impairment; -No behaviors; -An indwelling urinary catheter (a tube inserted into the bladder for continuous drainage of urine); -One Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer and one unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) pressure ulcer; -Required maximum assistance from the staff for transfers, dressing, eating, hygiene, and bathing. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitive impairment; -No behaviors; -An indwelling urinary catheter; -One Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer and a surgical wound; -Required maximum assistance from the staff for transfers, dressing, eating, hygiene, and bathing. Review of the resident's laboratory test results, showed the last [MEDICATION NAME] [MEDICATION]) level had been drawn at the facility on 5/29/16, with results of less than 2 (normal is 12 to 46). Review of the resident's electronic nurse's notes, showed the following: -6/19/16 at 6:56 P.M. - Certified Nurse Assistant (CNA) alerted the nurse of resident being lethargic and non-responsive. Assessed resident and noted pupils fixed and dilated, non-responsive, lethargic, bilateral upper extremities stiffened. 911 called, physician notified and new order to send to emergency room related to [MEDICAL CONDITION] history and unresponsiveness. Ambulance arrived, assessed resident, started intravenous (IV) fluids in right hand, transferred to hospital. Resident's emergency contact notified and nurse manager notified; -6/19/16 at 7:46 P.M. - Notified by hospital emergency room , resident admitted with [DIAGNOSES REDACTED]. -6/28/16 at 10:18 - Resident returned to facility around 6:00 P.M. this evening. Remains alert and oriented to person, place, and time, able to make some needs known with dysphasia (difficulty swallowing) noted as normal for resident. Pupils equal, round, reactive to light, lung sounds clear, bowel sounds in all four quadrants of abdomen, skin warm and dry to touch. Resident had some skin areas noted before he/she went to hospital, areas still there. Left heel black in color not open, no odor noted, measured at 1.5 centimeter (cm) by 2.0 cm, right ankle pressure area, Stage I (An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters:Skin temperature (warmth or coolness); Tissue consistency (firm or boggy); Sensation (pain, itching); and/or A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) almost healed, measured 1.5 cm by 1.0 cm. Right buttocks pressure area, Stage III, pink in color, no odor noted, measured 3.5 cm by 2.0 cm. Resident has a supra pubic catheter (tube surgically inserted into the bladder through the abdomen for the continuous drainage of urine) that had been inserted today, draining clear yellow urine, no odor noted. No change in medications, all have been verified by physician and faxed to pharmacy. Review of the resident's hospital laboratory test results, showed a [MEDICATION NAME] level drawn on 6/25/16 with a level of 41.8. Review of the resident's electronic Medication Administration Record [REDACTED] -[MEDICATION NAME] 1000 mg one tablet by mouth every night at bedtime; -[MEDICATION NAME] (used to treat MS) 40 mg Subq (subcutaneous-under the skin) every Monday, Wednesday, and Friday; -[MEDICATION NAME] (used to treat MS, relaxes the muscle) 2 mg one tablet by mouth four times a day; -[MEDICATION NAME] (used to treat muscle spasms) 20 mg one tablet by mouth four times a day; -[MEDICATION NAME] (antibiotic) 500 mg by mouth twice a day for osteo[DIAGNOSES REDACTED]; -Bactrim DS (double strength, an antibiotic used to treat UTI) one tablet by mouth twice a day; -[MEDICATION NAME] (antibiotic) 125 mg one capsule by mouth twice a day for [MEDICAL CONDITIONS] ([MEDICAL CONDITION], an infection of the bowels which causes watery, foul smelling stools); -[MEDICATION NAME] ([MEDICATION NAME]) 250 mg one by mouth twice a day; -[MEDICATION NAME] (antidepressant) 30 mg take three caps by mouth once a day; -[MEDICATION NAME] (antidepressant) 40 mg by mouth once daily; -Vitamin C (used in wound healing) 500 mg one tablet by mouth once daily; -Vitamin D3 (vitamin supplement) 1000 units by mouth once a daily; -Cranberry concentrate (used for UTI) 30 cubic centimeters (cc) by mouth once a day; -[MEDICATION NAME] (stool softener) 100 mg by mouth twice a day; -[MEDICATION NAME] sulfate (iron supplement) 325 mg by mouth once a day; -[MEDICATION NAME] (nasal spray used to treat nasal congestion) nasal spray 50 micrograms (mcg) in each spray two sprays in each nostril daily; -[MEDICATION NAME] (used to treat [MEDICAL CONDITION] disorder) 25 mcg one tablet by mouth daily before breakfast; -[MEDICATION NAME] XL ([MEDICATION NAME] for [MEDICAL CONDITION] bladder) 5 mg by mouth every night at bedtime; -[MEDICATION NAME] (suppresses gastric secretions) 40 mg one tablet by mouth every day before breakfast; -[MEDICATION NAME] (antiemetic) 10 mg by mouth twice a day, 30 minutes prior to Cipro; -Multivitamin with minerals one tablet by mouth once a day; -Zinc sulfate (used for wound healing) 220 mg one tablet by mouth once a day. Review of the resident's electronic treatment administration record (TAR), dated June 1 through June 30, 2016, showed the following undated treatment orders: -Left heel, apply comfort foam every evening shift; -Ankle elevator (foam) to left lower extremity at all times; -Right ankle lateral wounds, clean with wound cleanser, apply [MEDICATION NAME], cover with ABD (a thick absorbent dressing), cover with comfort foam every day shift; -Apply Z-guard (a protective barrier cream) to redness on buttocks every shift. Further review of the resident's nurse's notes, showed the following: -7/2/16 at 1:00 P.M. - Resident lying in bed this morning. Upper trunk is stiff. Only gave one word responses. Did not eat breakfast or lunch, did not open mouth. Physician notified and gave new orders for laboratory test and a urinalysis; -7/2/16 at 4:22 P.M. - Resident noted to be lethargic and unresponsive, muscles stiff. Physician notified and order to send to emergency room . 911 called at 3:17 P.M. and arrived at 3:26 P.M. Transferred to hospital emergency room . Review of the resident's hard chart (a paper chart not an electronic chart), showed a handwritten note on a piece of blank copy paper with the resident's name on the top, that the resident had returned to the facility on [DATE] at 6:30 P.M. Review of the resident's hospital transfer sheet, dated 7/7/16, showed the following: -[MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 0.25 milligram (mg) one tablet by mouth daily for 14 days; -[MEDICATION NAME] 750 mg two tablets (1500 mg) by mouth twice a day; -[MEDICATION NAME] (used for the prevention of blood clots) 40 mg subq, once a day; -[MEDICATION NAME] 40 mg Subq every Monday, Wednesday and Friday; -[MEDICATION NAME] 2 mg one tablet by mouth four times a day; -[MEDICATION NAME] 20 mg one tablet by mouth four times a day; -[MEDICATION NAME] 500 mg by mouth twice a day for osteo[DIAGNOSES REDACTED]; -Bactrim DS one tablet by mouth twice a day; -[MEDICATION NAME] 125 mg one capsule by mouth twice a day for [MEDICAL CONDITIONS]; -[MEDICATION NAME] 250 mg one by mouth twice a day; -[MEDICATION NAME] 30 mg take three caps by mouth once a day; -[MEDICATION NAME] 40 mg by mouth once daily; -Vitamin C 500 mg one tablet by mouth once daily; -Vitamin D3 1000 units by mouth once a daily; -Cranberry concentrate 30 cubic centimeters (cc) by mouth once a day; -[MEDICATION NAME] 100 mg by mouth twice a day; -[MEDICATION NAME] sulfate 325 mg by mouth once a day; -[MEDICATION NAME] nasal spray 50 micrograms (mcg) in each spray two sprays in each nostril daily; -[MEDICATION NAME] 25 mcg one tablet by mouth daily before breakfast; -[MEDICATION NAME] XL 5 mg by mouth every night at bedtime; -[MEDICATION NAME] 40 mg one tablet by mouth every day before breakfast; -[MEDICATION NAME] 10 mg by mouth twice a day, 30 minutes prior to Cipro; -Multivitamin with minerals one tablet by mouth once a day; -Zinc sulfate 220 mg one tablet by mouth once a day; -Venelex (used to aide in wound healing) ointment 87-788 mg per gram apply to affected area twice a day. No specification as to exactly where to apply; -[MEDICATION NAME] (antibiotic) 0.1% ointment apply to right ankle wound twice daily; -[MEDICATION NAME] (used to treat fungal infections) 2% powder apply to affected area twice a day. No specification as to exactly where to apply; -[MEDICATION NAME] (used to treat wounds) 1% cream apply to left heel wound; -[MEDICATION NAME] cream (a moisturizer) apply to extremities twice a day. Do not apply to wounds. Review of the resident's hospital wound notes, dated 7/6/16, showed the following: -Right lateral malleolus (bony process on each side of the ankle) and left lateral calf red, blanchable (skin turns when pressure applied and returns to normal color when pressure removed) chronic discoloration to leg with approximate 1 centimeter (cm) by 0.5 cm crusty brown scabbed area and approximate 1.5 cm by 0.5 cm dark red scabbed area over bony prominence; -Sacrococcygeal (tailbone) open fissure 3.2 cm by 0.4 cm; -Right upper lateral leg with approximate 3.0 cm by 0.5 cm crusted red lateral edges with yellow [MEDICATION NAME] (tissue) center. Review of the resident's electronic physician's orders [REDACTED]. Review of the resident's electronic Medication Administration Record [REDACTED]. Review of the resident's hard chart, showed no hand written POS, nurses notes, MAR indicated [REDACTED]. Further review of the resident's nurse's notes, showed the following: -No notes from 7/2/16 until 7/9/16; -7/9/16 at 7:59 P.M. - electronic note-Resident was found having [MEDICAL CONDITION] in bed in his/her room by CNA. Nurse arrived in room, assessed resident. [MEDICAL CONDITION] lasted for 5 minutes, resident remained unresponsive after [MEDICAL CONDITION] had stopped. Physician