Every finding on record at Brookfield Health Care Center

Based on interviews and record reviews, the facility failed to ensure that one resident (Resident #1), who had a diagnosis of diabetes mellitus (DM, a metabolic disease) and end-stage renal disease (ESRD, chronic irreversible kidney failure), who was receiving dialysis (a medical treatment that filters waste, extra salt, and fluid from the blood when the kidneys stop working) in a review of six sampled residents, received treatment and care per the facility's hemodialysis policy, when staff did not complete a pre-dialysis assessment that included a blood sugar finger stick (BSFS), did not offer the resident food prior to leaving the facility when the resident said he/she was hungry, and did not communicate with staff of the dialysis center when the resident was left in the lobby of the dialysis facility. The resident was found in the dialysis lobby with a low blood glucose level and change in mental status, requiring a transfer by emergency medical services (EMS) to a hospital for further evaluation and treatment. The facility census was 35. Review of the facility policy, Monitoring of Residents on Outside Appointments, last reviewed 06/29/23, showed the following:-3. Upon arriving to the appointment with the resident, the transport/escort will introduce themselves and ensure that the staff at the facility where the appointment is located has knowledge that they are present to assist in any care needs and monitoring of the resident. Review of the facility policy, Hemodialysis Policy, last reviewed 05/14/24, showed the following:-The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, mental, and psychosocial needs of residents receiving hemodialysis;-I. Care According to Standards of Practice:-1. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;-4. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -III. Coordination with Dialysis Facility:-2. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes;-3. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:-b. Physician/treatment orders, laboratory values, and vital signs;-d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. Review of the facility policy, Blood Glucose Monitoring Policy, last reviewed on 06/26/24, showed the facility will perform blood glucose monitoring as per physician's orders. 1. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 06/12/26, showed the following:-Cognitively intact;-Set-up or clean-up assistance for eating;-Used a wheelchair;-Substantial to maximum assistance for chair/bed-to-chair transfers;-Diagnoses end-stage renal disease (ESRD) and diabetes mellitus;-Received dialysis. Review of the resident's physician order sheet (POS), dated July 2026, showed the following:-Insulin glargine (Lantus, a long-acting insulin that starts working in one-two hours and lasts up to 24 hours) 20 units subcutaneously (SQ - beneath the skin) at bedtime, start date 07/10/26. Review of the resident's medical record showed a Pre/Post Dialysis Evaluation, dated 07/11/26 at 05:10 A.M.; facility staff documented the resident's pre-dialysis parameters to include the following: -Last meal eaten: dinner;-Meal/snack sent with resident: no;-Clinical change in condition over the past 24 hours: no;-Vital signs: body temperature 97.4 degrees Fahrenheit (normal value 97.8-99.1), blood pressure 117/72, heart rate 77, character-normal heart rate, respirations 22 breaths per minute), oxygen saturation (O2) level 97 percent (%) on room air, blood glucose 70 milligrams per deciliter (mg/dL) (normal pre-meal blood sugar range is 80 - 130, or less than 180 after eating), weight 197.5 pounds;-Pre-dialysis clinical suggestions:-If diabetic, obtain blood glucose per prn (as needed) order;-Review and monitor dietary intake;-Obtain vital signs;-Offer resident food or hydration;-Obtain blood sugar reading per facility protocol. Review of the resident's medication administration record (MAR), dated 07/13/26, showed Licensed Practical Nurse (LPN) A documented he/she administered Insulin glargine 20 units sq between 7-10 P.M. for blood glucose of 352 mg/dL. Review of the resident's MAR and electronic medical record (EMR), dated 07/14/26, showed no documentation of staff obtaining a blood glucose value on this day or any documented concerns regarding the resident. Review of the resident's EMR showed facility staff did not complete a pre-dialysis assessment of the resident on 07/14/26 prior to being transported to the dialysis center, that included last meal eaten, meal/snack sent with resident, clinical change in condition over the past 24 hours, vital signs, and blood glucose reading. Review of the document, Patient Note, dated 07/14/26 at 4:28 P.M., showed the dialysis center staff documented the following: -The nurse observed the resident sitting in the lobby appearing acutely ill and immediately transported the resident to the treatment floor for assessment;-The resident was extremely lethargic (drowsy and sluggish) and minimally responsive to verbal stimuli. At times, the resident would only repeat his/her first name. When asked his/her location, the resident repeatedly said a town other than the town he/she was in three times, indicating altered mental status;-Initial assessment revealed a blood glucose of 32 mg/dL. Vital signs were as follows: blood pressure 182/87, heart rate 67, oxygen was applied immediately and oxygen level 98% on nasal cannula (a light, flexible plastic device that delivers extra oxygen straight into the nose through two small prongs) oxygen at three liters per minute (3 L/min);-Emergency medical services (EMS) was activated and arrived at the facility. The resident left the dialysis clinic for transport to the local hospital for further evaluation and treatment;-Report was called to the hospital staff. Staff were notified at the resident's facility that he/she had been left at the dialysis facility in a poorly responsive condition without staff notifying the dialysis personnel of the resident's arrival or clinical status. Review of the document, Patient Care Record, dated 07/14/26 at 07:05 A.M., showed emergency medical staff (EMS) staff documented the following:-Primary impression (diagnosis): diabetic hypoglycemia (low blood glucose);-Chief complaint: resident dropped off at dialysis clinic with a blood sugar of 32;-Intravenous (through a vein) access was started in the resident's left arm and resident was given 25 grams of dextrose 50% (a sterile mixture of simple sugar and water given directly into a vein to treat low blood sugar or insulin shock when a person cannot eat or drink);-Mental status: resident was lethargic and did not respond to questioning;-Narrative: resident was dropped off at dialysis with a reported blood sugar of 32 mg/dL, which has been present for approximately one hour. Mental status: oriented to person and event, resident was lethargic and did not respond to questioning. Generalized symptoms: lethargy reported as primary. The primary assessment is diabetic hypoglycemia. An advanced life support (ALS) assessment was performed. IV access via left bicep (the large muscle on the front of the arm) fistula (resident's dialysis port) by the dialysis nurse on scene. Dextrose 50% was administered intravenously at a dosage of 25 grams. A 3-lead electrocardiogram (ECG, a heart monitor) was conducted. The resident was transported by this EMS unit to the hospital, with improved alertness noted upon arrival. Review of the document, Emergency Department (ED) provider note, dated 07/14/26 at 10:21 A.M., showed the emergency room (ER) physician documented the following:-The resident presented to the ED with fatigue, and a reported low (blood) glucose of 32 mg/dL upon arrival to dialysis;-The resident was lethargic but could answer questions;-He/She was sent to the ED from the dialysis center with an altered mental status associated with a low blood glucose of 32 mg/dL;-The resident said he/she typically ate breakfast before dialysis, but today he/she did not have breakfast;-The resident's hypoglycemia had a simple explanation, he/she was an insulin-requiring diabetic who missed his/her breakfast;-He/She was given a supply of sugar before arriving to the ED, and now his/her blood glucose was 96 mg/dL, but he/she was still somnolent (sleepy) with snoring respirations and repeatedly fell asleep in midsentence during his/her review of symptoms;-The resident's mouth was dry;-Bloodwork showed the resident's glucose was 85;-Because of his/her ongoing glucose needs, the resident was started on a D10 intravenous (IV) drip (continuous infusion solution containing 10% dextrose [glucose] dissolved in water or saline, providing 10 grams of sugar per 100 milliliter (ml) of fluid, used mainly to treat low blood sugar);-The resident was critically ill;-The resident was transferred to another hospital for a higher level of care than could be given at the receiving facility. During an interview on 07/22/26 at 01:10 P.M. and 07/23/26 at 12:50 P.M., the resident said the following:-He/She had been diabetic for years and received dialysis three times a week for end-stage kidney disease for at least 10 years;-He/She knew the symptoms of low blood sugar very well;-On 07/14/26 around 05:00 A.M., facility staff assisted him/her to get ready for dialysis;-He/She told the charge nurse he/she was hungry;-His/Her last meal or food intake was at supper on 07/13/26 around 05:30 P.M.; -He/She remembered not feeling right a few hours before he/she left for dialysis the morning of 07/14/26 and that LPN A gave him/her some milk to drink;-He/She did not remember if LPN A checked his/her blood sugar then, or what it was at that time;-The charge nurse did not offer him/her breakfast or a snack to eat and said the kitchen was not open yet;-The transporter arrived to take him/her to dialysis and said he/she was running behind and was in a big hurry;-He/She told the transporter he/she was hungry and had not eaten;-The transporter told him/her he/she did not have time to eat, because the transporter was running late;-The transporter did not offer him/her any food;-On the way to the dialysis center, he/she kept saying to the transporter, I need something to eat, I need something to eat;-The transporter told him/her the dialysis center would have something for him/her to eat there;-He/She told the transporter the dialysis center did not offer food or snacks; -He/She felt weak, sweaty, cranky (irritable), and his/her stomach wanted to throw up during the ride to the dialysis center;-The dialysis center was about 25 miles from the facility;-Mentally, he/she was mad because he/she was scared; he/she knew he/she was going to end up in the hospital because of a low blood sugar;-He/She remembered getting out of the van at the dialysis center and into the wheelchair but did not remember anything after that; -He/She woke up in the hospital and was told his/her blood sugar had bottomed out at the dialysis center;-He/She was hospitalized for a few days. During an interview on 07/22/26 at 01:45 P.M., a facility transporter said the following:-He/She was a certified nurse assistant (CNA) and was familiar with the signs and symptoms of low blood glucose, which could include tiredness, thirst, and pale and clammy (damp) skin;-He/She arrived at the facility around 05:20 A.M. on 07/14/26 to take the resident to the dialysis center;-He/She was late and, in a hurry, because the resident had to be at the dialysis center by 06:00 A.M. and the center was about 25 miles away from the facility;-The resident said he/she was hungry, but breakfast was not ready;-LPN A said the resident's blood sugar was fine, at 130;-He/She thought LPN A said there was no food or milk available to give the resident;-He/She stopped at a gas station on the way to the dialysis center to get gas;-No food, drinks, or snacks were available on the transport vehicle;-The resident said a few times that he/she was hungry;-He/She thought the dialysis clinic had food or snacks for residents; -He/She told the resident that he/she could get some food at the dialysis clinic;-At the dialysis clinic, he/she left the resident in the vehicle and went inside to get a wheelchair;-He/She entered the dialysis clinic and rang a doorbell for assistance, because he/she needed a wheelchair for the resident and the main entry into the lobby was locked;-A dialysis staff member (name unknown and not identified) unlocked the lobby door, and he/she told the dialysis staff member he/she needed a wheelchair for the resident;-He/She assisted the resident from the vehicle to the wheelchair and transferred the resident into the dialysis clinic lobby;-The lobby door was unlocked at that time; -No dialysis clinic staff was present when he/she left the resident in the lobby; -He/She could see other patients in the dialysis chairs and could see some dialysis staff working, but did not speak to anyone and did not tell the dialysis staff that the resident was in the lobby in a wheelchair; -The transporter assumed the dialysis staff knew the resident was there because he/she had asked for a wheelchair for the resident upon arrival;-The resident seemed to be ok when he/she left him/her in the lobby, he/she stood fine when transferred and looked ok;-He/She probably should have gotten the resident something to eat before they left the facility, when the resident said he/she was hungry;-Staff could go into the kitchen and get food for residents at any time;-He/She could have gotten the resident something to eat when he/she stopped at the gas station; -Usually, the night shift staff were responsible for getting residents ready for dialysis, and that included getting them an early breakfast;-He/She did tell the resident he/she was running late that morning. During an interview on 07/22/26 at 03:20 P.M., LPN A said the following:-The resident's blood glucose level was 352 mg/dL around 10:00 P.M. on 07/13/26;-He/She gave the resident his/her insulin glargine (Lantus, a long-acting insulin) at around 10:30 P.M. on 07/13/26;-The resident said he/she did not feel well around 03:30 A.M. on 07/14/26, so he/she checked the resident's blood glucose, and it was around 159 (mg/dL);-He/She gave the resident a small glass of milk and the resident said he/she felt better, and the resident went back to sleep;-He/She did not document the resident's blood glucose at that time; -He/She did not recheck the resident's blood glucose after that, or before the resident left for dialysis around 05:30 A.M., because he/she did not realize he/she was supposed to;-He/She obtained vital signs on the resident before the resident left for the dialysis clinic that morning but did not document them; -He/She did not complete a pre-dialysis assessment; he/she may have started it but did not complete it; -The resident said he/she was hungry before he/she left for dialysis;-There was no kitchen staff available, and LPN A did not find any milk for cereal to give the resident before he/she left;-He/She was not sure what other food was available in the kitchen to give the resident; -He/She thought the transporter said he/she would stop and get the resident something to eat on the way to the dialysis clinic;-He/She did not communicate to the dialysis clinic that the resident reported earlier in the morning that he/she did not feel right, his/her blood glucose at the time, or that the resident was hungry and had not eaten; -He/She probably should have checked the resident's blood glucose level after he/she gave the resident milk earlier in the morning and before the resident left for the dialysis clinic. During an interview on 07/23/26 at 12:45 A.M., the dietary manager said the following:-Nursing staff had access to the kitchen at all times;-The kitchen was always stocked with cold deli meats, peanut butter and jelly, bread for sandwiches, chips, cookies, fruit, juice and milk;-She always kept milk and juice stocked in the refrigerator for residents with diabetes;-If the milk containers were low, additional milk was available in the outdoor walk-in cooler, and nursing staff had the key to that cooler;-The kitchen had a list of residents who received dialysis and who required a meal or snack bag before they left the facility;-It was the responsibility of the night shift nursing staff to obtain food for the resident if the resident left in the early morning hours and the kitchen staff was not available. During an interview on 07/22/26 at 01:30 P.M. and 07/23/26 at 02:15 P.M., the Director of Nurses (DON) said the following:-The resident's blood glucose was last recorded in the EMR by LPN A on 07/13/26 at 10:21 P.M. and was elevated at 352 mg/dL;-Staff are expected to complete a pre and post dialysis assessment for all residents receiving dialysis;-She was not sure why a pre dialysis assessment was not completed for the resident prior to him/her leaving the facility the morning of 07/14/26; -The pre dialysis assessment would have required LPN A to check the resident's vital signs, a blood glucose level, indicate the last meal eaten, any condition changes which could include complaints of being hungry, and if any meal or snack was sent with the resident to dialysis;-It was the responsibility of the night shift nurse to provide breakfast, or pack a snack, for a resident who left in the early morning hours for dialysis when the kitchen staff was unavailable;-The resident should have received breakfast before he/she left for dialysis on 07/14/26, especially since the resident complained of feeling hungry;-Nursing staff have access to the kitchen and to food for the residents at all times; -The transporter should have notified the dialysis staff before he/she left the resident in the lobby of the dialysis clinic. During an interview on 07/23/26 at 02:50 P.M., the administrator said the following:-She would expect facility staff to offer food to any resident who complained of feeling hungry;-Nursing staff had access to the kitchen at all times; there would be no reason not to find something for a resident to eat;-She would expect the charge nurse to complete and document a pre-dialysis assessment to include the resident's vital signs, a blood glucose level, the last meal a resident ate, and any changes in the resident's condition or any concerns they might have; -The transporter should have alerted the dialysis staff that the resident was in the lobby in a wheelchair before he/she left. During an interview on 07/23/26 at 01:10 P.M., the resident's physician said the following:-He would expect staff to check, document, and recheck a blood glucose level and any interventions offered (such as food or drink given) for a diabetic resident with a complaint of not feeling right; -He would expect staff to check a blood glucose level and complete a pre-dialysis assessment prior to a resident leaving the facility for a dialysis appointment; -He would expect staff to offer and obtain food for any resident that complained of being hungry, and especially for a diabetic resident;-He would expect the charge nurse to be in communication with the dialysis team, by telephone, not by fax, of a resident's condition, blood glucose level, or complaints or concerns voiced by the resident before a dialysis appointment as necessary. MO#3094650

Based on interview and record review, the facility failed to notify the physician, timely, for one resident (Resident #3), in a review of four sampled residents, when the resident's continuous positive airway pressure (CPAP, a machine that keeps the airway open during sleep for persons with sleep apnea) mask broke on 1/24/26. The resident went 12 days in the facility without using the CPAP at night, due to not having a functioning mask available. The facility also failed to notify the physician when the resident experienced a change in condition on 01/31/26, which included low oxygen saturation, lethargy and anxiety. Staff sent the resident to the hospital on [DATE]. The resident was hypercapnic (condition characterized by abnormally high levels of carbon dioxide in the blood), was hospitalized for two days, and required treatment with a bilevel positive airway pressure (BiPap) machine (noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) to reduce the amount of carbon dioxide in the resident's blood. The census was 34.Review of the facility's Noninvasive Ventilation-CPAP policy, dated 5/14/24, showed the following:-Noninvasive ventilation referred to the administration of ventilator support without using an invasive device;-CPAP was a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by the machine, delivered through a tube into a mask that fits over the nose or mouth;-Replace equipment immediately when it is broken or malfunctions;-Replace equipment routinely in accordance with manufacturer recommendations. Review of the Resident #3's care plan, dated 10/28/25, showed the following:-The resident's diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), chronic respiratory failure, and sleep apnea;-Elevate head of bed to prevent shortness of breath while lying flat;-The resident had oxygen therapy;-Monitor for signs and symptoms of respiratory distress and report to physician as needed: respirations, pulse oximetry (checks percent of oxygen in the blood), restlessness, diaphoresis (sweating), headaches, lethargy (state of severe exhaustion, sluggishness, or lack of energy and motivation), confusion, cough, accessory muscle usage, and skin color;-Humidified oxygen via nasal cannula at six liters to keep oxygen saturations above 90%. Review of the resident's physician orders, dated January 2026, showed an order to apply the CPAP on the resident at bedtime with oxygen connected with settings of 14/8 and pressure support (PS, extra boost of pressure the machine provided when a person breathes in, compared to when a person breathed out) 6.0 related to COPD, and obstructive sleep apnea (serious sleep disorder where throat muscles relax too much during sleep, causing the airway to collapse and block breathing) (original order dated 10/20/25). Review of the resident's treatment administration record (TAR), dated 1/24/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/25/26 at 2:14 A.M., showed the CPAP mask was missing. Review of the resident's TAR, dated 1/25/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/26/26 at 10:38 A.M., showed the CPAP mask was no longer in use, awaiting a new mask. Review of the resident's TAR, dated 1/26/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/27/26 at 1:33 A.M., showed waiting for arrival of replacement pieces. Review of the resident's TAR, dated 1/27/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/28/26 at 12:17 A.M., showed awaiting parts and pieces to repair machine. Review of the resident's TAR, dated 1/28/26, showed the staff did not apply the resident's CPAP. Review of the resident's TAR, dated 1/29/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/30/26 at 2:01 P.M., showed the resident was not using CPAP, awaiting mask. Review of the resident's TAR, dated 1/30/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 1/31/26 at 12:23 A.M., showed the following:-Oxygen saturation of 91% (normal range 95% - 100%) on oxygen via nasal cannula;-The resident was lethargic;-He/She was anxious, which was a recent change in mood;-The resident asked the staff if something was wrong with him/her. Review of the resident's nurse note, dated 1/31/26 at 2:25 A.M., showed the resident was anxious/worried asking if anything was wrong with him/her because he/she never slept the day away like he/she did. Review of the resident's nurse note, dated 1/31/26 at 3:24 A.M., showed the following:-The resident was anxious this night and asked if something was wrong with him/her;-The resident said he/she doesn't sleep like he/she did;-He/She needed a silicone mask which was to be on order;-Oxygen saturation lower than normal.(There was no documentation the nurse contacted the physician regarding the resident's change in condition.) Review of the resident's TAR, dated 1/31/26, showed the staff did not apply the resident's CPAP. Review of the resident's TAR, dated 2/1/26, showed the staff did not apply the resident's CPAP. Review of the resident's TAR, dated 2/2/26, showed the staff did not apply the resident's CPAP. Review of the facility's email to the equipment supplier, dated 2/3/26 at 12:08 P.M., showed the following:-The facility had a resident who immediately needed a new CPAP mask and straps on his/her CPAP machine;-The Director of Nursing (DON) requested advice on how to order a new one. Review of the equipment supplier's email, dated 2/3/26 at 12:22 P.M., showed the supplier did not provide CPAP supplies. The facility then contacted their Corporate Office to find out who the correct supplier was for CPAP masks. Review of the resident's TAR, dated 2/3/26, showed the staff did not apply the resident's CPAP. Review of the resident's nurse note, dated 2/4/26 at 7:13 A.M., showed the following:-The staff found the resident not verbally responding or behaving as normal;-His/Her lips were slightly purple and his/her fingers were purple;-Oxygen saturation was 75% on 5 liters of oxygen;-The staff attempted several times to reposition the resident and assisted with oxygen intake, but his/her oxygen saturation stayed at 75% or just below;-The nurse contacted the physician, who gave an order to send the resident to the hospital for evaluation and treatment. Review of the resident's nurse note, dated 2/4/26 at 1:50 P.M., showed the resident was transferred to another hospital related to being on BiPap machine and having elevated carbon dioxide levels and also had a urinary tract infection. Review of the resident's hospital history and physical, dated 2/4/26, showed the following:-The resident had chronic respiratory failure and normally wore supplemental oxygen at 5 liters per nasal cannula at all times and CPAP with oxygen nightly;-Per facility report, the resident's CPAP was broken for three weeks;-The staff sent the resident to the hospital on 2/4/26 with altered mental status due to hypercapnia, likely associated with known CPAP malfunction;-The resident went without CPAP therapy at night for two to three weeks. Review of the resident's hospitalist progress note, dated 2/4/26, showed the resident needed to have home CPAP replaced prior to discharge. Review of the resident's nurse note, dated 2/6/26 at 2:00 P.M., showed the resident was readmitted to the facility. Review of the resident's physician orders, dated 2/6/26, showed to apply the CPAP on the resident at bedtime with oxygen connected with settings of 14/8 and PS 6.0 related to COPD and obstructive sleep apnea. Review of the resident's TAR, dated 2/6/26, showed the staff did not apply the resident's CPAP. Review of the resident's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 2/25/26, showed the following:-The resident was cognitively intact;-No refusal of care;-He/She experienced shortness of breath or trouble breathing when lying flat;-He/She used oxygen therapy and noninvasive mechanical ventilator as a resident of the facility within the last fourteen days of the assessment. During an interview on 3/18/26 at 9:55 A.M., Resident #3 said the following:-He/She had an adverse reaction from the old CPAP, resulting in being hospitalized ;-The staff provided him/her with a new mask that worked better. During an interview on 3/18/26 at 10:26 A.M., the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) said the following:-The staff was unable to apply the resident's CPAP because the mask was broken;-The resident went without the CPAP for a few days;-The staff documented when they did and did not apply the CPAP;-He/She knew the resident's carbon dioxide levels were increased so the staff sent him/her to the hospital. During an interview on 3/18/26 at 3:38 P.M., LPN A said the following:-The resident's CPAP mask broke, but the staff tried to keep it together with tape; however, a piece of the mask was broken and lost, the staff couldn't utilize the mask;-He/She worked with the resident on 1/31/26 when the resident showed a change in status and reported his/her concerns with the DON, but didn't call the physician;-He/She didn't remember calling the physician about the broken mask or when the resident had a change in condition;-He/She didn't call the physician because the resident didn't have any changes in lung sounds and was maintaining his/her oxygen saturation with the oxygen;-The resident slept more than usual but was still alert and oriented. During an interview on 3/19/26 at 8:34 A.M., LPN B said the following:-He/She knew the resident's CPAP mask was broken, but he/she didn't report it to the physician;-He/She didn't find any changes in the resident during the daily respiratory assessment, so he/she didn't call the physician regarding any changes;-He/She worked the day the resident returned from the hospital;-He/She called the physician to notify him/her the resident returned to the facility;-The physician said the resident needed a CPAP mask as soon as possible;-LPN B was not aware a mask had arrived and was available for the resident and LPN B did not look for the mask. During interviews on 3/18/26 at 10:30 A.M. and 1:10 P.M., the DON said the following:-She expected staff to contact her and the resident's physician when a CPAP mask was broken;-She didn't remember when the staff told her the resident's CPAP mask was broken. During an interview on 3/18/26 at 1:50 P.M., the Administrator said the following:-She expected the nurses to contact the physician when an ordered piece of care equipment was not functioning;-The nurses should contact the physician when a resident had a change from baseline;-The first email sent to order a new CPAP mask was sent to the wrong supplier;-When the facility contacted the correct supplier, it only took a couple of days to receive the CPAP mask. During an interview on 3/18/26 at 2:09 P.M., the resident's Primary Care Physician said the following:-The staff notified him/her of the resident's broken CPAP mask and change in condition;-He/She ordered the facility to get a new CPAP mask as soon as possible.-He/She didn't have a specific date on when the facility notified him/her about the resident's broken mask and change in condition. #2746113

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, received care and treatment in accordance with professional standards of practice when the resident presented with stroke like symptoms including facial drooping on the left side, slurred speech, delayed responses, and left sided weakness on 8/25/25. The Director of Nursing (DON) advised the resident's family that given the resident's age, treatment would potentially be limited. The facility failed to send the resident to the hospital for evaluation. The resident sustained a stroke and the resident's functional abilities declined as a result. Prior to the episode the resident was able to walk with a cane or walker for 125 feet, transfer from a wheelchair to the bed with minimal assistance and could use three pound weights on both his/her ankles during therapy. After the episode the resident was unable to sit for 30 seconds on the edge of the bed without support, stand for 10 seconds without support, was dependent on staff for sit to stand positioning and bed to chair transfers. The resident had severe mobility impairment and required assistance of two staff with a cane to take steps. The facility census was 23.Review of the facility's Notifying Clinicians Policy, dated 6/26/24, showed the following:-The purpose of the policy was to ensure the clinicians are properly notified of a resident's change in condition and overall health and/or mental status;-The clinician shall be notified of changes in conditions, emergent situations, routine diagnostics, and concerns of the resident's overall health status that included changes in behaviors, agitation, and anything regarding a change in the resident's baseline or condition;-The nurse will initiate verbal communication with the clinician when a condition or incident arises with a resident which would warrant an immediate implementation of a change in plan of care to include physician advisement or initiation of physician orders to avoid a delay in treatment that may cause worsening in condition. Review of WebMD (a health information website that provides up to date medical content) showed the following:-Signs of a stroke included one side of the face may sag, one arm may droop when both are raised, speech may sound strange or slurred;-If a person exhibits signs of a stroke, someone needs to call 911 immediately. Don't call your physician or family first;-You should get to the hospital as quickly as possible;-90% of people who have strokes have a blood clot that blocks the blood flow to the brain;-Once at the hospital, within 10 minutes a physician will complete an exam, within 15 minutes the physician will get blood tests, within 25 minutes a Computed Tomography (CT, a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce detailed images of the inside of the body, including the bones, muscles, fat, organs, and blood vessels) scan will be done to tell what kind of stroke occurred, and once the physician has the CT results treatment will begin;-If an ischemic stroke (when a blood clot blocks an artery in the brain, cutting off blood flow) was identified a blood clot busting drug would be administered, but it should happen within three hours of the stroke;-If a hemorrhagic stroke (occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue) was identified, surgery may be needed to stop the bleeding. Review of Resident #1's undated face sheet showed the following:-The resident admitted to the facility on [DATE];-The resident had diagnoses that included unspecified dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), high blood pressure, and cognitive communication deficit (trouble participating in conversations and difficulty understanding what was said). Review of the resident's Care Plan, dated 6/30/25, showed the following:-The resident was at risk for falls. Determine the resident's ability to transfer and initiate fall risk precautions;-The resident will be able to communicate basic needs daily. Ask simple questions and clear statements, communicate with the resident/family/caregivers regarding the resident's capabilities and needs, limit changes to the resident' general routine, and use a calm, gentle approach;-There was no documentation that showed the resident had symptoms of muscle weakness or slurred speech. The plan did not show the amount of staff assistance needed for the resident. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/16/25, showed the following:-The resident's cognition was severely impaired;-The resident usually understood others and made self-understood;-The resident required supervision for rolling in bed, change from sitting to lying positioning, transfers, ambulation, eating, and dressing;-The resident used a cane or walker to assist him/her with ambulation;-The resident had no impairments of upper or lower extremities. Review of the resident's Occupational Therapy treatment note, dated 8/21/25 at 9:00 A.M., showed the following:-The resident was instructed in active range of motion exercises to the left upper extremity that required minimal verbal and tactile cues;-The resident transferred from his/her wheelchair to the edge of the bed utilizing a single point cane in his/her right upper extremity with minimal assist to safely lower into a seated position. Review of the resident's Physical Therapy treatment note, dated 8/21/25 at 2:45 P.M., showed the following:-The resident performed seated therapy exercises with three pound ankle weights to increase strength for improved activities of daily living such as transfers and improved stability with standing activities;-The resident performed gait training throughout the facility with a single point cane that required contact guard assist (a method of providing physical support to a person who needed help with balance and stability by holding a gait belt (a device used to safely assist a person with balance)) for safety. The resident ambulated approximately 125 feet, two times;-The resident performed sit to stand transfer training from his/her wheelchair and required minimal assistance for all but one time. Review of the resident's Physical Therapy treatment note, dated 8/25/25 at 11:00 A.M. showed the following:-The resident acted very lethargic and had slurred speech;-Upon assessment of the resident, he/she needed moderate assistance for bed mobility and seemed to have pusher syndrome (a disorder following left or right brain damage in which one actively pushes away from the non-hemiparetic side (the side of the body not affected by weakness or paralysis), leading to a loss of postural balance) effect with stroke-like symptoms;-The resident drooled, had slurred speech, struggled with looking toward the left side, and the left upper and lower extremity movement was limited compared to the week before. Review of the resident's Occupational Therapy treatment note, dated 8/25/25 at 12:21 P.M., showed the following:-Nursing staff reported they believed the resident may have had a stroke;-The resident was trained in left upper extremity exercises and demonstrated increased difficulty with exercises including knuckle bend and making a fist. The resident required moderate verbal, visual and tactile cues;-The resident was trained in supine to sitting at the edge of the bed with minimal assistance;-The resident presented with left lateral lean while seated at the edge of the bed. The resident was able to correct with verbal cues but then returned to left lateral lean;-The resident was trained in functional transfer from the edge of the bed to the wheelchair utilizing a single point cane and required moderate assist for sit to stand and maximum assist for transfer, verbal and visual cues;-The resident had difficulty taking steps with the left lower extremity. Review of the resident's progress note, dated 8/25/25 at 12:32 P.M., written by the Director of Nursing (DON) showed the following:-The resident experienced increased confusion and weakness. She requested a urine sample from the physician, and the physician approved;-During physical therapy, the therapist and the DON believed the resident experienced stroke symptoms. The resident had slurred speech, delayed responses, left sided weakness in the upper and lower extremities;-The DON informed Family Member B of the symptoms. Family Member B asked if going to the emergency room would help;-The DON told Family Member B that given the resident's age, treatment would potentially be limited;-Family Member B informed the DON he/she did not want to send the resident to the hospital;-The resident's physician was aware. Review of the resident's medical record showed no documentation of an assessment after the resident presented with a change in condition that showed he/she had slurred speech, delayed responses and left sided weakness of the upper and lower extremities on the left side. During an interview on 10/2/25 at 11:21 A.M. the resident's Family Member B) said the following:-On 8/25/25 the DON called between 9:00A.M. and 10:00 A.M. and told him/her the resident had a minor stroke;-The DON said therapy had been working with the resident and noticed a change and reported it to the DON;-Family Member B asked if the resident should be sent to the hospital and the DON said the hospital could do nothing more than the facility could do and that it would not benefit the resident to go to the hospital;-Family Member B arrived at the facility and noticed the resident had drooping on the left side of his/her face, the resident could not move his/her left arm or leg, and the resident's speech was slow. One side of the resident's mouth was not working. The resident had to concentrate on what he/she was saying;-Family Member B was shocked by the resident's condition;-On 8/26/25, Family Member B went to visit the resident and found him/her on the toilet leaning to the left with his/her left hand in the trash can. The resident could not get himself/herself off the toilet;-Family Member B witnessed staff assisting the resident for transfers after 8/25/25. During these transfers the resident's left leg and left foot drug the floor. During an interview on 10/2/25 at 2:46 P.M. and 10/15/25 at 2:10 P.M. the DON said the following:-On 8/25/25, a certified nursing assistant was in the resident's room and told the DON the resident had some confusion;-The DON went to the resident's room and noticed the resident had confusion and delayed speech. The DON called the physician and explained the resident had confusion and delayed speech and asked for an order for a urine sample to check for a urinary tract infection. The physician approved the order; -The therapist was working with the resident and told the DON the resident had left sided weakness. The DON went to the resident's room and noted the