notified and gave an order to send the resident to the hospital. Emergency Medical System (EMS) arrived and resident transferred to hospital. Review of the resident's hospital admission record, dated 7/9/16, showed the following: -Presents to the emergency department for evaluation of [MEDICAL CONDITION] activity. Medical history includes MS and underlying [MEDICAL CONDITION] disorder. Has had eye twitching and facial twitching which apparently is different from his/her normal [MEDICAL CONDITION]. Also noted to be febrile (with fever) today. Patient was admitted on [DATE], for somewhat similar complaints. Ultimately discharged home on chronic antibiotics: Cipro, Bactrim and [MEDICATION NAME] for osteo[DIAGNOSES REDACTED] and C -diff. Was given [MEDICATION NAME] (a sedative) 2 mg Intravenously (IV) in route; -Presents to the emergency department for evaluation of possible [MEDICAL CONDITION] activity. However, this is apparently not his/her usual [MEDICAL CONDITION]. The symptoms are inconsistent and fatigable with observation. Concern remains for possible [DIAGNOSES REDACTED] (continuous [MEDICAL CONDITION] occurring without interruptions [MEDICATION NAME] more than 30 minutes and can be precipitated by the sudden withdrawal of anticonvulsant drugs). Unable to obtain an EEG at this time. Given [MEDICATION NAME] and [MEDICATION NAME] bolus. Patient has multiple drug resistant Escherichia coli (bacteria found in stool and dirt) and Proteus (bacteria found in dirt), which seems to not have been treated. Certainly may be contributed to his/her symptoms as well as fever. Will go to the intensive care unit for continued monitoring and further evaluation; -[MEDICATION NAME] level drawn on 7/9/16 at 8:40 P.M., showed a level of less than 2.0 (normal is 12 to 46). During an interview on 7/15/16 at 8:05 A.M., Nurse A said he/she was the only licensed nurse working the South hall on the evening of 7/7/16. She had worked at the facility for about one and one-half years. He/She said another nurse, Nurse J, came to assist him/her. Nurse A told Nurse J to call the physician and verify the orders. He/She did not do the readmission because the computers kept freezing up and he/she was not taught on how to place an admission in the computer. He/She told the night nurse, Nurse K, the admission had not been done because he/she was the only nurse and for Nurse K to do the admission. Nurse A did not do any hand written POS, MARs or TARs because he/she did not have an admission packet. Nurse A was not aware the physician had not been notified, medications verified, or administered any medications or treatments between 7/7/16 and 7/9/16. Nurse A again said he/she had not done anything with the readmission of Resident #27. During an interview on 7/4/16 at 11:45 A.M., Nurse J said he/she had stayed over the evening of 7/7/16, to work the South Hall. He/She arrived a few minutes before 6:00 P.M Nurse A was told by the day shift nurse (Nurse B) that Resident #27 would be returning to the facility from the hospital. Nurse A left the floor. Resident #27 arrived at the facility around 6:30 P.M., Nurse J assisted the paramedics to transfer the resident from the stretcher to his/her bed. Nurse A came into the resident's room, took the transfer papers from the paramedics and stayed in the resident's room. Nurse J left the room to pass medications to other residents. A couple of hours later, Nurse J noticed Nurse A had not placed any of the medications or treatment orders in the computer and offered to check the medications and treatments against the old orders. Nurse J pulled up the old MARs and TARs on the computer, compared them and told Nurse A there were four new medications and the rest were being continued. Nurse J said he/she does MDSs, does not do admissions and does not know how to do them. He/She said when Nurse A sat down at the computer, he/she just kept saying 'had to do the admission and computer was freezing up'. Nurse J stayed on the floor until after 11:00 P.M. and was unaware the resident had not been readmitted back into the facility. During an interview on 7/15/16 at 6:00 A.M., Nurse K said on 7/7/16 around 7:00 P.M., Nurse A had called him/her at home to come in early. Nurse A said Resident #27 had returned to the facility from the hospital and he/she did not have any help with the admission. Nurse K told Nurse A that he/she would not come in early. Nurse K arrived at the facility on 7/7/16 at 10:45 P.M. to find papers scattered all over the nurses station desk. When he/she questioned Nurse A, Nurse K was told it was the resident's admission, it had not been done and to leave it for the day shift to do. Nurse K did not do the admission because he/she works the night shift and is unfamiliar with how to do an admission in the computer. Nurse K said prior to the resident's hospitalization , he/she received [MEDICATION NAME] and [MEDICATION NAME] every morning on the night shift. Nurse K, who worked the night shift on 7/8/16, did not administer any medications or treatments to the resident between 7/7/16 and 7/9/16, did not chart on the resident and did not check the hard chart for any medications or treatments. Nurse K said he/she did not remember Nurse A saying anything about the computers freezing up, Nurse A was upset and said no one would help him/her with anything. During interviews on 7/14/16 at 1:40 P.M. and 7/15/16 at 6:40 A.M., Nurse B said he/she had worked at the facility since the end of May 2016. He/she worked the day shift on 7/7/16, but did not leave the facility until around 6:30 P.M., just as the resident was being brought into the facility by the paramedics. He/She did tell Nurse A that the resident would be returning that evening. Nurse B worked the day shift on 7/8/16, received report from night shift Nurse K, who told him/her the resident had been a paper admission. When Nurse B questioned Nurse K what a paper admission was, Nurse K did not know. He/She went to look at Resident #27, but did not do any charting on the resident or administer any medications or treatments to the resident. He/She told the evening supervisor that evening that Resident #27 was not in computer and was told the evening supervisor would look into it. He/she worked the day shift on 7/9/16 and the resident's information was still was not in the computer and he/she did not administer any medications, treatments, or do any charting on the resident. Nurse B said he/she knew the resident had wounds, had done treatments to the areas prior to him/her going to the hospital on [DATE] and thought it was strange there were no treatment orders. He/She did not go look at the transfer orders in the hard chart because he/she did not think about it, because he/she was use to the computer directing the resident care. He/She was in the facility the evening of 7/9/16 and saw the resident having small [MEDICAL CONDITION]. Nurse B said he/she did not place the resident's information into the computer because he/she did not know how to do an admission on the computer. During an interview on 7/14/16 at 11:35 A.M., Certified Medication Tech (CMT) I said he/she worked day shift on Friday 7/8/16. There was not any MAR indicated [REDACTED]. The resident was not in the computer. It would not allow him/her to pull up any previous medications. He/She did not administer any medications to the resident on 7/8/16. During an interview on 7/14/16 at 4:05 P.M., Nurse L said he/she worked evening shift on 7/8/16 and 7/9/16, but did not have the side of the hall that Resident #27 resided on and did not take care of the resident. He/She remembered staff not able to administer any medications or treatments because they could not get the resident's name to pop up in the computer under the MARs, TARs or POS. Nurse L witnessed Resident #27 having [MEDICAL CONDITION] on 7/9/16, prior to being sent out to the hospital. He/She said there were several [MEDICAL CONDITION], each lasted between 3 to 5 minutes long, the resident's whole body became stiff, back arched, and whole body shook very hard each time. During an interview on 7/14/16 at 12:15 P.M., Unit Manager N said he/she worked 7/8/16 and 7/9/16 as the Manager on Duty for the entire building. He/She did not see Resident #27 on either day, but was aware he/she had returned from the hospital. He/She did not know the resident had not been readmitted in the computer or that he/she did not receive any medications or treatments. On 7/9/16 between 6:00 P.M. and 7:00 P.M., he/she received a phone call from a nurse at the facility that the resident had [MEDICAL CONDITION] and instructed the nurse to call the physician. At that time, he/she was made aware the resident had never been readmitted , was not listed in the computer and he/she remotely checked the computer and found the resident had not been readmitted and there were no orders. Unit Manager N talked to Nurse A the morning of 7/10/16. Nurse A told him/her the computers kept freezing up, he/she could not complete the resident's readmission, but did hand write a nurse's note. During an interview on 7/14/16 at 10:15 A.M., the Director of Nurses (DON) said the resident had been sent out to the hospital on [DATE], returned on 7/7/16. Had not been readmitted to the facility by computer or hand written readmission. She verified there were no orders placed in the computer and staff would not be able to administer medications, treatments or document in his/her nurses notes on the computer. During an interview on 7/14/16 at 2:50 P.M., the administrator said if staff cannot admit/readmit a resident in the computer, she would expect staff to hand write the POS, MARs, TARs, nurse's notes, and assessments until they can be put into the computer. The hand written copies would be placed in the resident's chart. During an interview on 7/15/16 at 7:25 A.M., Evening Supervisor O said he/she did not work on 7/7/16, but worked the floor on a different unit on 7/8/16. Staff should call the Manager on Duty when they have any problems. He/She denied anyone discussing Resident #27 with him/her. He/She did not find out the resident had not been readmitted to the facility until 7/11/16. If staff are having any problems with the computer system, they can call Electronic Health Record (EHR) representative for the facility. The EHR representative is available 24 hours a day seven days a week. During an interview on 7/15/16 at 10:15 A.M., the Administrator said she did not work on 7/8/16, did not become aware that Resident #27 had not been readmitted on [DATE], and had not received any medications or treatments from 7/7/16 through 7/9/16, until 7/12/16, around 5:00 P.M. She immediately had Nurse A taken off the schedule and started an investigation. At 12:10 P.M. she said they do not have a policy/procedure for admission/readmission specific to the computers not working correctly or for the physician notification of admission/readmission. During an interview on 7/14/16 at 3:25 P.M., the physician said he was told the resident would be returning to the facility the evening of 7/7/16, but was never notified the resident had returned or to verify any medications. He does not see any of his residents in the hospital. He would have ordered the medications on the hospital transfer sheet and would expect the nurse at the facility to call him to verify the orders and then administer them as ordered. He said the resident not receiving the [MEDICATION NAME] as ordered would have definitely contributed to the [MEDICAL CONDITION] activity. Further review of the hospital consult note dated 7/11/16, showed the resident remained in the intensive care unit, had several wounds and was brought to the emergency department due to fever and [MEDICAL CONDITION]. The physician recommended the resident be evaluated for hospice. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility immediately started to inservice staff on how to admit/readmit residents when the computer system was not working correctly, the Unit Managers started checking all new admissions and readmissions the following morning after admission/readmission to ensure the admission process had been completed correctly and the findings from all new admissions/readmissions will be reviewed every day Monday through Friday during the morning meetings. The facility will continue to inservice staff, will administer a post test and will monitor staff during an admission/readmission to ensure all staff are knowledgeable on how to admit/readmit a resident. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation. 2. Review of Resident #8's medical record showed: -admitted from another facility on 6/7/16, under hospice care started on 4/22/16; -No MDS, as late as 7/19/16; -[DIAGNOSES REDACTED]. Review of the resident's care plan developed by the facility, dated 6/13/16, showed; -Focus, dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits; -Focus, nutritional problems, underweight, related to disease progression; -Focus, code status, do not resuscitate; -No other focus items listed; -No mention of hospice care and services, or coordination of care between the facility and hospice. Review of the resident's nurse's notes showed: -6/7/16 at 3:16 P.M., the resident arrived at 2:00 P.M. from another facility, had [MEDICAL CONDITION], alert times one, could stand for transfer with one assist. A family member said the resident can be combative and hit at nurse while doing skin assessment. Total care with ADLs and pericare, on hospice, hospice to do all bed baths, takes meds crushed, wears eye glasses, has own teeth, history of urinary tract infection which is not being treated; -7/12/16, 6:14 P.M., hospice nurse here today, no new orders; -No other nurse's notes regarding hospice care or visits. During an interview on 7/14/16 at 9:10 A.M., a hospice certified nurse aide (CNA), said he/she documented visits with hospice residents on an electronic device. Before leaving the facility, he/she communicated with staff in person about what care was provided and any changes discovered, and obtained an electronic signature. To his/her knowledge, there were no records of visits sent to, or left with the facility. The facility could probably get them if they wanted them. During an interview on 7/14/16 at 1:00 P.M., Nurse II said when the hospice nurse visited the resident, notes were made and kept in the hospice binder on the shelf at the nurse's station. Nurse II handed this surveyor the hospice binder. Review of the hospice binder showed no record of Resident #8. During an interview on 7/15/16 at 10:40 A.M., the DON said she found no hospice records in the facility for the resident and requested they be sent by fax. The unit manager and the hospice nurse were responsible for making sure the facility maintained the records, otherwise they would not know how to care for the resident. During an interview on 7/15/16 at 12:00 P.M., Unit Manager N said when hospice visited a resident she expected communication and coordination with facility staff regarding the care of the resident. She expected hospice admission information, plan of care and visit notes to be kept by the facility. Before hospice personnel left the facility, the charge nurse provided an electronic signature on the IPad. Any new orders, issues or concerns would be discussed with the charge nurse who would then communicate with the resident's physician. Resident #8's hospice provider was the only one who used electronic means to document visits. During an interview on 7/15/16 at 1:20 P.M., Unit Manager N provided a copy of the resident's hospice plan of care, medication record, skilled nursing and hospice aide notes and said a copy was placed in the binder at the nurse's station. MO 893

Based on interview and record review, the facility failed to follow one sampled resident's wishes and physician's order for Cardiopulmonary Resuscitation (CPR) when staff discovered the resident without signs of life. The nurse found the resident pulseless and not breathing and did not provide CPR or call 911. The resident was a full code (Resident #1). This deficient practice also had the potential to affect the other 79 residents the facility identified as having a full code status. The census was 180. 1. Review of the facility's CPR policy and procedure, dated [DATE], showed the following: -Residents requiring CPR will receive the procedure following the current American Heart Association (AHA) guidelines. -All licensed nursing staff can perform this emergency care when needed; -Call emergency medical services (EMS/911); -The supervisor and/or nurse in charge will contact the physician and report the emergency; -The supervisor or nurse in charge will notify Power of Attorney (POA)/Guardian as soon as the EMS has arrived on the scene to inform them of the emergency situation. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum regarding initiation of CPR, dated [DATE], showed prior to arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR certified staff must be available at all times. Review of Resident #1's physician's orders, dated [DATE], showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -[MEDICAL TREATMENT] three times a week; -Oxygen at 3 liters per nasal cannula; -Full code. Review of the resident's nursing admission summary, dated [DATE], showed the following: -Oriented to person, place and time; -Weak in lower extremities, difficulty walking, required assistance with transfers; -Complained of his/her feet being cold at all times; -Continent of bowel and bladder; -Bilateral lower extremities have ,[DATE]+ [MEDICAL CONDITION] (an indentation that lasts for 1 to 2 or more seconds after the release of applied pressure to an area), pulses faint, feet cool, skin dry and scaly. Review of the resident's care plan, dated [DATE], showed the following: -[MEDICAL CONDITION] and [MEDICAL TREATMENT] related to [MEDICAL CONDITION]; -[MEDICAL TREATMENT] three times a week; -Exertional shortness of breath; -Monitor changes in orientation, increased restlessness, anxiety and air hunger; -Assist resident/family/caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR. Review of the resident's social services note, dated [DATE] at 4:41 P.M., showed plans were being made for discharge home with family and home health services. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -No memory problem; -Extensive assistance with care and transfers; -Occasionally incontinent of bowel and bladder; -Occasional pain; -Shortness of breath on exertion or when sitting at rest; -Oxygen therapy; -[MEDICAL TREATMENT]. Review of the resident's progress note written by Nurse A, dated [DATE] at 4:50 A.M., showed the following: -Resident found by Certified Nurse Aide (CNA) B passed away in bed, lying in supine (on back) position, skin warm to touch, axillary (under arm, which is usually 0.5 to 1.0 degrees lower than an oral temperature) temperature 96 degrees Fahrenheit (F); -Notified Director of Nurses (DON), physician and resident's family member. Spoke with coroner's office. Resident cleaned up and prepared for family to arrive. Review of the facility investigation, dated [DATE], showed the following: -On [DATE] at approximately 3:30 A.M., CNA B was doing rounds and noticed the resident passed away. CNA B went to get Nurse A to assess the resident. Nurse A found the resident lying supine in bed, with his/her arms across his/her chest. He/She had no secretions in his/her mouth and his/her head was tilted back on the pillow. The resident had no pulse, and no rise or fall of his/her chest. The skin to his/her forehead was cool to touch and his/her neck was warm. Both lower extremities were warm and he/she had a heating pad on his/her feet, due to his/her feet being cold earlier in the shift. -Nurse A went to the nurse's station, looked for the resident's medical record to make the appropriate phone calls, and noticed the resident was a full code. Nurse A called the physician, DON, family and coroner; -On [DATE] at 9:00 A.M., it was discovered the resident was a full code and CPR had not been initiated; -The DON called the regional nurse to inform of the situation, and was told to notify Nurse A that he/she would be suspended pending the outcome of the investigation, because he/she did not initiate CPR on the resident who was a full code; -Nurse A said with his/her hospice background, he/she was used to being able to pronounce someone dead; -The DON informed Nurse A that upon his/her hire to the facility on [DATE], he/she signed a CPR policy to initiate CPR on every full code resident; -Statement of CNA B, dated [DATE], showed at approximately 3:30 A.M., CNA B found the resident expired in his/her room; -Statement of Nurse A, dated [DATE], showed the following: -Saw the resident on [DATE] at 10:00 P.M., and on [DATE] at 1:45 A.M., asleep in bed; -At 4:00 A.M., CNA B came to the nurse's station and asked Nurse A to come and see the resident, because he/she believed the resident was dead; -Observed the resident laying on his/her back in bed, with his/her arms across his/her chest, no secretions in his/her mouth and his/her head tilted back on the pillow; -Assessed that the resident had no pulse or respirations and immediately knew the resident had expired. The resident's forehead was cool, neck was warm and temperature was 96 degrees F. Both of the resident's legs were warm, and he/she had a heating pad on his/her feet; -Told CNA B the resident had expired, went to read his/her chart and make the appropriate phone calls; -Saw the resident was a full code; -Called the DON to tell him/her that the resident had expired and was a full code. Told the DON he/she would call the physician, family, coroner and mortuary; -Called the DON back to ask if there was anything he/she should do according to facility protocol or paperwork. The DON replied the death report was needed; -Called the physician, who asked for the resident's [DIAGNOSES REDACTED]. -On [DATE], staff was inserviced regarding CPR; -On [DATE], the investigation was completed. It was determined to allow Nurse A to return to work at the facility; -Facility management determined it was a violation of the facility policy and procedure for CPR and not a violation of state regulations. During an interview on [DATE] at 3:35 P.M., CNA B said the following: -He/she was reassigned to the resident's hall on [DATE] at 1:45 A.M. and started rounds at 2:15 A.M. When he/she made it to the resident's room at approximately 3:30 A.M., the resident was in bed expired; -Ran to tell Nurse A. They both ran to the resident's room; -The resident was laying down, with his/her mouth open, not breathing and his/her hands on his/her chest; -CNA B assumed the resident had just passed away. The resident's neck, back and arms were warm and his/her skin was not mottled (discoloration in irregular areas) purple color; -Nurse A told CNA B to get the resident's temperature, which was 96.5 degrees F; -Nurse A assessed the resident, said he/she was expired, went to the chart and made phone calls; -Nurse A said the resident was a full code; -CNA B asked if they should call a code and do CPR on the resident; -Nurse A said the resident was expired and he/she would call the supervisor; -CNA B knew the protocol since the resident was a full code. They should have called 911, got the crash cart and performed CPR. During an interview on [DATE] at 1:15 P.M., Nurse A said the following: -On [DATE], between 10:30 P.M. and 11:00 P.M., he/she observed the resident laying awake in bed. The resident said he/she was okay; -On [DATE] at 1:45 A.M., he/she observed the resident sleeping in bed, breathing with oxygen on and in no distress; -On [DATE] at 4:00 A.M., CNA B told Nurse A that he/she thought the resident was dead; -Nurse A and CNA B ran to the resident's room. Nurse A assessed the resident and said he/she was dead. The resident's hands and fingertips were cool, skin was warm to touch and temperature was 96 degrees F; -He/she could not say how long the resident had been dead, but knew it was for awhile; -Called the DON, asked about the protocol when they find a resident dead, and if 911 needed to be called. The DON asked if the resident was a full code. Nurse A said yes, but the resident had been dead for awhile; -Nurse A did not ask the DON if he/she should have performed CPR on the resident; -The DON did not ask if CPR had been performed on the resident, and said 911 did not need to be called; -The administrator called Nurse A on [DATE], and said the facility protocol was to call 911 and perform CPR on a full code resident; -Nurse A said CPR should have been performed on the resident, who was a full code. During an interview on [DATE] at 11:45 A.M., the administrator said the following: -The administrator was out of the country for the past week, just finished reviewing the investigation done by the DON regarding the resident, and was about to call the hotline with a self report; -On [DATE], the resident expired; -The resident was a full code and Nurse A did not do CPR. During an interview on [DATE] at 2:15 P.M., the DON said the following: -Nurse A called the DON on [DATE], after the resident died ; -Nurse A just said the resident died , asked what paperwork should be filled out and who should be called; -The DON did not ask if the resident was a full code or if CPR was done on the resident. Review of the administrator's statement, dated [DATE], showed the following: -Call placed to Nurse A on [DATE], to inform of decision made on [DATE], to separate employment due to incident of failure to perform CPR on a full code resident; -DON present for entire conversation. Initial discussion with Nurse A was about his/her failure to perform CPR and the CPR policy that was presented to him/her during orientation on [DATE]; -During the conversation, Nurse A stated he/she did receive the appropriate training from the facility, and his/her admitted failure to perform CPR was confirmed in his/her statement given to the DON during the investigation. Review of the plan of correction, dated [DATE], for a statement of deficiencies given on [DATE], for failure to provide CPR for a resident who was a full code, showed the following: -In-services will be completed by the DON/designee on Emergency Care: CPR Policy & Procedure, to RN/LPNs monthly for 3 months then quarterly for 12 months; -In-services will be completed by the DON/designee on Emergency Care: CPR Policy & Procedure for runner responsibilities, to CNAs monthly for 3 months then quarterly for 12 months. During an interview on [DATE] at 1:00 P.M., the administrator said the following: -Inservices regarding CPR were done in [DATE], but not February or [DATE]; -The administrator thought the inservices were to be done quarterly after that time, according to the plan of correction from [DATE]. The plan of correction showed inservices should have been done every month for three months, then quarterly; -An inservice regarding CPR was not done until [DATE], after this incident occurred. Review of information provided by the facility on [DATE], showed 79 residents with a full code status resided in the facility. During an interview on [DATE] at 4:10 P.M., the resident's physician said staff should have done CPR since the resident was a full code. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan of correction which included inservicing staff regarding cardiopulmonary resuscitation(CPR) on residents who have a full code status. The code status is visible at all times while logged into each resident's electronic medical record and inside of the hard chart. The facility will monitor residents and staff to ensure appropriate measures are taken for residents with a full code status. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the ''D'' level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation. MO 326 MO 354

Based on interview and record review, the facility failed to ensure staff followed physician's orders and a resident's wishes when they did not provide Cardiopulmonary Resuscitation (CPR) for one full code resident (Resident #1). Additionally, the facility failed to ensure a system was in place to inform staff of the code status for Resident #1. The facility census was 171. Review of the facility's CPR policy, last revised [DATE], showed the following: -Policy: All licensed nursing staff can perform emergency care when needed; -Procedure: -Call 911; -Obtain emergency cart; -Make the resident respond, if the resident did not respond, place them on their back. If in bed place a back board under the resident's back; -Start giving chest compressions by placing your hand's heel on the chest at the base of sternum. Begin 30 compressions. Pushdown at least 2 inches. The rate of compressions is 100 compressions per minute; -Open the airway with a head tilt-chin lift and give two breaths. Determine if you see the chest rise or not; -Continue giving compressions and breaths in the ration 30:2 for 100 compressions per minute until emergency medical services (EMS) arrive and take over the emergency situation; -The supervisor and/or nurse in charge of the resident will notify the physician and report the emergency; -Have a Certified Nurses Aide (CNA) at the door to be a runner for possible equipment or supplies needed for the emergency; -The licensed nursing personnel will stay and brief EMS crew using Situation, Background, Assessment and Recommendation (SBAR, a tool used to facilitate prompt and appropriate communication between facility staff) and any other information that would be helpful; -The supervisor and/or nurse in charge of the resident will get paperwork needed by EMS together and ready for transport; -The supervisor or nurse in charge will notify the resident's Power of Attorney (POA) as soon as EMS arrived on the scene to inform them of the emergency situation. 