left sided weakness, facial drooping added to the confusion and delayed speech; -She called the resident's physician again and explained all the symptoms of left sided weakness, slurred speech, facial drooping, and delayed responses, but the DON did not remember what the physician said to her;-She called Family Member B and told them the resident had a stroke;-She informed Family Member B on 8/25/25 the resident may have limited treatment options at the hospital. She did not know that for sure because she was not a physician. Family Member B asked what the hospital would do for the resident. The DON said it would be limited treatment; -After they spoke, Family Member B declined to send the resident to the hospital;-The protocol for sending a resident to the hospital was the nurse notified the DON of a resident's condition, the DON contacted the regional nurse, and they decided if there was something that could be done for the resident in house before sending them to the hospital;-She thought she had called the regional nurse about this resident's stroke like symptoms. The regional nurse would have said to send the resident to the emergency room. She did not call the regional nurse until after she spoke with the resident's family. Review of the resident's Significant Change MDS, dated [DATE], showed the following:-The resident's cognition was intact; (The resident's MDS dated [DATE] showed the resident had severely impaired cognition);-The resident required partial to moderate assistance from staff to roll left to right;-The resident required substantial to maximum assistance from staff for sitting to lying positions, chair to bed transfers, eating, and toileting;-The resident was dependent on staff for showering and dressing;-The resident used a wheelchair for ambulation;-The resident had impairment on one side of his/her upper extremity;-On the resident's prior MDS assessment the resident only required supervision for rolling in bed, sitting to lying positioning, chair to bed transfers, eating, dressing, toileting and the resident was able to walk with a cane or walker. Review of the resident's care plan, dated 9/13/25, showed the following:-The resident required substantial assistance from two staff members for bed mobility, dressing and transfers with a gait belt (an assistive device used to help safely transfer a person from a bed to a chair and assist with sitting and standing);-The resident was dependent on one staff member for locomotion on and off the unit in a wheelchair, personal hygiene, and eating;-The resident had impaired physical mobility related to decreased strength, endurance, or neurological impairment as evidenced by reliance on a wheelchair for movement;-The resident had a diagnosis of dementia. The resident will maintain his/her current level of cognitive function. Offer simple one step instruction during tasks and use consistent routines;-The resident had a power of attorney (POA) related to his/her cognitive impairment. Provide the POA with clear, understandable information about the resident's condition, prognosis, and treatment. Document all communications and decisions involving the POA;-No documentation that showed the resident had a history of stroke or documentation that addressed the resident's stroke like symptoms that occurred on 8/25/25 or the effect it had in his/her mobility and activities of daily living (ADLs). On 9/25/25 the resident transferred to a different long-term care facility. Review of the resident's Physical Therapy evaluation and plan of treatment (from the new facility), dated 9/25/25, showed the following:-The resident had a stroke like event approximately three weeks ago with left hemiparesis (weakness or paralysis on one side of the body), per family. The resident was left side dominant;-The resident now presented with severe balance impairment, weakness and ataxia (a neurological condition characterized by a lack of muscle coordination and balance) in the left lower extremity with decreased coordination and severe mobility impairment;-The resident was dependent on staff for sit to stand positioning and chair to bed transfers;-The resident could not sit unsupported for 30 seconds with feet flat on the floor and without back support and required moderate assistance to sit on the edge of the bed;-The resident could not stand for 10 seconds unsupported;-The resident had left hemiparesis with severe lean to the left upon rising to stand and was unable to take steps with the cane and required assistance of two staff;-The resident had severe balance and mobility impairment and would benefit from strengthening, neurological reeducation, balance and mobility training to reduce his/her fall risk and improve functional mobility. Review of the resident's CT scan, dated 10/1/25, showed the following:-The clinical indication was weakness and left hemiplegia (a condition that causes paralysis or weakness on one side of the body);-Impression: a new area of hypoattenuation (indicated brain tissue that has suffered a stroke) in the posterior right frontal white matter suggesting age-indeterminate infarct. During an interview on 10/15/25 at 1:30 P.M. the Physical Therapist said the following:-The Occupational Therapist told him/her the resident wasn't acting right;-During therapy on 8/25/25 the resident was drooling and had left sided weakness and leaned towards his/her left side;-Normally the resident could sit up from a lying position to the edge of the bed and transfer to his/her wheelchair. On 8/25/25, the resident was not able to complete those tasks without moderate assistance;-After the resident had the stroke like symptoms, he/she continued to decline and did not make any more progress with therapy. During an interview on 10/2/25 at 3:02 P. M. and 3:30 P.M. the Regional Director of Operations said the following:-She would consider a resident with stroke like symptoms an emergency and to send a resident to the hospital. During an interview on 10/8/25 at 4:06 P.M., the Regional Nurse Consultant said the following:-She did not recall a conversation with the facility DON about the resident with a change in condition or stroke like symptoms;-If she would have been called, she would have recommended the resident be sent to the hospital for evaluation;-Stroke like symptoms were an emergency and a resident should be sent to the hospital;-She would have expected the staff to send a resident to the hospital without calling her in that situation. During an interview on 10/9/25 at 8:55 A.M., the resident's physician said the following:-He did not recall the phone conversation with the DON on 8/25/25 regarding the resident's condition;-It was a typical response for him to tell facilities that if family wanted a resident sent to the hospital for an evaluation, then send them out. 2630157

Based on observation, interview and record review, the facility failed to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers), appropriately when transferring one resident (Resident #8) in a review of 16 sampled residents. Additionally, staff failed to reposition one resident (Resident #8), appropriately when staff lifted the resident by pulling on his/her pants. Staff failed to use a gait belt to transfer two residents (Resident #8 and #17) and instead, pulled on the resident's arms, back of neck and shoulders when assisting the resident from sitting to standing. The facility failed to store a portable oxygen tank securely when not in use for one resident (Resident #25). The facility census was 25. Review of the facility's policy, Safe Resident Handling Transfers Policy, revised 05/14/24, showed the following: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide, promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used; -It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety; -All employees will receive education on the proper use of a gait belt during orientation and annually; -It will be the responsibility of each employee to ensure they have it available for use at all times when at work; -Failure to use a gait belt properly may result in termination. Review of the facility's policy, Fire Safety - Oxygen Storage, revised on 12/27/24, showed the following: -Purpose: ensure that the facility follows required regulations and provide an environment that is free from dangerous storage practices; -The facility will ensure that all oxygen cylinders are properly stored in approved locations: -Oxygen cylinders shall be stored in a proper storage area free of any flammable storage practices; -All cylinders shall be stored in metal racks; -The policy did not address the proper storage of oxygen cylinders/tanks on a wheelchair. Review of a document, The Importance of Gait Belts for Safe Resident Handling, authored by AliMed and dated 06/19/2023, showed that using gait belts properly is crucial for ensuring the safety of both residents and caregivers during transfers and repositioning, mitigating the risks of falls, injuries, and discomfort associated with inadequate support. 1. Review of Resident #8's undated face sheet showed he/she had diagnoses that include Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down that causes pain in the joints). Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by staff, dated 04/18/25, showed the following: -Severely impaired cognition; -Dependent on staff for all transfers, rolling left and right and mobility via wheelchair. Review of the resident's care plan, revised on 05/16/25, showed the following: -The resident has a functional performance problem; -Requires total assist of one person for bed mobility and locomotion on and off the unit; -Requires extensive assist of one person for transfers. Observation on 06/10/25 at 8:54 A.M., showed the following: -Certified Nursing Assistant (CNA) F and CNA L assisted the resident to sit on the side of the bed by pulling on the back of the resident's neck and bilateral upper arms; -CNA F hooked his/her arm under the resident's right shoulder; -CNA L hooked his/her arm under the resident's left shoulder; -CNA F and CNA L instructed the resident to stand and the resident was able to bear weight; -CNA F and CNA L assisted the resident to a standing position by lifting the resident under the arms and by lifting by the back of the resident's pants and pivoted the resident into his/her wheelchair; -Staff did not use a gait belt during the transfer. Observation on 06/11/25 at 11:40 A.M., showed the following: -CNA F and CNA L assisted the resident to sit on the side of the bed by pulling on the back of his/her neck and bilateral upper arms; -CNA F hooked his/her arm under the resident's right shoulder; -CNA L hooked his/her arm under the resident's left shoulder; -CNA F and CNA L instructed the resident to stand and the resident was able to bear some weight but did not stand fully on his/her own; -CNA F and CNA L assisted the resident to a standing position by lifting the resident under the arms and by lifting by the back of the resident's pants and pivoted the resident into his/her wheelchair; -Staff did not use a gait belt during the transfer. Observation on 06/12/25 at 8:33 A.M., showed the following: -CNA E sat the resident on the side of the bed; the resident's feet touched the floor; -CNA E placed a gait belt around the resident; -CNA E assisted the resident to a standing position using the gait belt and pulling up under his/her left shoulder and pivot transferred to his/her wheelchair; -CNA E repositioned the resident in his/her wheelchair by pulling the back of his/her pants. During an interview on 06/12/25 at 1:09 P.M., CNA E said the following: -A gait belt should always be used during a manual transfer and the resident should be lifted by the gait belt and not under his/her shoulder; -If a resident was lifted under his/her shoulder or by the arm the resident could get hurt; -A resident should not be repositioned in the wheelchair by lifting on the back of his/her pants; -He/She did not recall lifting Resident #8 under his/her shoulder; -He/She should not have repositioned the resident by pulling on the back of his/her pants, but should have used the gait belt and repositioned by lifting from the front. During an interview on 06/12/25 at 1:16 P.M., CNA F said the following: -A gait belt should be used any time a resident was manually transferred; -Staff should never lift a resident under the shoulders, by the arms or by the back of the pants because it could hurt them; -He/She should not have lifted the resident under the arm, by the arms or by the back of the pants; -A gait belt should have been used for the resident's transfers. 2. Review of Resident #17's undated face sheet showed his/her diagnoses include dementia with psychotic disturbance (a group of thinking and social symptoms that interferes with daily functions that can include hallucinations or delusions) and anxiety disorder (intense, excessive, and persistent worry and fear about every day situations). Review of the resident's care plan, revised on 05/16/24, showed the following: -The resident has a current functional performance problem; -Extensive assistance of two staff for bed mobility; -Locomotion on and off the unit - independent/no set-up or physical assistance. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Substantial/maximum staff assistance for all transfers and bed mobility; -Ambulation without assistive devices and supervision 10, 50 and 150 feet; -No range of motion limitations. Observation on 06/12/25 at 8:19 A.M., showed the following: -CNA F and CNA O assisted the resident to a sit on the side of the bed; -CNA F and CNA O assisted the resident to a standing position by lifting the resident under his/her shoulder with one staff member on each side of the resident; -On immediate transfer, the resident was not standing straight up and was unsteady on his/her feet; -CNA F and CNA O did not assist the resident transfer utilizing a gait belt during the transfer or with ambulation. During an interview on 06/12/25 at 1:16 P.M., CNA F said the following: -He/She should not have lifted Resident #17 under the arms; -Resident #17 was usually easy to assist to a standing position just by holding his/her hands, but he/she needed more assistance during the observed transfer; -He/She should have used a gait belt to transfer the resident. 3. Review of Resident #25's undated face sheet showed the resident had diagnosis that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Partial/Moderate assistance from staff for hygiene, dressing, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and mobility in wheelchair 50 and 150 feet; -Oxygen therapy while a resident. Review of the resident's June 2025 Physician Order Sheet showed an order for oxygen via nasal cannula (prongs that go into the nares to deliver oxygen) at three liters per minute to maintain oxygen saturations (the amount of oxygen in the blood). Review of the resident's care plan, revised 06/09/25, showed the resident had oxygen therapy related to respiratory illness and COPD. Observation on 06/11/25 at 11:45 A.M., showed the resident lay in bed sleeping. The resident's wheelchair was located along the wall. A portable oxygen tank, approximately ¾ full, sat unsecured in a cloth holder in the seat of the resident's wheelchair. Observation on 06/12/25 at 7:59 A.M., showed the resident lay in bed sleeping. The resident's wheelchair was located along the wall. A portable oxygen tank approximately ¾ full, sat unsecured in a cloth holder in the seat of the resident's wheelchair. During an interview on 06/12/25 at 10:45 A.M., the resident said the following: -He/She was unsure who put the oxygen tank in his/her wheelchair seat; -He/She had not felt good and had been in his/her room for the past couple of days; -The oxygen tank normally hung on the back of his/her wheelchair by the holder. During an interview on 06/12/25 at 12:15 P.M., the maintenance director said a portable oxygen tank should never be left unsecured as it could cause injury if it fell and the stem broke. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should always use a gait belt during a manual transfer; -A resident should never be lifted under the shoulder, by the arms or by the back of their pants, as injury could occur; -A portable oxygen tank should always be stored in its holder and should never be left unsecured in the seat of a wheelchair. During an interview on 06/12/25 at 7:30 P.M., the Director of Nursing (DON) said the following: -A gait belt should be used for every manual transfer; -A resident should not be lifted by any part of their body as it could cause an injury; -A portable oxygen tank should always be secured and should never be sitting in the seat of a resident's wheelchair unsecured. During an interview on 06/12/25 at 7:50 P.M., the administrator said portable oxygen should always be secured and not left in a wheelchair unsecured.

Based on observation, interview, and record review, the facility failed to ensure food service equipment and kitchen/food storage room surfaces were appropriately cleaned to ensure sanitary conditions in accordance with professional standards for food service safety. The facility census was 25. 1. Observations on 06/09/25 between 10:00 A.M. and 2:13 P.M., and on 6/10/25 between 6:00 A.M. and 6:30 A.M., in the kitchen and dietary storage room showed the following: -The top surface of ice machine was dusty and soiled with debris. There was a white scaly material on the outside surface above the door hinge. The seal to the underside of ice machine door separated from the door and hung on the outside front surface of the machine; -The top, sides, and front of the upright refrigerator and freezer located in the kitchen, was soiled with food splatters, dust and debris. The floor in the refrigerator was covered with a yellow-colored liquid spill, and the freezer floor surface was covered with grated cheese; -The walls throughout the kitchen were soiled with food splatter, dust and debris; -The surfaces of the three doors to the kitchen (on the kitchen side of the doors) were soiled with dust and debris; -The exposed electrical boxes and conduits, located above the metal shelving with clean dishware, on the wall next to the food preparation table and throughout the kitchen, were soiled with dust and debris; -The four fluorescent light bulbs, located above the three-compartment sink, were soiled with dust and debris; -The fire suppression system control box, tank, and conduits/piping, located above and between the coffee maker/clean cups and the stovetop, were soiled with dust and debris; -The air vent covers, located above and below the wire racks containing clean plates/bowls in the kitchen and above tray racks in the storage room, were soiled with dust and debris; -The gas piping, located above the coffee maker and trays of clean coffee cups, was soiled with dust and debris; -The top surface of the coffee maker was soiled with dust and debris; -The inside surface of the microwave oven contained food splatter and debris; -A countertop mixer (not in use at the time of the observations), located on the food preparation table, had a buildup of food splatter and debris; -A toaster, located on the food preparation table, was soiled with food splatter and debris; -An industrial floor mixer (not in use at the time of the observations), located next to the food preparation table, was soiled with food splatter, and the mixing bowl was not covered; -A meat slicer (not in use at the time of the observations), located on a cart next to the upright refrigerator/freezer in the kitchen, was soiled with debris on the cutting surface and was not covered; -The stainless-steel backsplash on the six burner stovetop had a heavy buildup of carbon and food splatter; -The front and sides of the stovetop/griddle/oven were soiled with food splatter, stains and dried liquid runs; -The top and inside surface of the oven door had a heavy carbon/oily buildup; -The left front leg of the stainless-steel preparation table, located next to the stovetop/griddle/oven, had a buildup of food splatter and liquid run marks. During an interview on 6/12/25 at 8:50 A.M., the Dietary Manager said the following: -He was responsible for monitoring the dietary department, and was aware of the identified areas; -All dietary staff were responsible for daily cleaning/sanitizing of the identified areas in the kitchen and storage room; -The identified areas should be cleaned and sanitized daily/weekly and on an ongoing basis.