1. Review of Resident #1's undated face sheet, showed the following: -Admission [DATE]; -Resident listed as own responsible party; -Resident's spouse (also Resident #1's roommate) listed as emergency contact; -No code status documented. Review of the resident's care plan, dated [DATE], showed the following: -Problems: falls, chronic pain, skin integrity, chewing difficulty, activities, weight gain, behaviors, dementia, elopement and smoking; -The resident's care plan did not address his/her code status or any respiratory problems. Review of the resident's Physician's Order Sheet (POS), dated [DATE], showed his/her advanced directives were current and verified he/she was a full code. Review of the resident's social service progress notes, showed care plan meetings were held on [DATE] and [DATE], but there was no documentation the resident's code status was verified. Review of the resident's readmission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Understood/understands; -Cognitively intact; -Required limited assistance with bed mobility, dressing, toileting and personal hygiene; -Required extensive assistance for walking in room; -Required supervision with eating and transfers. Review of the resident's undated [DIAGNOSES REDACTED]. -[MEDICAL CONDITION]; -Shortness of breath; -[MEDICAL CONDITION] ([MEDICAL CONDITION], impaired heart function); -High blood pressure; -[MEDICAL CONDITIONS] (hardening of the arteries); -Diabetes; -[MEDICAL CONDITION]; -[DIAGNOSES REDACTED] (deficiency of potassium in the bloodstream); -[MEDICAL CONDITION] (mood disorder); -Depression; -[MEDICAL CONDITION]; -Anxiety; -Altered mental status; -Mild cognitive impairment; -Arthropathy (joint disease); -Irritable Bowel Syndrome (IBS). Review of the resident's social service progress notes, showed the following: -A [DATE] entry, the resident went to the hospital on [DATE] due to [MEDICAL CONDITION], and returned on [DATE]. There was no documentation the resident's code status was verified. -A [DATE] entry, a care plan meeting was held. There was no documentation the resident's code status was verified. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's social service progress note, dated [DATE], showed a care plan meeting was held. There was no documentation the resident's code status was verified. Review of the resident's progress notes, dated [DATE], showed Nurse A documented at 9:10 P.M., scheduled medications and a breathing treatment were administered. The resident coughed up a small amount of sputum. Oxygen saturation at 10:00 P.M. was 93%, by earlobe, on 5 liters per nasal cannula via oxygen concentrator. No complaints voiced, call light within reach. The resident sat in his/her rocking chair watching television. Review of the Resident #1's progress note, dated [DATE] at 11:00 P.M., showed Nurse A documented during rounds with the night shift nurse, the resident was found slumped in this/her rocking chair, blue in color, barely warm to touch. The oximeter (oxygen saturation machine) showed a flat line (no pulse/heart beat). Resident #3 was in the next bed at that time. Nurse A told Resident #3 that the resident had passed away and asked if he/she wanted CPR done. Resident #3 looked at the resident and saw he/she was blue and said, No, do not. Staff assisted the resident back to bed. The resident's body was cleansed and prepped. Resident #3 was the resident's only living relative and was informed of the death. No other living relatives were found in the resident's medical record. The nursing supervisor, resident's physician's exchange and the coroner were notified of the resident's death. During an interview on [DATE] at 4:20 P.M., Nurse A said he/she worked on [DATE] from 3:00 P.M. through 11:00 P.M., and was assigned to Resident #1 and Resident #3. He/she did not recall any concerns voiced in report regarding Resident #1. Nurse A had concerns about Resident #1 for over a week. He/she had not been able to obtain oxygen saturations above 90% on the resident's fingers for the past week. The nurse notified the resident's physician three or four times that week regarding the resident's medical condition. The physician instructed him/her to obtain the oxygen saturation from the resident's ear. On [DATE], the nurse received the resident's chest x-ray results and contacted the resident's on call primary care physician. Orders were received and instead of documenting the new orders on the physician's order sheet, he/she documented the orders on the chest x-ray results page. The physician ordered [MEDICATION NAME], a nebulizer treatment and for staff to monitor the resident's oxygen saturation to ensure it did not go below 90% and his/her temperature to ensure it did not go above 100.5. Nurse A said none of the medication orders were new. Nurse A obtained a full set of vital signs for Resident #1 when he/she arrived to work on [DATE]. The vital signs included blood pressure, pulse, temperature, respirations and oxygen saturation. Nurse A did not document the assessment in the resident's medical record, there was too much going on and he/she did not remember to do everything. Nurse A administered the resident's scheduled breathing treatment at approximately 8:00 P.M. At approximately 9:55 P.M., the resident asked for PRN [MEDICATION NAME] and he/she administered the [MEDICATION NAME] at approximately 10:00 P.M. It was the last time he/she observed the resident alive. At that time, the resident was sitting in his/her rocking chair with 5 liters of oxygen via nasal cannula, watching television with the call light within reach. At 11:06 P.M., the night shift nurse (Nurse B) and Nurse A entered the resident's room. The resident was in his/her rocking chair, not moving with his/her eyes closed. Nurse A said the resident's face was blue, his/her skin was cool to the touch and was not breathing. The resident was obviously gone. Resident #3 was sleeping in a bed next to the resident. Nurse A told Resident #3 that Resident #1 had passed away. Nurse A then asked Resident #3 if he/she wanted staff to do CPR for Resident #1. Resident #3 said, No that would be mean. Neither nurse initiated CPR or called 911. Nurse A assessed Resident #1 again to confirm he/she had no signs of life, he/she was not breathing, had no pulse and the oxygen saturation machine read zero. Nurse A went to the nurse's station and called the on call nursing supervisor, Nurse C. Nurse A reported staff found Resident #1 with no signs of life and cool to the touch. Nurse A also reported no CPR was done because Resident #3 said not to. Nurse C told him/her to look in Resident #1's medical record to see if he/she had a healthcare power of attorney (POA). Nurse A could not find that documentation in the resident's medical record. The resident's face sheet showed Resident #3 was Resident #1's next of kin and emergency contact. There was no code status in the medical record. He/she performed CPR many times and would have done so if Resident #3 had said to do CPR. He/she did not recall documenting in the medical record the resident was barely warm. The resident's body temperature had significantly dropped from normal, he/she was not ice cold but definitely cool. Nurse A recalled being inserviced regarding code status a few weeks prior, but he/she thought when Resident #3 said no CPR, that was sufficient. He/she knew the facility's CPR policy. When a resident is found unresponsive, staff call a code blue, call 911, all nurses respond and CPR is performed. Facility staff did not ask him/her to provide a written statement or question him/her regarding the resident's death. Review of the facility's inservice training report, dated [DATE], showed staff, including Nurse A, attended training regarding the SBAR and code status. The inservice instructed staff to initiate CPR, call 911 and notify the resident's physician for residents who are a full code status. Review of the resident's spouse (Resident #3) annual MDS, dated [DATE], showed the following: -Admission: [DATE]; -Understands/understood; -BIMS score: 10 (,[DATE], indicates moderate impairment). During an interview on [DATE] at 3:15 P.M., Resident #3 said Nurse A woke him/her up and told him/her Resident #1 passed away. He/she saw the resident after staff transferred Resident #1 to bed. Resident #3 said Resident #1 did not appear blue or discolored. His/her color was normal. Resident #3 said Resident #1 complained about breathing difficulties for a few days. Resident #3 did not recall Nurse A asking him/her if he/she wanted CPR performed on Resident #1. During an interview on [DATE] at 2:30 P.M., Nurse C said he/she was the supervisor on call on [DATE]. Nurse A called him/her at 11:45 P.M., and reported Resident #1 passed away. He/she asked Nurse A if CPR was initiated and if 911 was called. Nurse A told Nurse C Resident #3 said not to do CPR, so CPR was not initiated and 911 was not called. Nurse C asked Nurse A if Resident #1 was his/her own responsible party or if he/she had a healthcare POA. Nurse A did not know that information. Nurse C said he/she was concerned that if Resident #1 was his/her own responsible party and did not have a healthcare POA, then Resident #3 would not have the right to say not to perform CPR. Nurse C did not talk to management regarding his/her concerns. During an interview on [DATE] at 4:10 P.M., the Director of Nursing (DON) said if the on-call nurse had questions or concerns related to resident care, she expected the on call nurse to notify the ADON or herself. The nurse educator was inservicing staff at that time on the CPR policy and where to locate residents' code status in the medical record. No inservices were done prior to the surveyor coming to the facility on [DATE]. During an interview on [DATE] at 1:17 P.M., CNA E said he/she worked from 3:00 P.M. through 11:00 P.M. on [DATE], and was assigned to the resident. He/she worked with the resident often and knew the resident well. The resident was alert and could make his/her needs known. At approximately 11:00 P.M., CNA E heard staff yelling for assistance at the resident's room. When he/she entered the resident's room, he/she saw the resident was in his/her rocking chair and his/her face was white/pale. He/she did not recall the resident's face being blue. Nurse A disconnected the resident's oxygen at that time. Nurse A and Nurse B were in the room with the resident. CNA E did not see either nurse take the resident's vital signs. He/she assisted staff transfer the resident to bed and with post mortem care. He/she did not observe discoloration to the resident's skin during post mortem care. Although CNA E was in the room, he/she did not hear conversations between the nurses and Resident #3. He/she did not hear staff discussing CPR either. CPR was not initiated, and he/she was not told to call 911 or to obtain the resident's medical record. Nurse B told CNA E a few days later that he/she did not know Resident #1 was a full code. During an interview on [DATE] at 8:55 A.M., CNA G said he/she worked from 3:00 P.M. through 11:00 P.M. on [DATE]. He/she was not assigned to the resident that shift, but did work with the resident. At 10:00 P.M., the resident was in his/her rocking chair, with oxygen on via nasal cannula, watching television. At approximately 11:00 P.M., the CNA heard staff yelling down the hall at the resident's room. When he/she entered the resident's room, he/she saw the resident's face was pale. He/she did not hear staff discuss the resident's CPR status or a conversation between Nurse A and Resident #3. CPR was not initiated and he/she was not told to call 911 or to get the resident's medical record. CNA G assisted with transferring the resident to bed and post mortem care. The resident was not stiff when they transferred him/her to bed and his/her skin was not blue, it was pale. During an interview on [DATE] at 2:05 P.M., the Assistant Director of Nursing (ADON) said the facility was not investigating the incident and staff were not asked to provide written statements. Nurse A was not suspended and no staff questioned him/her regarding Resident #1's code status or the events that occurred on the evening on [DATE]. When a resident has a Do Not Resuscitate (DNR) code status they have it documented in the resident's medical record, close to the front of the medical record. The resident did not have a form in his/her record to indicate if the resident was a full code. A resident's code status is documented on the first page of the medical record, on the face sheet and on the physician's order sheet. During an interview on [DATE] at 8:40 A.M., Nurse B said he/she worked from 10:35 P.M. on [DATE] to 7:00 A.M. on [DATE]. Nurse B received report from Nurse A, and Nurse A said he/she was concerned about the resident's breathing. At approximately 11:00 P.M., Nurse A and Nurse B entered the resident's room to assess him/her. The resident sat in his/her rocking chair and his/her color was off. The resident's face was a blue/gray color, but he/she was not discolored anywhere else. Nurse B felt for a carotid artery (neck) and radial (wrist) pulse, but the resident did not have one. He/she did not observe respirations and saw no air coming from the resident's nose. He/she did a sternal (breast bone) rub (apply firm pressure then rub up and down the sternum) and the resident did not respond. Nurse B took the resident's blood pressure, temperature and oxygen saturation while he/she did the assessment. Nurse A told him/her the resident was a no code. Nurse B assisted other staff to transfer the resident to bed. The resident was not stiff at that time, rigor mortis (one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the body to stiffen) had not set in. He/she assisted staff with post mortem care and the resident had facial discoloration, but there was no discoloration or mottling (areas of skin that are splotchy and of varying colors). While Nurse B assisted with post mortem care, Nurse A spoke to Resident #3, but he/she did not hear their conversation. At approximately 11:30 P.M., Nurse B looked at Resident #1's medical record and saw he/she was a full code. When he/she questioned Nurse A about Resident #1's code status, Nurse A said since Resident #3 was Resident's #1's next of kin and said not to do CPR, to let it go. Nurse B said when a resident had breathing issues, he/she would go through the medical record and find the code status. Nurse B did not think twice when Nurse A said the resident was a no code. The DON asked Nurse B to write a statement on [DATE], but facility staff did not ask her any questions about the events of that night prior to [DATE]. During an interview on [DATE] at 11:30 A.M., Nurse A said at approximately 11:00 P.M., he/she and Nurse B entered the resident's room. When the resident was assessed to have no signs of life, Nurse A did not take the resident's vital signs. The resident was transferred to bed with the assistance of staff. The resident's feet were mottled, but he/she was not stiff, rigor mortis was not present and no livor mortis (a settling of the blood in the lower portion of the body, causing a purplish red discoloration of the skin) was assessed while staff provided post mortem care. He/she did not recall talking to Nurse B regarding the resident's code status after post mortem care was provided. Nurse A was responsible for completing the death reporting form, but he/she thought the coroner would complete the information on the form regarding rigor mortis, livor mortis, body temperature and external temperature at the time of death. Nurse A said CPR should have been initiated because Resident #1 was his/her own responsible party. Review of the resident's death reporting form, dated [DATE], showed the following: -Passed away at 11:06 P.M.; -Last observed at 10:00 P.M.; -Nurse A and B found the resident unresponsive and pronounced him/her dead; -Recent complaints: shortness of breath on 5 liters of oxygen; -Chest x-ray negative; -Staff did not document what position the resident's body was in, livor mortis, rigor mortis, decomposition, marks/injuries, body temperature and environmental temperature. During an interview on [DATE] at 3:45 P.M., the social worker verified the resident did not have a healthcare POA and was his/her own responsible party. She verified a resident code status at the quarterly care plan meeting. She documents the information in the social service progress notes in the resident's medical record. The code status for a resident was located on the first page of the resident's medical record, the face sheet and the POS. During an interview on [DATE] at 12:20 P.M., the medical records personnel said a resident's code status was on their face sheet. The problem was the residents' [DIAGNOSES REDACTED]. The residents' face sheets are in a plastic sleeve in the medical record. Staff would have to physically pull out the second page of the residents' face sheet to view the code status. There was no sticker to indicate full code status that he/she knew of. Sometimes a resident's chart would change colors depending on the services received. When those services were discontinued some staff would start a new medical record so the code status would not be in the new medical record. During interviews on [DATE] at 2:50 P.M. and 4:10 P.M., the DON said she read Resident #1's nurse's note, dated [DATE] at 11:00 P.M., during the interdisciplinary meeting on [DATE]. It is the facility's policy when a resident was a full code staff should initiate CPR. The resident's next of kin or emergency contact could not give permission to not do CPR. Resident #3 was Resident #1's emergency contact and next of kin not his/her healthcare power of attorney. No investigation was started regarding Resident #1's code status and no written statements were obtained. She did not speak with Nurse A about Resident #1's code status or the events that took place. Nurse A was inserviced on code status and change in condition on [DATE]. The DON did not know why Nurse A did not follow the facility's CPR policy. Nurse A was suspended on [DATE] for not following the facility's CPR policy. During an interview on [DATE] at 11:20 A.M., the resident's physician said he expected staff to follow all physician's orders. The facility should have a system in place to communicate a resident's code status and follow it. He was not aware the resident was a full code and staff did not initiate CPR or call 911. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed a plan which showed all nursing staff were to be inserviced regarding cardiopulmonary resuscitation (CPR) on residents who have a full code status. The facility implemented a system to ensure all residents' code status were visible at all times on the first page on the inside of the hard chart, available to each licensed staff member. The facility still needs to monitor to ensure each resident's code status is on the first page of the hard chart and staff know how to find a resident's code status. The facility also still needs to ensure all staff have been inserviced and understand their responsibilities regarding the actual procedure for CPR. The facility will monitor residents' code status and staff to ensure appropriate measures are taken for residents with a full code status. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. MO 724