Based on interview and record review, the facility failed to ensure each certified nurse assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. Five of five CNAs (CNA H, CNA F, CNA I, CNA J and CNA D) sampled did not have the required 12 hours of in-service education. The facility census was 25. Review of the facility's policy, Nursing Aide Training Program Policy, revised 05/18/24, showed the following: -This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides; 1. The facility, with oversight from the Director of Nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education; 2. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year; a. The facility shall maintain documentation of training during the current training year, and shall forward to the Human Resources (HR) Director at the completion of the training year to be maintained in the employee's personnel file; b. It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review; 3. Information from the facility assessment will be utilized in forming a baseline educational calendar; 4. In-service training will be provided by qualified personnel and will be based on the special needs of the residents in the facility. Minimum training will include: a. Effective communication; b. Dementia management and care of the cognitively impaired; c. Abuse, neglect, and exploitation prevention; d. Elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program; e. Resident rights and facility responsibilities; f. Written standards, policies, and procedures for the facility's infection prevention and control program; g. Requirements under the facility's compliance and ethics program; h. Safety and emergency procedures; i. Behavioral health (e.g., mental, psychosocial, or substance use disorders, a history of trauma and or post-traumatic stress disorder, or other behavioral health conditions); j. Identification of changes in condition; k. Cultural competency; 5. Additional training will be provided to each nurse aide based on any areas of weakness as determined in the nurse aide's performance reviews; a. The DON shall communicate the educational needs of the employee upon final review of the annual performance appraisal; b. Education that is needed based on the performance appraisal will be completed within 90 days of the appraisal, unless otherwise specified in the appraisal; 6. A variety of methods may be used to provide training, and to evaluate learning; 7. Content of training shall be current and reflect professional standards and guidelines. Content shall be reviewed on a regular basis, and updated as needed; 8. Random, periodic audits and/or interviews will be performed throughout the year as part of the facility's QAPI program to verify retention of information and continued competency. 1. Review of the undated Facility Assessment showed the following: -We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations and technical/hands-on skills; -Refer to Staff Development Training Plan; -Staff are trained on policies and procedures, consistent with their roles; -We evaluate policies and procedures that are required in the provision of care on a routine basis through our QAPI process; -This includes determining if new or updated policies are needed, and ensuring they are developed or updated. 2. Review of the undated Facility Staff Development plan showed the following: -January: dementia management; -February: resident abuse prevention; -March: areas of weakness, training should address individual areas of weakness identified in nurse aides' performance reviews. This ensures that nurse aides improve in areas where they may be lacking; -April: special needs of residents; -May: communication skills; -June: resident rights and facility responsibilities; -July: QAPI; -August: infection control; -September: compliance and ethics; -October: safety procedures; -November: personal care skills; -December: nutrition and hydration; -Other: facility will conduct additional/necessary training's or competencies if needed; -The facility staff development plan should be reviewed and updated annually to ensure it remains relevant and effective; 2. Performance reviews: after conducting staff performance reviews, the plan should be adjusted to address any newly identified areas of weakness or training needs; -If there are updates to healthcare regulations or standards, the plan should be reviewed to ensure compliance; -The Facility Staff Development plan does not addresses the following required trainings per the facility Nursing Aide Training Program Policy: i. behavioral health (e.g., mental, psychosocial, or substance use disorders, a history of trauma and or post-traumatic stress disorder, or other behavioral health conditions), j. identification of changes in condition or k. cultural competency. 3. Review of CNA H's employee file showed the employee's date of hire was 08/04/23. Review of education completed from 06/27/24 - 05/08/25 showed the CNA attended the following: -Peri-care and hand hygiene training on 03/27/25, (did not include agenda or time of education); -Evacuation of residents and bed bound/hand washing/dignity/aspiration risk/ and emergency response procedures for fire/tornado and active shooter training on 05/08/25, (did not include agenda or time of education). The employee's education was documented on sign-in sheets (with multiple employees). Review of the CNA H's employee file did not show an annual performance review or individual tracking for 12 hours of in-service education per year to include all of the required education, per the facility Nursing Aide Training Program Policy. 4. Review of CNA F's employee file showed the employee's date of hire was 03/01/24. Review of education completed from 06/27/24 - 05/08/25 showed the CNA attended the following: -High fall risk, substance abuse and neglect/abuse training on 06/27/24, (did not include agenda or time of education); -Resident rights to primary care provider and pharmacies/UDA's/Hoyer (a mechanical lift for dependent residents) slings/fire safety and handbook updates training on 08/28/24, (did not include agenda or time of education); -Controlled substances and abuse/neglect/exploitation training on 01/02/25, (did not include agenda or time of education); -Peri-care and hand hygiene training on 03/27/25, (did not include agenda or time of education); -Evacuation of residents and bed bound/hand washing/dignity/aspiration risk/ and emergency response procedures for fire/tornado and active shooter training on 05/08/25, (did not include agenda or time of education). The employee's education was documented on sign-in sheets (with multiple employees). Review of the CNA F's employee file did not show an annual performance review or individual tracking for 12 hours of in-service education per year to include all of the required education, per the facility Nursing Aide Training Program Policy. 5. Review of CNA I's employee file showed the employee's date of hire was 11/12/21. Review of education completed from 06/27/24 - 05/08/25 showed the CNA attended the following: -High fall risk, substance abuse and neglect/abuse training on 06/27/24, (did not include agenda or time of education); -Communication with dementia including behaviors training on 10/18/24, (did not include agenda or time of education); -Bed Bugs/safety and moving equipment/sexual harassment training on 02/27/25, (did not include agenda or time of education); -Peri-care and hand hygiene training on 03/27/25, (did not include agenda or time of education); -Evacuation of residents and bed bound/hand washing/dignity/aspiration risk/ and emergency response procedures for fire/tornado and active shooter training on 05/08/25, (did not include agenda or time of education). The employee's education was documented on sign-in sheets (with multiple employees). Review of the CNA I's employee file did not show an annual performance review or individual tracking for 12 hours of in-service education per year to include all of the required education, per the facility Nursing Aide Training Program Policy. 6. Review of CNA J's employee file showed the employee's date of hire was 03/01/24. Review of education completed from 06/27/24 - 05/08/25 showed the CNA attended the following: -High fall risk/substance abuse and neglect/abuse training on 06/27/24, (did not include agenda or time of education); -Resident rights to primary care provider and pharmacies/UDA's/Hoyer (a mechanical lift for dependent residents) slings/fire safety and handbook updates training on 08/28/24, (did not include agenda or time of education); -Communication with dementia including behaviors training on 10/18/24, (did not include agenda or time of education); -Controlled substances and abuse/neglect/exploitation training on 01/02/25, (did not include agenda or time of education); -Bed Bugs/safety and moving equipment/sexual harassment training on 02/27/25, (did not include agenda or time of education);-Peri-care and hand hygiene training on 03/27/25, (did not include agenda or time of education); -Evacuation of residents and bed bound/hand washing/dignity/aspiration risk/ and emergency response procedures for fire/tornado and active shooter training on 05/08/25, (did not include agenda or time of education). The employee's education was documented on sign-in sheets (with multiple employees). Review of the CNA J's employee file did not show an annual performance review or individual tracking for 12 hours of in-service education per year to include all of the required education, per the facility Nursing Aide Training Program Policy. 7. Review of CNA D's employee file showed the employee's date of hire was 05/20/24. Review of education completed from 06/27/24 - 05/08/25 showed the CNA attended the following: -High fall risk/substance abuse and neglect/abuse training on 06/27/24, (did not include agenda or time of education); -QAPI and Enhanced Barrier Precautions training on 07/25/24, (did not include agenda or time of education); -Resident rights to primary care provider and pharmacies/UDA's/Hoyer (a mechanical lift for dependent residents) slings/fire safety and handbook updates training on 08/28/24, (did not include agenda or time of education). The employee's education was documented on sign-in sheets (with multiple employees). Review of the CNA D's employee file did not show an annual performance review or individual tracking for 12 hours of in-service education per year to include all of the required education, per the facility Nursing Aide Training Program Policy. During an interview on 06/12/25 at 5:10 P.M., the Assistant Director of Nursing (ADON) said to her knowledge, no one had been tracking the CNA education or completing the performance evaluations for CNA's or identified potential areas for additional education. During an interview on 06/12/25 at 7:50 P.M., the administrator said he was aware there was a required 12-hour training requirement for CNA's and was aware the training and evaluations had not been completed.

Based on interview and record review, the facility failed to provided a Registered Nurse (RN) eight consecutive hours a day, seven days a week. Additionally the facility failed to have a full time Director of Nursing (DON) from 05/10/25 through 06/09/25. The facility census was 25. Review of the facility's policy, Sufficient Staff Policy, revised 05/18/24, showed the following: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -Except when waived, the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week; -The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Review of the undated Facility Assessment showed the following: -The facility had a DON; -Staffing patterns: RN eight hours per resident day; -Overall staffing needs: RN's to provide direct care one total needed, RN's available to provide direct care (includes DON and RN's with administrative duties) two total needed. 1. Review of the RN individual employee timecards from 05/05/25 through 06/09/25 showed the following: -On 05/05/25 there were no hours of RN coverage in 24 hours reviewed; -On 05/06/25 there were 5.75 hours of RN coverage in 24 hours reviewed; -On 05/09/25 there were 5.5 hours of RN coverage in 24 hours reviewed; -On 05/12/25 there were 5.5 hours of RN coverage in 24 hours reviewed; -On 05/16/25 there were no hours of RN coverage in 24 hours reviewed; -On 05/19/25 there were 5.25 hours of RN coverage in 24 hours reviewed; -On 05/23/25 there were 7.5 hours of RN coverage in 24 hours reviewed; -On 05/27/25 there were 5.75 hours of RN coverage in 24 hours reviewed; -On 05/28/25 there were 6 hours of RN coverage in 24 hours reviewed; -On 05/30/25 there were 4 hours of RN coverage in 24 hours reviewed; -On 06/01/25 there were no hours of RN coverage in 24 hours reviewed; -On 06/02/25 there were 5/75 hours of RN coverage in 24 hours reviewed. During an interview on 06/12/25 at 7:21 P.M., RN C said the following: -There had been multiple days the facility did not have an RN for eight hours of the day; -When he/she worked, he/she had been serving as the RN in the building; -He/She did not always work eight hours when serving as the RN in the building; -There had been multiple days since he/she stepped down as the DON that the building had been without a full-time DON; -The facility had been without a full-time DON for almost a month. During an interview on 06/09/25 at 9:45 A.M. and 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the following: -The facility did not have a full-time DON at this time; -The facility was without a DON from the period of 05/10/25 through 06/09/25; -During that time, the corporate DON was in the facility some, but not full-time, and not for the entire time the facility was without a DON; -There should be an RN in the building eight hours each day; -There should be a full-time DON. During an interview on 06/12/25 at 7:50 P.M., the administrator said the following: -He was aware of the requirement for an RN in the building eight hours of every day; -Recently the facility had not had an RN in the building eight hours of every day; -There should be a full-time DON in the facility. MO254153 MO254369

Based on observation, interview and record review, the facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center for Disease Control (CDC) an American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, failed to develop a water management team that conducted meetings and failed to complete a water flow map. Additionally, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #8 and #24), in a review of 16 sampled residents. The facility failed to ensure proper infection control was utilized for blood glucose testing (checking the level of sugar in a drop of blood) for five residents (Resident #22, #10, #7, #16, and #19) to prevent the spread of contaminates (bacteria and viruses) that cause infection. The facility census was 25. Review of the facility's policy, Legionella Surveillance Policy, revised 06/26/24, showed the following: -It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections; -Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaire's disease; -Primary prevention strategy refers to the approaches to prevention and control of Legionella infections in health care facilities with no identified cases; -Secondary prevention strategy refers to the approaches to prevention and control of Legionella infections in health care facilities with identified cases; -Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems; -In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies; -In the case of a definite or possible health-care associated Legionnaires' disease within a 12 month period, the facility shall implement secondary prevention strategies in addition to primary prevention strategies until such time the water management team determines those strategies are no longer necessary, or as advised by local and/or state health department staff; -To pose a health risk, Legionella has to grow in numbers and be aerosolized so people can breathe in small, contaminated water droplets; -Legionella grows best in water temperatures of 77F-108F, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs; -Legionella can make people sick when the germs spread in droplets small enough for people to breathe in. Medical devices, cooling towers, showers, hot tubs, and fountains create aerosols; -Although uncommon, legionella may be contracted by aspiration of contaminated drinking water. Legionella is not usually spread from person to person; -The incubation period for Legionnaire's disease is generally 2-10 days; -Signs and symptoms of Legionnaire's disease are similar to pneumonia by other pathogens and include cough, fever, positive chest radiograph, sputum production, and new/changed lung examination abnormalities; 5. Primary prevention strategies: a. Diagnostic testing: i. The facility shall use the McGreer criteria when diagnosing pneumonia; ii. Residents with health-care associated pneumonia or who have failed antibiotic therapy for community-acquired pneumonia shall be tested for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test; b. Investigation for a facility source of Legionella, which may include culturing of facility water for Legionella: i. The Infection Preventionist will investigate all cases of definite healthcare associated Legionnaires' disease for the source of Legionella; ii. The Infection Preventionist will also investigate for the source of Legionella when two or more possible healthcare-associated Legionnaires' diseases are identified; c. Physical controls: i. Cooling towers and potable water systems shall be routinely maintained; ii. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations; iii. Non-potable water systems shall be routinely cleaned and disinfected; iv. Nebulization devices shall be filled only with sterile fluid (e.g., sterile water or aerosol medication); d. Temperature controls: i. Cold water shall be stored and distributed below 68F; ii. Hot water shall be stored above 140F and circulated at a minimum return temperature of 124F. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD (Legionnaire's disease) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the undated, Centers for Disease Control and Prevention Legionella Environmental Assessment Form showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F and Legionella become dormant below 68 degrees F. 1. Review of the facility provided water management program, last revised 05/05/22, showed the following: -In-service of water management program on 05/05/22, from 9:15 A.M. to 9:30 A.M.; -Environmental assessment of water systems, undated, shows question one, the type of facility, on page one of thirteen pages answered and the rest of the assessment was left blank; -An additional undated assessment showed question #1, #2 and #4 of 35 questions answered with pages four through 12 left blank as well as appendix A, B, C and D; -CDC Legionella Environmental Assessment form was completely blank. Review of water temperatures, obtained by the state agency on 06/12/25, showed the following water temperatures fell between 77 and 113 degrees, temperatures at which legionella generally grows well: -At 1:58 P.M., the end of 300 hall, room [ROOM NUMBER], left-side hot-water faucet temperature was 110.7 degrees F (too cool); -At 2:12 P.M., the front of 300 hall, room [ROOM NUMBER], left-side hot-water faucet temperature was 111.6 degrees F (too cool); -At 2:45 P.M., the front of 100 hall, room [ROOM NUMBER], right-side cold-water faucet temperature was 79.5 degrees F (too warm). During an interview on 06/12/25 at 2:07 P.M., the maintenance director said the following: -He has been the maintenance director for two years; -He was not well versed on what the water management team was and what the responsibilities of the team were, but thought he was on the team; -One of the administrators had him flush the unused portion of the building for 15 minutes weekly, but that was all he has ever done to flush the lines; -The new company has said something about testing the water, but he was not sure when that would occur; -He only checked hot water temperatures in the building; -He did not have a water flow diagram; -The water management team does not meet on a regular basis; -He had not heard of ASHRAE or seen the ASHRAE guidelines. During an interview on 06/12/25 at 3:30 P.M., the Infection Preventionist (IP) said she was not part of the water management team. She did not evaluate any residents with pneumonia for possible legionella infection. During an interview on 06/12/25 at 4:59 P.M., the administrator said the following: -There was no water management team; -He would follow the CDC toolkit to develop a water management team in the future; -He was unsure what ASHRAE guidelines were or what ASHRAE was. 2. Review of Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions) dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. Hand washing remained the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. 