Based on observation, interview and record review, the facility failed to ensure pressure ulcer assessments were timely, appropriate, consistent, and that interventions were implemented as ordered to promote the healing of pressure ulcers for one of three sampled residents (Resident #1). The census was 175. Review of Resident #1's hospital discharge record, dated 2/25/14, showed [DIAGNOSES REDACTED]. -A mechanical fall with traumatic right humeral (upper arm) fracture with repair; -Acute [MEDICAL CONDITION]; -Diabetes; -[MEDICAL CONDITION]: the resident would be discharged with an indwelling urinary catheter (a tube inserted into the bladder to drain urine); -Skin assessment; buttocks (did not specify left, right or both buttocks) red with skin shear. Review of the resident's hospital transfer sheet, dated 2/25/14, showed an order for [REDACTED]. Review of the resident's face sheet, showed an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's nursing demographics/orientation to the facility form (nursing assessment), dated 2/25/14, showed in the section designated for skin integrity, staff documented the following: -Right upper extremity (RUE), 55 staples, with bruising to the front and back side of the arm; -Coccyx area had a 3.0 centimeter (cm) by 2.0 cm unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown eschar (tan, brown or black)) area in the wound bed; -Right gluteal fold had a 5.0 cm by 2.0 cm blister. Stage N/A (unavailable); -RUE lateral side of arm had a 4.0 cm by 5.0 cm blister. Review of the resident's pressure ulcer risk assessment form, dated 2/25/14, showed staff documented the resident was high risk for pressure ulcers. Review of the resident's progress notes, dated 2/25/14, showed the following; -At 3:00 P.M., admitted to the facility; -Sling on RUE with 55 staples and a small amount of serous (clear) fluid drainage, with the skin taut (hard) and red. Multiple open blisters; -A 4.0 cm by 5.0 cm open blister on the right lateral arm; -A 0.5 cm blister/abrasion on the right upper arm; -An area between coccyx (crack of the buttocks), dark in color with a small amount of bleeding, approximately 3.0 cm by 2.0 cm, (no information about stage of area provided); -A 4.0 cm by 3.0 cm open blister on right gluteus (buttock); -[MEDICAL CONDITION] to both lower legs; -No documentation of an open area on the left buttock. -An indwelling urinary catheter that drained clear yellow urine; Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED]. -A #16 French indwelling urinary catheter to be changed monthly; -Catheter care every shift. Review of the resident's skin impairment bodygram (a diagram of a human body with the front and the back shown. Not in the resident's medical record), dated 2/26/14, showed the following: -The front of the right arm had 55 staples and a 5.0 cm by 4.0 cm blister at the right elbow; -An area on the left buttock that measured 2.0 cm by 2.0 cm (no stage included with the documentation); -The area between the buttocks (coccyx area) measured 3.5 cm by 3.0 cm and had yellow and black slough; -An area on the right buttock that measured 3.0 cm by 4.5 cm (no stage included with the documentation); -Bruising to the back of the right shoulder (no size or description provided); -Bilateral feet dry and cracked. Review of the resident's progress notes, dated 2/26/14, showed no documentation the resident's physician was notified of the new area on the left buttock. Review of the resident's skin grid (skin assessment tool, used by the facility), dated 2/27/14, showed the following: -The front of the right arm had 55 staples and a 5.0 cm by 4.0 cm blister at the right elbow; -A Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer on the left buttock that measured 2.0 cm by 2.0 cm; -A unstageable (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) pressure ulcer between the buttocks (coccyx area) that measured 3.5 cm by 3.0 cm with yellow and black slough; -A Stage II pressure ulcer on the right buttock that measured 3.0 cm by 4.5 cm; -Bruising to the back of the right shoulder (no size or description provided); -Bilateral feet dry and cracked. Review of the facility's skin/wound log (not a part of the resident's permanent record), dated 2/27/14, showed the resident listed on the report with the following: -Right arm/shoulder, 55 staples with a dry dressing; -Right forearm/inner elbow, 5.0 cm by 4.0 cm blister, no interventions noted; -Shearing (no location noted) 3.0 cm by 3.5 cm, interventions included wound gel; -Gluteal sulcus (crack of the buttocks), 3.5 cm by 3.0 cm with yellow/black slough, no interventions noted; -Left buttock, 3.0 cm by 4.5 cm open and beefy red. No interventions or staging noted; -Right buttock 3.0 cm by 4.5 cm area, open and beefy red. No interventions or staging noted. Review of the resident's progress notes, dated 2/27/14, showed no documentation the resident's physician was notified of an unstageable pressure ulcer between the resident's buttocks (coccyx area) or the pressure ulcer on the left buttock. Review of the resident's treatment administration record (TAR), dated 2/25 - 28/14, showed the following: -an order for [REDACTED]. -No initials that staff provided the treatment with the dry dressing daily; -an order for [REDACTED]. -Staff initialed they provided the treatment every shift; -No additional treatment orders for the resident's buttocks. Review of the resident's POS, dated 2/25 - 28/14, showed no new treatment orders for the resident's buttocks. Review of the resident's TAR, dated 3/1 - 5/14, showed the following: -an order for [REDACTED]. -No initials by staff to indicate the treatment was provided from 3/1 - 5/14; -an order for [REDACTED]. -Staff initialed they provided the treatment every shift; -No other treatments for the resident's buttocks. Review of the resident's facility history and physical, dated 3/3/13, showed the following: -Generalized weakness of the right arm with pain; -Post operative condition worse; complicated by low blood pressure, elevated troponin levels (indicates heart problems) and [MEDICAL CONDITION]; -Skin condition; right shoulder staples, right buttock ulcer and skin tears; -Assessment and Plan; no mention of pressure ulcers. Review of the resident's five day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/14, showed: -Required extensive of one staff member for transfers, bed mobility, dressing and toilet use; -Indwelling urinary catheter; -Always incontinent of urine; -Occasionally incontinent of bowel; -One Stage I (An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: -Skin temperature (warmth or coolness); -Tissue consistency (firm or boggy); -Sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues) pressure ulcer; -No Stage II, Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.), or unstageable pressure ulcers; -At risk of developing pressure ulcers. Review of the resident's progress notes, dated 3/4/14, showed the following: -At 3:56 A.M., Staff documented the resident's coccyx wound (pressure ulcer) is larger and sore. Barrier cream applied. PRN (as needed) pain medication provided. Will inform the day shift nurse of the resident's bottom and need for a treatment order; -At 10:59 A.M., Areas noted to buttocks darkened (no further description) area to inner coccyx which is spreading to inner buttock (no further description, including measurements). PRN pain medication given. (No information the resident's primary care physician was notified of the worsening pressure ulcer). -At 5:55 P.M., Area on coccyx getting worse related to resident's incontinence of stool and not getting out of bed. Resident and his/her family member made aware. (No information the resident's physician was notified of worsening pressure ulcer or that resident was refusing to get out of bed). Review of the resident's progress note, dated 3/5/14 at 3:56 P.M., showed the resident went to the hospital due to abnormal laboratory test results. Review of the resident's emergency room (ER) record, dated 3/5/14, showed the following: -Presented to the ER with a skin ulcer (pressure ulcer), failure to thrive and abnormal laboratory results; -Deep Stage II ulcer of superior gluteal fold with [DIAGNOSES REDACTED] (swelling) and induration (hardening) of lower back. Review of the resident's hospital specialized wound consult, dated 3/5/14, showed the following: -Sacral/coccyx wound; 9.0 cm by 9.0 cm indurated red area, blistered with open pink 1.0 cm by 2.5 cm Stage II; -Gluteal cleft wound; 8.0 cm by 6.0 cm with 2.0 depth, with light yellow outer edges and 6.0 cm by 4.0 cm soft black tissue at the center (unstageable). -Right buttocks; 5.0 cm by 2.5 cm Stage II; -Wounds were odorous (smelled bad). Review of the resident's post invasive-procedure surgery note, dated 3/12/14, showed the following: -Pre operative diagnosis; sacral wound; -Post operative diagnosis; same; -Operative procedure; diverting [MEDICAL CONDITION] (opening for portion of the colon through the abdominal wall to the outside surface to excrete feces (to prevent contamination of the pressure ulcer)), placement of a negative pressure wound dressing (wound vac); -Operation performed; incision and drainage of sacral abscess, excisional debridement (surgery to remove dead tissue) debridement of a sacral decubitus ulcer measuring 15 cm by 23 cm with 5.0 cm depth, placement of a wound vac. Review of the resident's hospital transfer sheet, dated 3/17/14, showed the following: -Orders for an all in one mattress (pressure relief mattress); -Orders for a wound vac to coccyx and to change every three days. Review of the resident's re-admit screening (nursing assessment), dated 3/17/14, showed the following: -readmitted after a hospital stay; -Vital signs recorded and dated 3/19/14; -Skin assessment; -Right thigh (front) skin tear measured 0.5 cm by 2.0 cm; -Abdomen, surgical incision (no measurements); -Sacrum, surgical incision