3. Review of the facility's policy, Glove Utilization Policy, revised 05/18/24, showed the following: -The purpose of this procedure is to provide guidelines for the use of gloves. To prevent the spread of infection and disease to residents and employees; to protect wounds from contamination; to protect hands from potentially infectious material; and to prevent exposure to the HIV (human immunodeficiency virus; damages the immune system and interferes with the body's ability to fight infection and disease), (AIDS) (a chronic immune system disease caused by HIV) and Hepatitis B (HBV) (a serious liver infection caused by a virus, transmitted through contact with infected blood or body fluids); -When gloves are indicated, disposable single-use gloves should be worn; -Used gloves should be discarded into the waste receptacle inside the examination or treatment room; -Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces; -Wash hands after removing gloves. (Note: gloves do not replace hand washing); 7. Gloves should be removed before removing the mask and gown and should be discarded into the designated waste receptacle inside the room; -Use gloves when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. -Gloves are to be changed and hands washed, new gloves donned before a clean dressing is applied; when the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.; when cleaning up spills or splashes of blood or body fluids; when cleaning potentially contaminated items; and whenever in doubt. 4. Review of Resident #8's undated face sheet showed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by staff, dated 04/18/25, showed the following: -Severely impaired cognition; -Dependent on staff for feeding, oral hygiene, personal hygiene, toileting hygiene, shower/bathing, upper and lower body dressing including putting on/taking off footwear, all transfers, rolling left and right and mobility via wheelchair; -Always incontinent of urine; -Frequently incontinent of bowel. Review of the resident's care plan, revised on 05/16/25, showed the following: -The resident has a functional performance problem; -Requires total assist of one person for bed mobility, dressing, eating, locomotion on and off the unit, personal hygiene and toilet use; -Requires extensive assist of one person for transfers; -Assist with peri-care/hygiene related to incontinence. Observation on 06/10/25 at 8:54 A.M., showed the following: -The resident lay in bed and wore an incontinence brief soiled with urine; -Certified Nurse Assistant (CNA) L used hand sanitizer and applied gloves and provided perineal care to the the resident; -CNA F assisted with positioning of the resident and did not wear gloves; -CNA L removed his/her gloves, threw them in the trash, and applied a new pair of gloves; -CNA L did not perform hand hygiene between glove changes; -CNA L assisted CNA F in applying a new incontinent brief and pants on the resident; -CNA L and CNA F transferred the resident to his/her wheelchair; -CNA L removed his/her gloves, threw them in the trash, and washed his/her hands; -CNA F washed his/her hands and pushed the resident to the dining room. During an interview on 06/12/25 at 1:16 P.M., CNA F said the following: -Gloves should be used when providing resident cares such as peri-care; -He/She did not recall not using gloves when providing care for the resident. 5. Review of Resident #24's face sheet showed the following: -Diagnoses of chronic multifocal osteomyelitis of right ankle and foot, and type two diabetes with a foot ulcer. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment of one side of lower extremities; -Moderate assistance for personal hygiene; -Dependent for toilet hygiene; -Moderate assistance for rolling left and right in bed; -Dependent for chair/bed-to-chair transfers; -Frequently incontinent of bladder, always incontinent of bowel. Observation on 6/10/25 at 8:05 A.M. showed the following: -The resident lay in bed and wore an incontinence brief soiled with urine; -CNA F and Certified Medication Technician (CMT) N used hand sanitizer and applied a gown and gloves; -CNA F provided peri care; -CMT N assisted with positioning of the resident; -CMT N assisted CNA F in applying a new incontinence brief; -CNA F did not change gloves or perform hand hygiene when going from dirty to clean. During an interview on 6/12/25 at 1:10 P.M. CNA F said handwashing should be completed often, especially before and after feeding, before and after cares, during cares, and with glove changes. 6. Review of the facility's policy, Glucometer Disinfection Policy, revised 04/30/24, showed the following: -The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees; -The facility will ensure blood glucometer's will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use; -If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter will not be used for multiple residents; -The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV (human immunodeficiency virus - virus that attacks the immune system), Hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation) and Hepatitis B (a virus that causes a serious liver infection) virus; -Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident; -PROCEDURE: -Retrieve (2) disinfectant wipes from container; -Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; -After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry; -Discard disinfectant wipes in waste receptacle; -Perform hand hygiene. 7. Review of the Super Sani Wipe Germicidal Wipe by PDI, manufacturers instructions, dated 2021, showed to unfold a clean wipe and thoroughly wet the surface. Allow treated surface to remain wet for two minutes, and let air dry. 8. Observation on 06/10/25, at 7:19 A.M., showed the following: -Licensed Practical Nurse (LPN) A stood at the medication cart in the hall and prepared medications for Resident #22; -LPN A removed a glucometer out of the top drawer of the medication cart and placed the glucometer on top of the medication cart; -LPN A donned gloves without first performing hand hygiene; -LPN A entered the resident's room and placed the glucometer on the resident's bedside dresser with no barrier; -LPN A obtained a drop of blood from a finger stick and placed the drop of blood on the test strip inserted in the glucometer; -LPN A took the glucometer back out to the medication cart and placed the glucometer on top of the medication cart; -LPN A removed his/her gloves and applied alcohol gel to his/her hands; -LPN A opened a Sani cloth germicidal wipe, unfolded the wipe, wiped the surface of the glucometer and placed the glucometer (a multi resident use glucometer) back in the top drawer; -LPN did not place a barrier on the resident's bedside dresser or medication cart, did not cleanse the top of the medication cart after placing a contaminated glucometer on the medication cart, did not keep the surface of the glucometer wet for two minutes or allow the glucometer to air dry. -At 7:23 A.M. LPN A removed a glucometer from the medication cart that was covered with a bag and labeled with Resident #10's name on top of the medication cart with no barrier; -LPN A donned gloves, entered the Resident #10's room and placed the resident's glucometer on the resident's bed side dresser without a barrier; -LPN A obtained a drop of blood and placed it on the glucometer test strip; -LPN A walked out of the resident's room and placed the glucometer on the medication cart without a barrier; -LPN A removed his/her gloves and cleaned his/her hands with alcohol; -LPN A did not clean or disinfect the glucometer before placing the glucometer back in the bag and then back into the medication cart; -LPN A did not clean the top of the medication cart. -At 7:33 A.M. LPN A removed a glucometer from the medication cart that was covered with a bag and labeled with Resident #7's name out of the front of the top drawer and placed it on top of the medication cart; -LPN A did not clean the glucometer and donned gloves; -LPN A entered Resident's #7's room and placed the glucometer on the resident's bed side table without a barrier; -LPN A obtained a drop of blood and placed it on the glucometer test strip; -LPN A left the room and placed the glucometer on the medication cart without a barrier; -LPN A removed his/her gloves and did not wash his/her hands or perform hand hygiene; -LPN A did not clean and disinfect the glucometer; he/she placed the glucometer meter back in the bag labeled with Resident #7's name and then put the glucometer back into the medication cart; -LPN A did not clean the top of the contaminated medication cart. - At 7:48 A.M. LPN A removed a glucometer from the medication cart that was not in a back - the same multi resident use glucometer used for Resident #22, and placed it on top of the medication cart; -Without cleaning the glucometer, LPN A donned gloves; -LPN A entered Resident's #16's room and placed the glucometer on the resident's blanket that was covered the resident's stomach without a barrier; -LPN A obtained a drop of blood and placed it on the glucometer test strip; -LPN A walked out of the resident's room and placed the glucometer on the medication cart without a barrier; -LPN A removed his/her gloves and performed hand hygiene with alcohol gel; -LPN A did not clean or disinfect the multi resident use before placing the glucometer back in the medication cart; -LPN A did not clean the top of the contaminated medication cart. -At 8:06 A.M. LPN A donned gloves, removed a glucometer from the medication cart that was in a bag labeled with Resident #19's name and placed it on top of the medication cart; -LPN A did not clean the glucometer; -LPN A approached Resident #19 at the dining room table, and placed the glucometer on the dining room table next to the resident without a barrier; -LPN A obtained a drop of blood and placed it on the glucometer test strip; -LPN A then returned the glucometer to the top of the medication cart; -LPN A removed his/her gloves and did not perform hand hygiene or wash his/her hands; -LPN A did not clean or disinfect the glucometer before placing the glucometer back in the bag labeled for the resident; the bag also contained the resident's Basaglar insulin pen. LPN A placed the bag in the medication cart; -LPN A did not cleanse the top of the medication cart. During an interview on 06/18/25, at 3:00 P.M., Licensed Practical Nurse (LPN) A said the following: -Staff are expected to wash hands before touching a resident, change gloves if they become visibly soiled, and after providing care to a resident; -Staff are expected to change gloves and wash hands or sanitize with alcohol gel with gloves changes if not soiled, staff were not always cleansing hands with glove changes; -He/She prefers two staff provide perineal care so that one staff member can keep clean hands and one does the cleaning of the resident; -Glucometers should be cleaned with Sani-wipes (pre-moistened disposable wipes designed for cleaning and disinfecting various surfaces) before and after use; -He/She was not aware if the glucometers had to stay wet from the Sani-wipes for a certain amount of time. During an interview on 06/12/25, at 7:30 P.M., the Assistant Director of Nursing said staff should wash their hands before and after gloving, before and after medication pass, after using the restroom, when hands are visibly soiled, and when hands are contaminated. All residents have their own glucometers and staff are only to use the back up glucometer if they question a monitor and not routinely. Staff are expected to clean glucometers using the germicidal sanitizing wipes, the surface of the glucometer should remain wet for the length of time directed by manufacturer instructions. During an interview on 06/12/25, at 7:30 P.M., the Director of Nursing said staff are expected to change gloves from dirty to clean, if visibly soiled. Staff are expected to clean glucometers after use, especially between each resident using the germicidal sanitizing wipes, the surface of the glucometer should remain wet for the length of time directed by the manufacturer instructions. Glucometers are expected to be placed on a barrier when placed on a surface to prevent contamination of the glucometer and the surface. If a barrier is not used then staff should clean the surface that could be contaminated in addition to the glucometer.

Based on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use for two residents (Resident #229 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Antibiotic Stewardship Program, dated 06/29/23, showed the following: -To optimize antibiotic use in our nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach; -This Facility Antibiotic Stewardship Program (ASP) will comply with all state and federal laws and regulations; -The ASP will be run by the Facility Antibiotic Steward, who will lead the Antibiotic Stewardship Team (AST); -At a minimum, the AST will be comprised of the Director of Nursing, a nurse with administrative duties, and a charge nurse; -The facility ASP will use a systematic evaluation of ongoing treatment which includes, but is not limited to; -Including a systemic evaluation of an ongoing treatment need, after the period of initial treatment. (e.g. once antibiotic started, initiate an antibiotic time out); -The facility will track and monitor antibiotic prescribing practices and resistance patterns among its residents; -The facility Antibiotic Steward will review and generate the Infection Log in the electronic medical record system; -The facility Antibiotic Steward, in collaboration with the Facility AST, will conduct formal training activities, and provide ongoing education in-services for facility staff, physicians, prescribing practitioners, residents, and resident family members; -The facility Antibiotic Steward and the AST will also provide information about antibiotic usage, in accordance with requirements at including antibiotic resistance and optimal prescribing methods; -The facility Antibiotic Steward and the AST will also use routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections; - The Facility Antibiotic Steward will review and audit the Infection Log weekly; -Additionally, the Facility Antibiotic Steward will track the following: antibiotic time-outs, recommended actions for evaluation of ongoing treatment needs, interventions for syndrome-specific antibiotic use and antibiotic prophylaxis, multi-drug resistant infections, formal training activities and ongoing education related to antibiotic usage for facility staff, residents, and prescribing practitioners, consulting Pharmacist recommendations, and completed documentation. -The Facility Antibiotic Steward will also educate facility licensed nursing staff during the new hire orientation period on the Infection Control/Antibiotic usage documentation requirements; -The Facility Antibiotic Steward and AST will establish facility criteria for their Infection Prevention and Control Program and initiating the use of antibiotics, using a nationally recognized surveillance criteria, McGeer, Loeb, or a modified Loeb as its starting point for making possible intervention recommendations to the providers based on the systematic data collected; -The Facility Antibiotic Steward and the AST will initiate communication of recommendations with physician and/or prescribing practitioner using the McGeer/Loeb criteria listed in Appendix A; -The facility will include antibiotic use recommendations (if applicable) in its Quality Assurance Program Improvement (QAPI) program; -The ASP will use the CDC web page information and fact sheets for reference and training purposes. 1. Record review of facility Antibiotic Medications Report, provided by the Assistant Director of Nursing who was the Infection Preventionist (IP) for the facility, showed the following: -Review of the last 12 months of antibiotic use showed a printed list of resident antibiotic use from the electronic health record program; -For residents with UTI's, there was no documentation of indication of culture and sensitivity or organism being treated; -For wound infections, there was no documentation for indication of type of infection or signs and symptoms of infection; -No tracking of post antibiotic use was completed; -No indication of staff education provided if an increase in infections was documented; -No indication of resident education with infection documented; -No indication of evaluation of appropriateness of antibiotics documented; -No use of McGreer criteria documented; -No communication with providers documented. 2. Review of Resident #229's face sheet showed diagnoses of meningitis (inflammation of the brain and spinal cord membranes, typically caused by an infection), lymphedema (tissue swelling), and irritant contact dermatitis (skin inflammation). Review of the resident's Progress Notes, dated 06/09/25 at 8:51 A.M., showed the resident had scattered open areas to bilateral lower extremities related to lymphedema. The open areas had minimal drainage and no odor. The resident complained of discomfort when pressure was applied to the areas. The right foot had non pitting edema (swelling caused by fluid buildup in tissues that does not leave an indentation when pressed). Physician notified. Review of the resident's Progress Notes, dated 06/09/25 at 9:24 A.M. showed the physician gave orders to start lasix (a diuretic medication) 20 milligrams (mg) daily and Keflex (an antibiotic) 500 mg three times a day for seven days. Review of the resident's Physician Orders, dated 06/09/25, showed an order for Keflex oral capsule, give 500 mg by mouth three times a day related to lymphedema for seven days. Review of the facility's Tracking Log showed Keflex was noted on the log. There was no evidence of evaluation of the antibiotic use using McGreer criteria, no evidence of post antibiotic use and no culture and sensitivity of any drainage from the resident's wounds. 3. Review of Resident #15's face sheet showed the resident admitted to the facility 12/13/21. Review of the resident's Nurses Note, dated 02/24/25 at 1:35 P.M., showed the resident was lethargic, responded to painful stimuli for only a second then goes back to sleep or says he/she was fine. The resident was breathing with accessory muscles (the body is working harder to breathe, suggesting respiratory distress), and not responding to commands when asked to grip hands or open eyes. Oxygen saturation (the amount of oxygen circulating in the blood) was 85 percent (%) (normal result is 95 - 100%) on room air, 93% on oxygen at 3 liters/minute via nasal cannula (prongs placed in the nares that deliver oxygen). Notified the physician and received order to send resident to the emergency room for evaluation and treatment. Review of the resident's Nurses Note, dated 02/24/25 at 2:04 P.M., showed the resident transferred to the emergency room via emergency medical services (EMS). Review of the resident's Nurses Note, dated 02/24/25 at 5:09 P.M., showed the resident returned from the emergency room with a diagnosis of pneumonia and a urinary tract infection and an order for levaquin (antibiotic) for ten days. Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed levaquin 500 mg daily for ten days for pneumonia and a urinary tract infection; start on 02/24/25. Review of the resident's POS, dated May 2025, showed and order for azithromycin (antibiotic) 250 mg, administer two tablets by mouth one time then administer one tablet by mouth at bedtime for cough/sore throat for four days. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/12/25, showed the following: -Severe cognitive impairment; -Diagnosis of pneumonia; -Antibiotics received. Review of the facility's Tracking Log showed levaquin and azithromycin were documented on the facility tracking log. There was no evidence staff evaluated use of the antibiotic using McGreer criteria, and no evidence of post antibiotic use, no culture and sensitivity of any sputum or urine related to either course of antibiotics. During an interview on 06/11/25 at 1:30 P.M., the Infection Preventionist (IP) said the following: -She was responsible for antibiotic stewardship; -She had a log she used to list all antibiotics; -She tracked on a map where infections were in the facility; -She provided the number of each type of infection and antibiotics used to the Quality Assurance committee at meetings; -She did not evaluate the appropriateness of antibiotics, culture and sensitivity reports, or trends with cultures showing resistance; -She did not use McGreer criteria to evaluate appropriate antibiotic use; -She did not communicate with physicians if antibiotic use was appropriate or not; -The facility did not have a team that evaluated appropriateness and trends related to antibiotic use and types of infections, or resistant strains of bacteria in the facility. During an interview on 06/12/25, at 7:30 P.M., the Administrator said he expected the facility staff to follow the Antibiotic Stewardship policy.

Based on observation, interview and record review, the facility failed to repair or paint areas to maintain a homelike environment in resident rooms #101, #404 and #207. The facility census was 25. Review of the facility policy, Safe and Homelike Environment, dated 06/05/25, showed the following: -In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas; -A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment A determination of homelike should include the resident's opinion of the living environment; -Report any furniture in disrepair to Maintenance promptly; -Report any unresolved environmental concerns to the Administrator. 1. Observation on 06/09/25 at 1:05 P.M., showed the following: -The bathroom door in room [ROOM NUMBER] with large pieces of missing veneer exposing the unfinished wood underneath; -Door frames inside the bathroom in room [ROOM NUMBER] had several areas with missing paint and black marks on the inside of the bathroom doors; -The bottom half of the exterior door to room [ROOM NUMBER] was covered with metal, the edges of the metal were wavy and bent exposing a sharp metal edge; -The exterior door frame to room [ROOM NUMBER] had several areas of missing paint. 2. Observation on 06/10/25 at 8:07 A.M., showed the following: -The entry door for room [ROOM NUMBER] had multiple scratches near the bottom of the door, deep enough to expose the wood underneath; -The doorframe of room [ROOM NUMBER] was scratched in multiple areas and had missing paint; -Two areas of the wall in room [ROOM NUMBER]-A with patched, white drywall mud that were unpainted; -In 404-A, approximately 12 inches of the plastic trim around the footboard of the bed was loose and separated from the footboard, exposing the particle board under the trim. 3. Observation on 06/11/25 at 11:08 A.M., showed the following: -The door to room [ROOM NUMBER] had a covering over the lower half of the door. The inner and outer edges of the covering were separated from the door exposing unfinished wood and missing paint; -The gray covering was marred with black marks and scuffs. During an interview on 06/12/25 at 3:48 P.M., the Maintenance Supervisor said the following: -Staff are expected to report if a door frame or door was in need of repair; -He was everywhere, everyday, but could not catch all the repairs all by himself; -Painting and touch up was constant because the wheelchairs and equipment run into the doors and door frames daily. During an interview on 06/12/25 at 7:30 P.M., the Administrator said the following: -He started at the facility 04/28/25; -He expected all staff to monitor for repairs needed in the facility; -Maintenance staff always looked for areas that needed repair; -Staff should report anytime a repair is needed to maintenance; -Staff should add any area or issue in need of repair to the maintenance log.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, for three residents (Resident #4, #11, and #14), in a review of 16 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (a decline or improvement in two or more assessed areas of resident status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revisions of the care plan. The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, Chapter 2, revised October 2024, showed the following: -The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change; -A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan; -When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met; -After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record; -An SCSA is appropriate when: 1. There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments; and 2. The resident's condition is not expected to return to baseline within two weeks; -An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. Review of the facility policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed the following: - To understand the changes presented by CMS for the MDS 3.0, to define the intent of each section of the MDS 3.0 and to ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties; - MDS's must be kept current and up to date; -The MDS will be completed within twenty-four (24) hours of the Assessment Reference Date (ARD) being due; -MDS's must be transmitted weekly with validation reports printed out and kept within the MDS office for easy access and viewing if needed. 1. Review of Resident #11's face sheet showed his/her diagnoses included dementia, chronic kidney disease, major depressive disorder, unspecified osteoarthritis, generalized anxiety disorder, adult failure to thrive and muscle weakness. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Not receiving hospice services. Review of the resident's physician order sheet, dated 04/04/25, showed an order to admit the resident to hospice. (The addition of hospice met the criteria of a SCSA and should have been completed within 14 days of admission to hospice. No documentation to show a SCSA was completed within 14 days of admission to hospice services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Receiving hospice services; (This assessment was completed 53 days after being admitted to hospice services.) During an interview on 06/18/25 at 3:09 P.M., the Regional MDS Coordinator said the significant change MDS should have been completed within three weeks of starting hospice and it was probably missed due to so many MDS Coordinator changes. 2. Review of Resident #14's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/17/24, showed the following: -Moderate cognitive impairment; -Diagnoses included stroke with hemiplegia (weakness or paralysis to one side of the body), end stage renal disease, and traumatic brain injury; -Independent with toileting hygiene, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, wheel 50 feet, and wheel 150 feet; -Set up or clean up assistance from staff for eating, and oral hygiene; -Requires partial/moderate assistance from staff for shower/bathe, upper body dressing, lower body dressing, and putting on/taking off footwear; -Occasionally incontinent of bladder, and continent of bowel. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was not independent with any activities of daily living (ADL's); -Requires supervision/touching assistance from staff members for eating, oral hygiene, personal hygiene, roll left and right, and chair/bed-to-chair transfer; -Requires partial/moderate assistance from staff for toileting hygiene, sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, and wheel 50 feet; -Requires substantial/maximal assistance from staff for shower/bathe, lower body dressing, and putting on/taking off footwear; -Dependent on staff for wheeling 150 feet; -Frequently incontinent of bladder and bowel. Review of the resident's medical record showed no evidence staff completed a SCSA after the resident had a decline in every ADL listed in section GG and a decline in incontinence. 3. Review of Resident #4's face sheet showed the following: -Diagnoses of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), unspecified dementia, delusional disorders, generalized osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wear down), bunion (a bony bump that forms on the joint at the base of the big toe) of unspecified foot, major depressive disorder, vitamin D deficiency, carpal tunnel syndrome (numbness and tingling in the hand and arm caused by a pinched nerve in the wrist), bursitis (painful swelling of the fluid-filled pads that act as cushions at the joints) of right shoulder, and dizziness and giddiness (sensation of feeling lightheaded, dizzy or unsteady). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No impairment of upper or lower extremities; -Set-up assistance for eating; -Independent with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right in bed, sitting on side of bed to lying flat on the bed, lying flat on the bed to sitting on the side of the bed, sitting to standing, chair/bed-to-chair transfers, toilet transfers, to walk 10 feet, to walk 50 feet with two turns and to walk 150 feet; -Supervision for shower/bathing and for tub/shower transfer. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Supervision for eating (decrease in ability to perform independently); -Supervision for oral hygiene (decrease in ability to perform independently); -Supervision for toileting hygiene (decrease in ability to perform independently); -Supervision for upper body dressing (decrease in ability to perform independently); -Supervision for lower body dressing (decrease in ability to perform independently -Supervision for putting on/taking off footwear (decrease in ability to perform independently); -Supervision for personal hygiene (decrease in ability to perform independently); -Supervision to walk 50 feet with two turns (decrease in ability to perform independently); -Supervision to walk 150 feet (decrease in ability to perform independently); (This assessment met the criteria of an SCSA and should have been completed as an SCSA assessment, but instead, was completed as a quarterly assessment). During an interview on 06/18/25 at 3:09 P.M., the Regional MDS Coordinator said the significant change MDS was probably missed due to so many MDS Coordinator changes. 4. During an interview on 6/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the following: -A significant change MDS should be completed when there was a change in two or more sections, or two or more care areas in section GG, or hospice starts/stops; -The MDS coordinator determines if a significant change MDS was required, based off of charting; -The MDS coordinator was not on site, but does come to the facility to conduct resident interviews; -The MDS should be completed by following the RAI manual. During an interview on 06/18/25 at 3:09 P.M., the Regional MDS Coordinator said the following: -She started doing MDS's at the facility at the end of April into the beginning of May 2025; -Prior to that there were a couple different MDS coordinators covering; -She was now fully responsible for the facility as well as three other facilities; -She follows the RAI manual to complete MDS's; -A significant change was required when t here was a change in two areas, or notified of a change in condition, and should be completed within three weeks of the change; -A significant change was identified from the last completed MDS; -The communication process was confusing as she was not on site; -She was made aware of significant changes through a group chat with the Director of Nursing (DON), ADON and the Social Service Director.

Based on observation, interview and record review, the facility failed to ensure code status matched on all resident documents and their door name plates to ensure staff responded appropriately to provide or not provide Cardio Pulmonary Resuscitation (CPR) (an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) according to the resident's wishes if the resident was found without a heart beat or respirations for four residents (Resident #20, #22, #24, and #229) in a sample of 16 residents. The facility census was 25. Review of the facility policy, Communication of Code status, last revised [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; -In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive; -When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record; -Examples of directions to be documented include, but are not limited to: -Full Code (a medical term that indicates one's wishes to receive all possible life-saving measures in the event of a cardiac or respiratory arrest); -Do Not Resuscitate (DNR) (a medical term that indicates the individual does not want CPR performed if his/her heart stops beating or they stop breathing); -The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record; -The designated sections of the medical record include the physician orders, care plan and individualized service plan; -Additional means of communication of code status include a black dot on the door/name plate; (did not include what a black dot indicated, facility currently used a blue dot); -In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code; -The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services; -The Social Services Director shall maintain a list of residents who have an Advance Directive on file; -The resident's code status will be reviewed at least quarterly and documented in the medical record. 1. Review Resident #20's Care Plan, dated [DATE], showed the resident as a DNR status. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated [DATE], showed the resident had moderately impaired cognition. Review of resident's admission packet code form, dated [DATE], showed the resident signed he/she wanted to be a Full Code. Review of the resident's advanced directive portion of his/her electronic medical record (EMR) showed the resident was Full Code. Review of the resident's physician order sheet (POS), dated [DATE], showed the resident was Full Code. Observation on [DATE] at 8:10 A.M. showed the resident's door/name plate did not have a blue dot. Review of the facility list of full code residents, dated [DATE], on [DATE] at 9:00 A.M., showed the list included the resident was Full Code. During an interview on [DATE] at 9:15 A.M., the resident said he/she wanted to be a Full Code. 2. Review of Resident #22's significant change in status MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's Care Plan, dated [DATE], showed the resident was Full Code. Review of the resident's POS, dated [DATE], showed the resident's code status was DNR. Observation on [DATE] at 8:51 A.M., showed the resident's name plate by their bedroom door with a blue dot. Review of the facility list of full code residents, dated [DATE], on [DATE] at 9:00 A.M., showed the resident was not on the list. Review of the resident's advanced directive portion of his/her EMR showed the resident was a DNR. During an interview on [DATE] at 1:22 P.M., the resident and his/her spouse said the resident wanted to be DNR. 3. Review of Resident #24's face sheet showed the following: -admitted on [DATE]; -He/She was his/her own person. Review of the resident's Resuscitation Order, dated [DATE], showed the resident signed he/she wanted to be a Full Code. Review of the resident's care plan, dated [DATE], showed the resident was Full Code. Review of the resident's advanced directive portion of his/her EMR showed the resident was Full Code. Review of the resident's Physician Order Sheet, dated [DATE], showed the resident was Full Code. Observation on [DATE] at 11:01 A.M. showed the resident's door/name plate had a blue dot. Review of the facility list of Full Code residents, dated [DATE], on [DATE] at 9:00 A.M., showed the resident was not on the list. 4. Review of Resident #229's face sheet showed the following: -He/She admitted on [DATE]; -He/She was his/her own person. Review of the resident's baseline care plan, dated [DATE], showed no indication of code status. Review of the resident's Full Code Form, dated [DATE], showed the resident signed he/she wanted to be a Full Code. Review of the resident's comprehensive care plan, revised [DATE], showed no indication of code status. Review of the resident's Physician Order Sheet, dated [DATE], showed no order indicating the resident's elected code status. Observation on [DATE] at 11:01 A.M., showed the resident's door/name plate did not have a blue dot. Review of the resident's advanced directive portion of his/her EMR showed the resident had no code status identified. Review of the facility list of Full Code residents, dated [DATE], on [DATE] at 9:00 A.M., showed the list included the resident as a Full Code. 5. During an interview on [DATE] at 7:15 A.M., Certified Nurse Assist (CNA) F said blue dots on a resident's door meant the resident was Full Code. There was a list of Full Code residents on the crash cart. If there was a question about code status he/she would ask the charge nurse. During interviews on [DATE] at 8:00 A.M. and on [DATE] at 3:00 P.M., Licensed Practical Nurse (LPN) A said the following: -A blue dot on the resident's name plate meant the resident was Full Code; -A resident's code status on the resident's POS, care plan, and the top of the EMR care status should all match. If a resident was a Full Code they should be on the posted Full Code List and should have a blue dot on the name/face plate to his/her room; -Code Status should be on the base line care plan; -On admission to the facility, the resident may not have the DNR code status signed by the physician, so the resident was put in as a Full Code and then changed when staff could obtain a physician's signature; sometimes staff needed to update a code status. During an interview on [DATE] at 1:20 P.M., the Social Service Director (SSD) said the following: -The code status for a resident was listed at the top of their EMR, on the resident's POS and on the resident's care plan; -She was responsible to update the list of full code residents weekly; -Each week she printed the full code list and every department head received a copy; -The full code list was posted in house keeping, laundry, shower rooms, on the crash cart and at the nurses station; -Full code residents have a blue dot on the name plate of the door to their rooms; -She spoke to residents about their code status, the charge nurse obtained the physician's order and the Assistant Director of Nursing (ADON) placed the blue dot on the resident's name plate by the door to the resident's room. During an interview on [DATE] at 7:30 P.M., the ADON said the following: -A resident's code status should be clear and match on all documents and lists; -If there were inconsistencies or confusion, the resident's physician's order would be considered the correct information; -A blue dot on the resident's door signified the resident as Full Code.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure one dependent resident (Resident #24) was able to smoke outside, ensure residents received restorative services or to ensure call lights were answered timely to accommodate resident needs for five residents (Resident #5, #13, #16, #22, and #24) in a review of 16 sampled residents. The facility census was 25. Review of the facility's policy, Call Lights Accessibility and Timely Response, revised 04/30/24, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desired, the appropriate personnel should be notified. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the facility had no restorative program at this time. 1. Review of the undated Facility Assessment showed the following: -Average daily census is 23; -Disease/Conditions and physical/cognitive disabilities for which the facility provides care for include neurological systems, including hemiparesis (muscle weakness on one side of the body), hemiplegia (partial paralysis on one side of the body), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), quadriplegia (paralysis that affects the ability to move the uppers and lower body), cardiovascular accident/stroke (a medical condition where blood flow to the brain is interrupted that can include sudden numbness or weakness and difficulty walking), neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) and muscle weakness; -The facility assessment will be used to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care; -Resident acuity affecting nursing aides: assistance provided with dressing - 14, assistance provided with bathing - 23, assistance provided with transfers - 19, assistance provided with eating - one, assistance provided with toileting - 13, assistance provided with mobility - 16, assistance provided with splints/braces - one and assistance provided with behavioral symptoms - three; -Facility resources (staffing): One Director of Nursing (DON), one Assistant Director of Nursing (ADON), four Licensed Practical Nurses (LPN), six Registered Nurses (RN), four medication aides or technicians, 12 Certified Nursing Assistants (CNA), zero Restorative Nursing Assistant, one infection preventionist and one regional minimum data set (MDS) nurse; -Overall staffing needs: Nurse Aides (CNAs, NAs, medication technicians) - three; -Staffing needs as per resident unit: CNAs - three; -Staffing needs as per shift (adjust as needed) Days: CNAs - three; -Specialized rehabilitation services - zero rehabilitation techs; -Staffing was based on acuity. 2. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, dated 05/09/25 through 06/08/25, showed the following dates with two CNA's scheduled on the day shift when the facility assessment identified three CNA's were needed for the shift: -05/16/25; -05/18/25; -05/19/25; -05/26/25; -05/29/25; -05/31/25; -06/02/25; -06/04/25; -06/05/25; -06/06/25; -06/07/25; -06/08/25. 3. Review of the resident council meeting minutes showed the following: -On 04/02/25, residents said call lights were not working and the residents wanted the call lights answered timely; the staff responsible were the Maintenance Supervisor and the Director of Nursing; -On 05/08/25, residents wanted call lights answered timely and the staff responsible was the Assistant Director of Nursing (ADON); -On 06/04/25, residents wanted call lights answered timely and the staff responsible were the ADON and the Administrator. 4. Review of Resident #5's face sheet showed his/her diagnoses included chronic osteomyelitis (a long-term bone infection and chronic pain syndrome (persistent pain that last weeks to years). Review of the resident's care plan, revised on 05/02/25, showed the following: -Acute pain/chronic pain; -Administer pain medications per order. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/20/25, showed the following: -Cognitively intact; -Scheduled pain medication and as needed pain medication given. Review of the resident's call light logs, dated 06/06/25 through 06/09/25, showed the following: -On 06/06/25 at 12:27 A.M., the call light went unanswered for 20 minutes; -On 06/06/25 at 2:15 A.M., the call light went unanswered for 19 minutes; -On 06/06/25 at 4:06 P.M., the call light went unanswered for 19 minutes; -On 06/06/25 at 5:23 P.M., the call light went unanswered for 42 minutes. Review of the resident's June 2025 medication administration record (MAR) showed an as needed oxycodone hydrochloride (a narcotic pain medication) 10 milligrams (mg) administered on 06/06/25 at 5:57 P.M. Review of the resident's call light logs, dated 06/06/25 through 06/09/25, showed the following: -On 06/07/25 at 5:51 P.M., the call light went unanswered for 21 minutes; -On 06/07/25 at 7:09 P.M., the call light went unanswered for 19 minutes; -On 06/08/25 at 3:41 P.M., the call light went unanswered for 27 minutes. Review of the resident's June 2025 MAR showed an as needed oxycodone hydrochloride 10 mg administered on 06/08/25 at 4:55 P.M. Review of the resident's call light logs, dated 06/06/25 through 06/09/25, showed on 06/09/25, at 11:05 A.M., the call light went unanswered for 19 minutes. During an interview on 06/09/25 at 2:38 P.M., the resident said sometimes it took almost 40 minutes for staff to answer the call light. When he/she turned on the call light it was usually to request a pain pill. Review of the resident's call light log for 06/09/25 showed at 8:58 P.M., the call light went unanswered for 26 minutes. During an interview on 06/10/25 at 6:41 A.M., the resident said he/she had the call light on for about 30 minutes yesterday evening (6/9/25) before staff responded so he/she could get a pain pill. 5. Review of Resident #13's Care Plan, dated 02/05/25, showed the following: -Diagnoses include quadriplegia (paralysis of all extremities), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet) and chronic pain related to trauma; -Impaired physical mobility; -Resident will be free of complications of immobility; -Assist resident in performing movements / tasks; -Evaluate skin for areas of blanching or redness; -Observe ROM in all joints; -Passive ROM shiftly; -Dependent on staff for all ADL's; -Resident eats in his/her room, and is fed by staff; -Resident is an aspiration risk. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Limited ROM all extremities; -Dependent on staff for all activities of daily living (ADL'S); -PRN (as needed) pain medications, no non-med interventions for pain; -Takes opioid (pain relieving medication) daily; -No therapy, no range of motion or other ADL's provided by restorative nursing. Review of the resident's call light log, dated 06/06/25 through 06/09/25, showed the following: -On 06/06/25 at 3:15 A.M., the call light went unanswered for 37 minutes; -On 06/06/25 at 10:32 P.M., the call light went unanswered for 28 minutes; -On 06/07/25 at 9:56 A.M., the call light went unanswered for 37 minutes. During an interview on 06/11/25 at 4:15 P.M., the resident said the following: -Sometimes he/she had problems with staff answering call lights timely; -He/She has had to wait an hour for staff when he/she had pain and discomfort; -When he/she lays on any type of wrinkle it burned and having to wait for a long time was miserable; -Waiting an hour have your call light answered made him/her feel staff did not care about him/her; -There was not enough staff to do ROM with him/her; -The aides will assist him/her to stretch when he/she asks, but it was not the same as a good ROM program where he/she would receive active ROM to all joints for several repetitions; -He/She felt guilty asking the aides with a full assignment to do more than a few stretches because it took time and they were very busy; -Since his/her contractures have gotten worse, he/she has knots in his/her muscles and it was miserable; his/her muscles will get so tight he/she could feel pulsations in the muscle. 6. Review of Resident #22's care plan, last updated 02/04/25, showed the following: -Chronic pain, polymyalgia rheumatica (PMR)( is a condition causing pain and stiffness, primarily in the shoulders, neck, and hips), tremors, and frequent falls; -Resident has impaired visual function; -Resident uses oxygen; -Trouble swallowing; -Eight falls in the last year (not all in the facility); -Ensure the resident's call light is in reach at all times, ensure prompt response to all request for assistance; -Chronic pain administer medications as ordered; -Resident requires limited physical assistance from staff for: dressing and walking in his/her room; -Resident requires extensive physical assistance from staff for: toilet use, transfers, and personal hygiene. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognition moderately impaired; -Requires supervision/touching assistance from staff members for eating, upper body dressing, to walk 10 feet, and wheel 50 feet with two turns; -Requires partial/moderate assistance from staff for oral hygiene, personal hygiene, and walk 50 feet with two turns; -Requires substantial/maximal assistance from staff for lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 150 feet, and wheel 150 feet; -Dependent on staff for toileting hygiene and to shower/bathe. Review of the resident's call light log, dated 06/06/25 through 06/09/25, showed the following: -On 06/06/25 at 7:39 A.M., the call light went unanswered for 18 minutes; -On 06/06/25 at 11:33 A.M., the call light went unanswered for 18 minutes; -On 06/06/25 at 6:00 P.M., the call light went unanswered for 26 minutes; -On 06/06/25 at 9:37 P.M., the call light went unanswered for 17 minutes; -On 06/07/25 at 4:36 A.M., the call light went unanswered for 27 minutes; -On 06/07/25 at 10:08 A.M., the call light went unanswered for 29 minutes; -On 06/07/25 at 6:15 P.M., the call light went unanswered for 42 minutes; -On 06/07/25 at 7:43 P.M., the call light went unanswered for 19 minutes; -On 06/08/25 at 5:41 A.M., the call light went unanswered for 56 minutes; -On 06/08/25 at 10:44 A.M., the call light went unanswered for 17 minutes; -On 06/08/25 at 3:51 P.M., the call light went unanswered for 31 minutes; -On 06/09/25 at 1:14 A.M., the call light went unanswered for 28 minutes; -On 06/09/25 at 2:46 A.M., the call light went unanswered for 18 minutes; -On 06/09/25 at 6:37 A.M., the call light went unanswered for 24 minutes; -On 06/09/25 at 7:36 P.M., the call light went unanswered for 52 minutes; -On 06/09/25 at 11:16 P.M., the call light went unanswered for 41 minutes. During an interview on 06/11/25 at 12:36 P.M., the resident said sometimes he/she has to wait a long time to get his/her call light answered. The resident's spouse (present at time of interview) said the resident has to wait a long time to get his/her call light answered at meal times and shift change. The resident and his/her spouse said they do not feel like the facility has enough staff during busy times like meals and shift changes to answer call lights. 7. Review of Resident #24's face sheet showed the following: -He/She was his/her own person; -Diagnoses of pulmonary fibrosis (chronic lung disease) and acute respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily functions). Review of the resident's smoking and safety assessment, dated 04/08/25, showed the following: -The resident uses tobacco products; -The resident follows the facility's policy on location and time of smoking; -The resident was able to demonstrate safe smoking techniques without the help of staff. Review of the resident's care plan, revised 04/10/25, showed the following: -He/She used tobacco; -The resident requires supervision while smoking. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 05/12/25, showed the following: -Cognitively intact; -Dependent for chair and bed-to-chair transfers. Review of the resident's call light log, dated 06/06/25 through 06/08/25, showed the following: -On 06/06/25 at 10:41 A.M., the call light went unanswered for 22 minutes; -On 06/06/25 at 5:44 P.M., the call light went unanswered for 24 minutes; -On 06/06/25 at 9:37 P.M., the call light went unanswered for 19 minutes; -On 06/07/25 at 12:58 P.M., the call light went unanswered for 28 minutes; -On 06/08/25 at 7:34 A.M. the call light went unanswered for 37 minutes. Review of the resident's progress notes, dated 6/8/25 at 8:54 A.M., showed the resident was upset and crying due to not being able to go out to smoke. Staff educated the resident there were only two aides and one nurse working, and they were all busy assisting with breakfast, so there was nobody available to get the resident up with the mechanical lift and take him/her outside to smoke. The resident was still upset at 9:00 A.M. Review of the resident's call light log, dated 06/09/25 at 10:30 A.M., showed the call light went unanswered for 21 minutes. During an interview on 06/09/25 at 3:05 P.M., the resident said the following: -He/She was a smoker; -He/She required a mechanical lift and two staff to get out of bed; -When he/she went out to smoke, a staff member had to stay with her; -Call light response time varied, there were many occasions he/she had to wait 30 to 45 minutes; -Call light response time was slower on the day shift than during the evening or night shifts. Observation on 06/10/25 at 7:49 A.M. showed the following: -Resident shouting from room stating why am I being ignored; -Certified Medication Technician (CMT) N entered the room and asked the resident what was wrong; -The resident said he/she was supposed to go out for the 7:00 A.M. smoke break, but was still waiting 45 minutes later; -CMT N exited the room and walked down the hall looking for other staff; -At 7:53 A.M. the Assistant Director of Nursing (ADON) and Social Services Director (SSD) entered the resident's room and the ADON said staff would not be able to take him/her out right now due to the time; -The resident yelled he/she was tired of always missing smoke breaks because of staff. During an interview on 6/12/25 at 3:02 P.M. the SSD said the following: -The resident had been educated on the facilities smoking schedule and to utilize his/her call light prior to the scheduled time if he/she wanted to go out to smoke; -The resident had been educated that if his/her light was not answered in 15 minutes, then staff were busy providing cares, which the resident had also been educated as taking priority over smoke breaks; -The resident was educated that he/she was not being denied going to smoke, but would have to wait for cares that were higher priority; -The 7:00 A.M. smoke time was the hardest to accommodate as staff are busy getting other residents up to breakfast and feeding and monitoring them. 8. Review of Resident #16's face sheet showed his/her diagnoses include lumbar region radiculopathy (pinching of the nerves at the root which can cause pain or weakness). Review of the resident's care plan, revised on 05/16/25, showed the following: -The resident has current functional performance; -Needs limited assistance of one person for bed mobility and dressing; -Needs extensive assistance of one person with personal hygiene and toilet use; -Anticipate the resident's needs for pain relief and respond immediately to any complaints of pain. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Partial/moderate assistance from staff for oral hygiene, upper body dressing and personal hygiene; -Substantial/maximum assistance from staff for bathing, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand transfer, chair/bed-to-chair transfer, toilet transfer and tub/shower transfers; -Dependent on staff for toileting hygiene, lower body dressing and putting on/taking off footwear; -Frequently incontinent of bowel and bladder. Review of the resident's call light logs, dated 06/06/25 through 06/09/25, showed the following: -On 06/06/25 at 1:14 A.M., the call light went unanswered for 18 minutes; -On 06/07/25 at 10:06 A.M., the call light went unanswered for 27 minutes; -On 06/08/25 at 5:30 A.M., the call light went unanswered for 20 minutes; -On 06/08/25 at 9:27 P.M., the call light went unanswered for 20 minutes; -On 06/09/25 at 5:25 A.M., the call light went unanswered for 41 minutes. 9. During an interview on 06/11/25 at 4:45 P.M., CNA M said the following: -The resident has contractures, especially in his/her right arm; -The facility did not have a restorative aide or anyone designated to do a full ROM program; -IT was difficult to answer call lights at meal times and shift change times; -The facility did not have enough staff to stay with the residents eating in their room who were aspiration risk, assist in the dining room and answer lights. It was not possible to be in two places at once. During an interview on 06/12/25 at 1:03 P.M., CNA D said the following: -It was difficult to answer call lights with only two CNA's on the floor; -When there are only two CNA's on the floor, it was hard to take the residents to smoke and answer the call lights timely; -Call lights should be answered within five minutes if there was no an emergency. During an interview on 06/12/25 at 1:09 P.M., CNA E said call lights should be answered within five minutes. During an interview on 06/12/25 at 1:16 P.M., CNA F said call lights should be answered in less than five minutes. During an interview on 06/11/25 at 10:05 A.M., and 06/12/25 at 7:21 P.M., Registered Nurse (RN) C said the following: -They did not know how to run the call light report so no one was monitoring the call light report; -Days and evening shift could be tricky on answering call lights during mealtimes and staff breaks; -Sometimes smoke breaks were late because there was no staff to take the resident out at the assigned time due to mealtimes and less staff on evening shift; -Call lights should ideally be answered within 5 minutes. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nurses (ADON) said the following: -A resident should be allowed to go out to smoke during assigned times regardless of the staffing situation; -Call lights should be answered as quickly as possible with 15 minutes pushing the limit and no more than 20 minutes; -The restorative program has been hard to implement due to staffing issues with no DON in the building to oversee the restorative program. During an interview on 06/12/25 at 7:30 P.M., the Director of Nurses (DON) said the following: -Call lights should be answered as quickly as possible, ideally within 5 minutes with 15 minutes pushing the limit; -If a resident needed to go to smoke break and the assigned staff was busy, she would expect other staff be utilized to complete the smoke break. During an interview on 06/12/25 at 7:55 P.M., the administrator said the following: -Call lights should be answered in a timely manner; -Resident smoke breaks should occur as scheduled; if the assigned staff cannot complete the smoking task, other staff should be utilized; -He had not had a DON until 06/09/25, so had not been able to effectively look at all the processes to see if additional staffing was needed; -He did not know if the facility needed higher number of staff during meal times and shift changes or reorganization to make sufficient use of staff. MO254369

Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #10, #16, #23, and #24) in a sample of 16 residents, and one additional resident (Resident #23). The facility census was 25. Review of the facility policy Transcription of Orders/Following Physician's Orders, last revised 05/18/24, showed the following: -The purpose of this policy is to ensure that all physicians' orders are followed; -To ensure a process is in place to monitor nurses in following physician's orders; -The Licensed Nurse will review electronic Medication Administration Records (MARs) & electronic Treatment Administration Records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. -If a medication is marked as not given, the reasoning for not being given should be explained in the progress notes and to the Director of Nursing (DON)/Assistant Director of Nursing (ADON)/Registered Nurse (RN), and the Administrator must be notified; -The Physician and Legal Guardian (if applicable) must also be notified; -The nurse's progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have; -For Electronic MARS/TARS: The medication will be documented as not given by selecting the corresponding chart code for the reason why it was not given, and a progress note will be written. 1. Review of Resident #10's Face Sheet showed the resident with a diagnosis of diabetes mellitus (inability to regulate blood sugar). Review of the resident's Care Plan, initiated 05/29/25, showed the following: -The resident has diabetes mellitus; -Diabetes medication as ordered by the physician; -Fasting blood sugar as ordered by the physician. Review of the resident's Physician's Orders Sheet (POS), dated June 2025, showed the following: -Accuchecks (finger stick to collect a drop of blood that analyzes blood glucose (sugar) in a hand held device) before meals and at bedtime, notify the physician if blood glucose is less than 70 or more than 350; -Humalog Injection Solution ( fast-acting insulin used to control blood sugar levels in people with diabetes) 100 units/milliliter (ml): Inject per sliding scale: if 100 - 150 = 2 units; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 400 = 10 units and notify physician for greater than 400, subcutaneously before meals related to type II diabetes mellitus. Observation on 06/10/25, at 07:23 A.M., showed the following: -Licensed Practical Nurse (LPN) A obtained the resident's blood glucose in his/her room which read 101; -LPN A told the resident his/her blood glucose was 101 and too low so he/she was not going to give the resident his/her sliding scale insulin; -LPN A left the resident's room without administering the ordered insulin. Review of the resident's MAR, dated 06/10/25, showed LPN A documented the resident's blood glucose of 101, and he/she did not administer the resident's Humalog sliding scale insulin with a number 9 other see progress note. Review of the resident's Nurses Note, dated 06/10/25, at 07:30 A.M., showed LPN A documented the he/she held Humalog sliding scale insulin because the resident's blood glucose was low and the resident was not eating breakfast at the time of the blood glucose check. Review of the resident's Nurses Notes showed no documentation staff notified the DON/ADON/RN, Administrator, physician or legal guardian per policy. There was no documentation of a plan/solution because of the medication not being administered and any adverse reactions that the resident may have. 2. Review of Resident #16's Face Sheet showed the resident with a diagnosis of diabetes mellitus Review of the resident's Care Plan, updated 02/04/25, showed the following: -Risk for secondary complications related to diabetes; -Resident will remain free of secondary complications; -Administer medications related to diabetes as ordered; -Monitor Accuchecks as ordered. Review of the resident's POS, dated June 2025, showed the following: -Accuchecks every morning and at bedtime, notify the physician if blood glucose is less than 70 or more than 350; -Free Style Libre 3 Sensor (continuous glucose sensor that is placed just below the epidermis (top layer of skin)): Inject 1 device intradermally on evening shift every 14 day(s) for blood glucose monitoring; -Humalog Injection Solution 100 unit/ml: Inject as per sliding scale: if 100 - 149 = 4 units; 150 - 199 = 6 units; 200 - 249 = 8 units; 250 - 299 = 10 units; 300 - 999 =12 units, 10 units for blood sugar >300, subcutaneously every morning and at bedtime related to diabetes; -Lantus Injection Solution 100 unit/ml, inject 20 units at bedtime. Review of the resident's MAR, dated 06/07/25, showed staff documented the resident's Lantus insulin at bedtime as 9 (was not administered see nurses notes). Review of the resident's Nurses Notes, dated 06/07/25, showed no documentation regarding staff holding the resident's Lantus at bedtime. Review of the resident's Care Plan, updated 06/09/25, showed the following: -Free Style Libre 3 Sensor (Continuous Glucose System Sensor); -Ensure the resident effectively uses the Free Style Libre 3 sensor to monitor and manage their blood glucose levels. Review of the resident's MAR, dated 06/09/25, showed staff did not administer the resident's bedtime Lantus insulin. Review of the resident's Nurses Notes, dated 06/09/25, at 6:47 P.M., showed staff documented the resident's bedtime Lantus for 06/09/25 was not administered (no explanation documented). Observation on 06/10/25, at 07:48 A.M., showed the following: -LPN A pulled the Free Style Libre reader out of the medication cart; -LPN A entered the resident's room and held the reader close to the sensor on the back of the resident's left arm; the meter read the resident's blood glucose was 50, he/she ran it again an the meter read 52; -LPN A asked the resident if he/she was having any symptoms of low blood sugar and the resident denied any symptoms; -LPN A went to the medication cart in the hall and obtained a glucometer; -LPN A went back to the resident's bedside and obtained the resident's blood glucose with the using the glucometer and the resident's blood glucose read 111. During an interview on 06/10/25, at 07:54 A.M., LPN A said he/she was going to hold the resident's insulin. LPN A thought the Free Style Libre reader was inaccurate and the glucometer (Accucheck) was accurate based on looking at the resident and the resident did not have any symptoms of a low blood sugar but using his/her nursing judgement, was going to hold the ordered 4 units of Humalog. He/She would make a note using nursing judgement. Review of the resident's MAR, dated 06/10/25, showed LPN A documented the resident's blood glucose as 111, and he/she held the resident's Humalog sliding scale with a number 9,other see progress note. Review of the resident's Nurses Note, dated 06/10/25, at 07:53 A.M., showed LPN A documented Free Style Libre 3 read 52, rechecked with glucose reader and received reading of 111. The resident was talking with this nurse and responding appropriately to questions. This nurse gave resident one glass of orange juice and held insulin based on nursing judgement. 