measuring 19 cm by 5.0 cm by 3.5 cm; -Right shoulder, surgical incision (no measurements); -Surgical incision/[MEDICAL CONDITION] to the left abdomen; (no measurements or description of surgical site). -Wound from sacrum through gluteal sulcus to the coccyx, (no measurements); -Right arm/shoulder incision, (no measurements). Review of the resident's POS, dated 3/17/14, showed the following orders: -Follow up with surgeon in one week; -Wound vac to coccyx, change every three days; -Ostomy care every shift; -Urinary catheter care every shift. Review of the resident's progress notes, showed no documentation for 3/17/14. Review of the resident's progress notes, dated 3/18/14, showed staff documented the following: -At 3:49 A.M., Re-admitted on [DATE] at 9:30 P.M., per evening shift nurses. Physician called at 12:30 A.M., and orders verified and faxed to pharmacy; -At 1:30 P.M., wound vac still not in place. Still waiting on orders for wound vac settings. Dressing was saturated, dry dressing applied. Will report to next shift; -At 10:08 P.M., alert and oriented x 2, total care with activities of daily living, assisted with meal, less than 25% consumed. Has a single lumen peripherally inserted central catheter (PICC, a form of intravenous access that can be used for a prolonged period of time) in the left upper extremity. Dressing clean, dry and intact. Denies pain/discomfort. Turned every two hours, no distress noted, call light in reach. (No further documentation about the wound vac). Review of the resident's skin impairment bodygram, dated 3/18/14, showed the following: -Front of right arm/shoulder; a line drawn through with no measurements; -Abdomen; 19 staples; -Left side of the abdomen; [MEDICAL CONDITION] -Right upper thigh; staff drew a square, no documentation of what the square represented or measurements; -Discoloration of both lower extremities; -Back of diagram, staff drew a circle around the coccyx area and identified it as surgical post debridement; no description of the area or measurements noted. Review of the resident's skin impairment bodygram, dated 3/19/14, showed the following: -Back of diagram, staff drew a circle around the coccyx area and identified it as a surgical post wound debridement that measured 19.0 cm by 5.0 cm with 3.5 cm depth. Observation on 3/19/14 at 8:48 A.M., showed the resident lay in bed on his/her back on a low air loss mattress. No wound vac was visible. Observation on 3/19/14 at 9:31 A.M., showed the resident lay in bed on a low air loss mattress. A urinary drainage bag with approximately 300 cubic centimeters (cc) of clear yellow urine hung at the side of the bed. Staff rolled the resident to his/her right side. A large blood soaked dressing covered the resident's entire buttock area. No wound vac was present. During an interview on 3/19/14 at 10:00 A.M., Licensed Practical Nurse (LPN) A said the resident returned from the hospital on [DATE], late in the evening. The resident returned with orders for a wound vac, but the orders did not specify the wound vac setting. The resident's physician told the admitting nurse to call the resident's surgeon and get the order for the setting. Staff has been unable to contact the resident's surgeon to get orders for the setting. LPN A tried again on 3/19/14 at 9:30 A.M., and was told by the surgeon's office staff he was on vacation. LPN A called the resident's physician to let him know the resident's surgeon was unavailable to give orders and received a new treatment order. During an interview on 3/19/14 at 10:05 A.M., the Director of Nursing (DON) said she was not aware the staff was having trouble getting orders for the settings for the resident's wound vac. The DON called the surgeon's office and was informed the staff was attempting to contact the wrong physician. The DON called the discharging hospital and obtained the correct name and phone number for the resident's surgeon. After speaking with the surgeon's office nurse, the DON obtained an order for [REDACTED]. Staff should have notified the resident's physician that they could not get a hold of the surgeon. The resident came back to the facility late in the evening on Monday 3/17/14, the evening nurse did the admission paperwork and the night shift nurse called to verify the orders. She would not expect the night shift nurse to call the surgeon for wound vac setting orders. The day shift nurse should have contacted the surgeon for the orders and applied the wound vac. During an interview on 3/19/14 at 12:50 P.M., LPN B said he/she works the day shift. He/She was notified by the night shift that the resident had an order for [REDACTED]. She did place a clean dry dressing over the resident's pressure ulcer. During an interview on 3/20/14 at 12:21 P.M., Registered Nurse (RN) C said he/she worked the evening shift on 3/18/14. The day shift nurse did pass the information along that the resident had orders for a wound vac, but the facility did not have orders for the setting of the wound vac. The evening nurse waited for the surgeon to call and when the surgeon did not call he/she got busy and forgot about it. He/She did not do any treatments to the resident's buttocks during his/her shift. During an interview on 3/19/14 at 1:50 P.M., the unit manager said he/she is responsible for measuring all wounds on the rehab unit. If he/she is not working when a resident is admitted he/she will see the resident on his/her next scheduled day. Admitting nurses are supposed to get approximate wound measurements and chart them in the record, but the nurses are not supposed to lock the chart until the unit manager gets measurements also. The unit manager does all of the wound measurements weekly on Wednesdays. The measurements are recorded on the skin impairment bodygram and on the wound report/log. Then the information is put into the resident's permanent record on the skin grid. The bodygram sheet and the wound report/log are not part of the resident's permanent record. He/She will make recommendations about treatment orders and give the information to the unit floor nurse. The floor nurses should call the physician for orders. When the resident was admitted on [DATE], he/she was admitted with an unstageable pressure ulcer in the area between the buttocks (coccyx area). The area had yellow slough and black tissue. He/She could not remember if he/she made a recommendation to change the treatment order to something other than barrier cream. Barrier cream is not an appropriate treatment for [REDACTED]. He/She did not work on 3/17/14, when the resident was readmitted with orders for a wound vac. He/She found out about the orders on 3/18/14, when he/she returned to work and directed the day shift nurse to get the wound vac out of central supply and contact the surgeon for orders. The unit manager was not aware the day shift nurse did not follow his/her directions and passed the information to the evening nurse. During an interview on 3/19/14 at 2:30 P.M., the DON said the wound vac had been applied to the resident's pressure ulcer. The unit manager did a skin assessment and measured the wound prior to applying the wound vac. There were no changes in the size of the wound since the measurement documented on 3/17/14. She was aware the resident had an unstageable pressure ulcer during his/her first admission on 2/25/14. She was not aware the only treatment provided to the pressure ulcer was barrier cream. Barrier cream is not an appropriate treatment for [REDACTED]. During an interview on 3/20/14 at 10:15 A.M., the resident's physician said the facility notified him on 3/19/14, they were having problems getting in touch with the resident's surgeon to get orders for the wound vac. He would not have provided orders for the wound vac settings, but would have ordered another type of treatment until the surgeon could be notified. A dry dressing is not an appropriate treatment for [REDACTED]. He/She was the resident's physician during his/her first admission. He was aware the resident had an open area on his/her buttocks, but was not aware the area had yellow slough and a black necrotic area. Barrier cream is not an appropriate treatment for [REDACTED]. During an interview on 4/8/14 at 12:33 P.M., the resident's physician said if he had been told on 2/27/14, the resident had an open area on his/her buttocks with yellow slough and a black necrotic area, he would have ordered a debridement treatment. Moisture barrier and a dry dressing is not an appropriate treatment for [REDACTED]. During an interview on 3/19/14 at 1:30 P.M., the facility's medical director said he was not notified the facility was having difficulty reaching the resident's surgeon. He would have provided wound vac settings until staff could reach the surgeon. Review of the facility's policy titled, "Wound Care; Pressure Sore Risk Assessment", dated 9/7/07, showed the following: -A pressure ulcer risk assessment will be completed on all new admissions, quarterly and with any significant change in condition; -Staff to implement assessment/prevention protocol as indicated based on the score; -All residents with a pressure ulcer risk assessment score of 12 or lower or Stage III or Stage IV will have skin assessed at least daily for signs or symptoms of skin breakdown. Document on the TAR; -Residents with a pressure ulcer risk assessment score of 13 - 18 will have skin assessed at least weekly. Document on the TAR; -Initiate an at risk plan of care on admission; -Initials on the flow record (TAR) indicate skin inspection was completed with no abnormalities; -Potential pain is to be assessed per pain policy; -Newly identified pressure ulcer areas must be immediately documented on the plan of care, a pressure ulcer report initiated, measurements completed, physician notified and family notified and documentation completed; -Notify dietary. MO 290