3. Review of Resident #24's face sheet showed the following: -He/She was his/her own person; -Diagnoses of chronic multifocal osteomyelitis of right ankle and foot, type II diabetes with foot ulcer, non-pressure chronic ulcer of right foot with fat layer exposed, urinary tract infection, methicillin resistant staphylococcus aureus infection, pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)of right buttock stage two (Partial-thickness skin loss with exposed dermis), pressure ulcer of left buttock unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue that is hard or soft in texture)), pressure ulcer of right heel unstageable, pressure-induced deep tissue damage (Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) of left heel, non-pressure chronic ulcer of right and left heel and midfoot (a persistent open sore or wound on the skin that doesn't result from prolonged pressure). Review of the resident's Physician Orders, dated 5/7/25, showed the following order: -Ceftriaxone sodium (an antibiotic medication) in dextrose (sterile solution used to provide your body with extra water and carbohydrates) intravenous solution 40 milligram(mg)/milliliter(ml), use 100 ml/hour(hr) intravenously in the afternoon for infection; -Vancomycin hydrochloride (an antibiotic medication) intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/12/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Cognitively intact; -Has moisture associated skin damage (MASD), an infection of the foot and a diabetic foot ulcer; -Received IV antibiotics via central line. Review of the resident's MAR, dated 5/19/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/20/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/22/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/23/25, showed no documentation staff administered ceftriaxone sodium in dextrose intravenous solution 40 milligrams(mg)/milliliter(ml), use 100 ml/hour(hr) intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/23/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/25/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/27/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 5/28/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 6/2/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 6/5/25, showed documentation of not administered due to hold, see progress notes for vancomycin hydrochloride intravenous solution, use 1,250 mg intravenously in the afternoon for infection. Review of the resident's Progress Notes, dated 6/5/25, showed vancomycin trough level received, physician notified of results, gave orders to hold today's dose and decrease dose to 1,000 mg every afternoon starting tomorrow, and redraw trough level in four days. Review of the resident's Physician Orders, dated 6/6/25 showed an order for vancomycin hydrochloride intravenous solution, use 1,000 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 6/6/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,000 mg intravenously in the afternoon for infection. Review of the resident's MAR, dated 6/9/25, showed no documentation staff administered vancomycin hydrochloride intravenous solution, use 1,000 mg intravenously in the afternoon for infection. During interview on 6/18/25 at 3:54 P.M. the Assistant Director of Nursing (ADON) said she could not recall a reason why she would not have documented administration of the resident's vancomycin. During an interview on 06/18/25, at 3:00 P.M., Licensed Practical Nurse (LPN) A said the following: -The bags of ceftriaxone the facility had took longer than scheduled on the MAR to infuse, so the vancomycin would have been late, pushing it on to night shift to administer; -Night shift may not have seen the order for the vancomycin or known to administer it since it was technically scheduled on day shift; -If it wasn't documented, it probably was not given; -It was likely an oversight due to the way both antibiotics were scheduled and the fact that they could not be infused together. 4. Review of Resident #23's undated face sheet showed the following: -He/She was his/her own responsible party; -Diagnosis of type II diabetes. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of care; -Received daily insulin injections. Review of the resident's Physician Orders, dated 4/22/25, showed an order for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to Type II diabetes. Review of the resident's MAR, dated 5/15/25, showed the following: -Documentation of not administered due to hold for blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 140. Review of the resident's MAR, dated 5/21/25, showed showed the following: -Documentation of not administered due to hold for blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type II diabetes; -Blood sugar at 6:30 A.M. was 106. Review of the resident's Progress Notes, dated 5/21/25, showed Lantus not administered based on nursing judgement. Review of the resident's MAR, dated 5/23/25, showed the following: -Documentation of not administered other see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 123. Review of the resident's Progress Notes, dated 5/23/25, showed Lantus not administered due to resident refusal saying he/she did not want it due to blood sugars frequently running low. Review of the resident's MAR, dated 5/25/25, showed the following: -Documentation of not administered due to hold see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 96. Review of the resident's Progress Notes, dated 5/25/25, showed Lantus held due to a low blood sugar of 96 and resident saying he/she did not want the insulin with a low blood sugar. Review of the resident's MAR, dated 5/27/25, showed the following: -Documentation of not administered due to other, see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 111. Review of the resident's Progress Notes, dated 5/27/25, showed the resident refused due to blood sugar frequently running low. Review of the resident's MAR, dated 5/28/25, showed the following: -Documentation of not administered due to other see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 109. Review of the resident's Progress Notes, dated 5/28/25, showed the resident refused due to blood sugar frequently running low. Review of the resident's MAR, dated 5/29/25, showed the following: -Documentation of not administered due to other see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 109. Review of the resident's Progress Notes, dated 5/29/25, showed the resident refused due to blood sugar frequently running low. Review of the resident's MAR, dated 5/30/25, showed the following: -Documentation of not administered due to blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 120. Review of the resident's MAR, dated 6/1/25, showed the following: -Documentation of not administered due to hold for blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 95. Review of the resident's MAR, dated 6/2/25, showed the following: -Documentation of not administered due to hold for blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 107. Review of the resident's MAR, dated 6/3/25, showed the following: -Documentation of not administered due to other see progress notes for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 113. Review of the resident's Progress Notes, dated 5/29/25, showed the resident refused due to blood sugar frequently running low. Review of the resident's MAR, dated 6/4/25, showed the following: -Documentation of not administered due to hold for blood sugar outside of parameters for Lantus Solostar subcutaneous solution pen-injector 100 unit/ml, inject 10 units subcutaneously in the morning related to type two diabetes; -Blood sugar at 6:30 A.M. was 93. During an interview on 6/11/25 at 11:04 A.M. the resident said he/she had never declined his/her insulin. During an interview on 06/18/25, at 3:00 P.M., Licensed Practical Nurse (LPN) A said the following: -Sometimes the resident would refuse if his/her blood sugar was 120 or lower; -If it was documented as refused, the resident refused; -He/She did not notify the physician if the resident refused; -Sometimes he/she would hold based on nursing judgement and he/she did not notify the physician first. 5. During an interview on 06/18/25, at 3:00 P.M., Licensed Practical Nurse (LPN) A said the following: -The nurses were holding insulin if they thought a resident's blood glucose was too low; -Insulin is expected to be administered according to sliding scale orders or the nurse needs to call the physician; -The nurses were not calling the physicians. During an interview on 06/12/25, at 7:30 P.M., the Director of Nursing said the following: -Staff are expected to follow physician orders; -Sliding scale insulin should be given as ordered; -It is not an accepted practice to document hold per nursing judgement unless the nurse contacts the physician for further instructions; -Insulin should be administered unless there were physician ordered parameters to hold the insulin, or the physician has been called and orders received; -If a medication was unavailable or could not be administered the nurse should notify the physician and document direction given by the physician. During an interview on 06/19/25, at 9:47 A.M., the resident's physician said the following: -He expects nurses to follow the orders given for sliding scale insulin; -Staff should not make a judgement call to hold insulin without contacting the physician; -The physician has to be involved, if not it was for the physician to understand what was going on with a resident's blood glucose. -If nurses held long acting insulin then a resident's blood sugars would not longer be controlled; -IV antibiotics should be administered as ordered with documentation that it was completed, or the nurse should notify the physician.

Based on interview and record review, the facility failed to provide pneumococcal vaccinations (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for four residents (Residents #15, #5, #229 and #4), of five residents reviewed for immunization status. Resident #15 developed symptoms of lethargy (a state of sleepiness or unresponsiveness) and decreased oxygen saturation (the measurement of oxygen circulating in the blood), resulting in a trip to the emergency room and a diagnosis of pneumonia, the resident was not up to date with pneumonia vaccines according to CDC guidelines. The facility census was 25. Review of the facility's policy Pneumococcal Immunizations, revised 05/14/2024, showed the following: -The purpose of this policy is to ensure that all residents residing in the facility are offered pneumococcal immunizations to prevent infection and the spread of communicable diseases. -As part of the admission process, the resident and/or the resident's legal representative will be provided education on the benefits and potential side effects of pneumococcal immunization. -The resident or their legal representative will be informed that the pneumococcal immunization will be offered upon admission per CDC guidelines; -The pneumococcal immunization will not be given if the immunization is medically contraindicated, the facility has evidence to support the resident received the immunization, or the resident or their legal representative has refused the immunization; -All CDC recommendations for pneumococcal immunization will be followed; -The resident or their legal representative will be required to sign the revolving consent form attached to this policy. The resident or their legal representative will be told this form provides consent for the pneumococcal immunization as needed unless those immunizations are medically contraindicated; -The resident or their legal representative will be informed they can revoke the revolving consent form at any time but such revocation must be in writing; -The resident or their legal representative will be provided education on the benefits and potential side effects of the immunizations; -On admission and yearly, the resident or their legal representative will sign a form showing the resident or their legal representative has been educated on and is aware of the benefits and potential side effects of receiving the immunizations; -Pneumococcal immunization will be offered upon admission and a second pneumococcal immunization may be recommended after five years from the first immunization. Pneumococcal immunization will be given unless the immunization is medically contraindicated, the facility has evidence the resident has already been immunized during this time period, or the resident or their legal representative refuse the immunization. Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following: -For adults 50 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. If the PPSV23 is not available, the PCV20 or PCV21 may be used; -If PCV20 or PCV21 is administered, regardless of which vaccine is used, their pneumococcal vaccinations are complete; -For adults 50 years or older who received the PPSV23 only at any age, administer the PCV15, PCV20 or the PCV 21 at least one year after the PPSV23 was administered; -For adults 50 years or older who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered; -For adults 50 years or older who received the PCV13 at any age and the PPSV23 when less than [AGE] years of age, administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose; -For adults 65 years or older who received the PCV13 at any age and the PPSV23 at 65 years or older, the individual and their vaccination provider may choose to administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose. (Refer to the CDC's Shared Clinical Decision-Making PCV20 or PVC21 Vaccination for Adults 65 Years or Older for additional information on clinical decision making.) 1. Review of Resident #15's face sheet showed the resident has a guardian, the resident admitted to the facility 12/13/21. Review of the resident's Immunization Record, showed pneumococcal polysaccharide (PPSV23) administered on 11/20/1998. Review of the resident's Nurses Note, dated 02/24/25 at 1:35 P.M., showed the resident was lethargic, responds to painful stimuli for only a second then goes back to sleep or says he/she was fine. The resident is breathing with accessory muscles, and not responding to commands when asked to grip hands or open eyes. Oxygen saturation 85 percent (%) on room air 93% on oxygen at 3 liters/minute via nasal cannula. Notified the physician and received order to send resident to the emergency room for evaluation and treatment. Review of the resident's Nurses Note, dated 02/24/25 at 2:04 P.M., showed the resident transferred to the emergency room via emergency medical services (EMS). Review of the resident's Nurses Note, dated 02/24/25 at 5:09 P.M., showed the resident returned from the emergency room with a diagnosis of pneumonia and orders for levaquin (antibiotic) for ten days. Review of the resident's admission Contract, dated 4/28/25, showed Pneumococcal Immunization, I agree to receive the pneumococcal immunization on a recurring basis and have been educated on the benefits and potential side effects of the immunization. I understand this provides authorization for an initial pneumococcal immunization and for a follow-up immunization when required unless and until I revoke this authorization in writing, the document contained the resident's guardian's signature. Review of the resident's Physician's Order Sheet (POS), dated May 2025, showed an order for azithromycin (antibiotic) 250 milligrams (mg) administer two tablets by mouth one time then administer one tablet by mouth at bedtime for cough for four days. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/12/25, showed the following: -Severe cognitive impairment; -Diagnosis of pneumonia; -Antibiotics were received; -Pneumococcal vaccination was not up do date, it was not offered. Review of the resident's medical record showed no documentation of any other pneumococcal vaccinations other than the PPSV23 administered on 11/20/1998. Review of the CDC recommendations showed the resident should receive one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23. 2. Review of Resident #5's immunization records showed the resident received a pneumovax vaccine on 07/18/14 with no indication of what type he/she received. Review of the resident's undated face sheet showed the following: -He/She was greater than [AGE] years of age; -He/She admitted on [DATE] and re-admitted on [DATE]; -The resident was his/her own responsible party for decision making. Review of the resident's hospital Discharge summary, dated [DATE], showed the resident went to the hospital on [DATE] with a diagnosis of chronic respiratory failure due to Coronavirus (COVID)-pneumonia (severe form of pneumonia that can develop in some individuals with COVID-19 (an infectious respiratory illness caused by the SARS-CoV-2 virus). Review of the resident's admission packet, dated 04/16/25, showed the resident signed a consent form to receive the pneumococcal immunization. During an interview on 06/09/25 at 2:38 P.M., the resident said the following; -He/She has been in the hospital three time in the past few months, once for COVID and two times for respiratory issues; -He/She signed a paper for a pneumonia shot but had not gotten it yet; -He/She would like to get the pneumonia immunization. Review of the resident's Physician Orders, dated 6/10/25, showed the resident used oxygen to keep oxygen saturation above 90% and used a Bilevel Positive Airway Pressure (BiPap) (a type of non-invasive ventilation used to help people with breathing difficulties) at night. 3. Review of Resident #229's face sheet showed the following: -He/She was greater than [AGE] years old; -He/She was his/her own responsible party; -admitted on [DATE]. Review of the resident's admission Packet, dated 5/29/25, showed the resident signed a consent form to receive the pneumococcal immunization. Review of the resident's medical record showed no documentation of any pneumococcal vaccinations. During an interview on 6/10/25 at 8:25 A.M. the resident said he/she would like to receive the pneumonia immunization to stay up to date and protect him/herself. 4. Review of Resident #4's face sheet showed the following: -He/She was greater than [AGE] years old; -He/She was his/her own responsible party; -admitted on [DATE]. Review of the resident's medical record showed the resident was offered and refused the PPV23 on 2/17/23 and no education was provided. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal not up to date, offered and declined. Review of the resident's admission Packet, signed 5/2/25, showed the resident signed a consent form to receive the pneumococcal immunization. Review of the resident's medical record showed no documentation staff offered or provided the pneumococcal vaccination. 5. During an interview on 06/11/25, at 01:30 P.M., the Assistant Director of Nursing said the following: -Immunization history was obtained on admission and immunizations are entered in the Immunization tab of the electronic medical record; -Consents are signed for immunizations on admission; -The facility recently revised the admission packet and the new contracts were signed in April 2025 and May 2025; -Pneumococcal vaccinations are expected to be offered according to the CDC recommendations; -If the resident or resident representatives sign the consent, then staff are expected to administer the vaccinations to the resident; -She was not responsible to ensure immunizations are completed according to the CDC recommendations. During an interview on 06/12/25, at 7:30 P.M., the Director of Nursing (DON) said she expected pneumococcal immunizations to be offered and administered according to the resident or resident representative consents and according to the CDC schedule. The DON and Infection Preventionist were responsible for monitoring and ensuring residents were up to date with immunizations.

Based on interview and record review, the facility failed to ensure staff training needs as identified in the facility assessment and the facility staff development plan were met. The facility also failed to ensure 12 hours of training were completed per calendar year to include dementia management and resident abuse prevention training per year for five certified nursing assistants (CNA)'s (CNA H, CNA F, CNA I, CNA J and CNA D), in a sample of five CNA's who have been employed over a year. The facility census was 25. Review of the facility's policy, Nursing Aide Training Program Policy, revised 05/18/24, showed the following: -This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides; -The facility, with oversight from the Director of Nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education; -Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year; -The facility shall maintain documentation of training during the current training year, and shall forward to the Human Resources (HR) Director at the completion of the training year to be maintained in the employee's personnel file; -It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review; -Information from the facility assessment will be utilized in forming a baseline educational calendar; -In-service training will be provided by qualified personnel and will be based on the special needs of the residents in the facility. Minimum training will include: a. Effective communication; b. Dementia management and care of the cognitively impaired; c. Abuse, neglect, and exploitation prevention; d. Elements and goals of the facility's QAPI program; e. Resident rights and facility responsibilities; f. Written standards, policies, and procedures for the facility's infection prevention and control program; g. Requirements under the facility's compliance and ethics program; h. Safety and emergency procedures; i. Behavioral health (e.g., mental, psychosocial, or substance use disorders, a history of trauma and or post-traumatic stress disorder, or other behavioral health conditions); j. Identification of changes in condition; k. Cultural competency; -A variety of methods may be used to provide training, and to evaluate learning; -Content of training shall be current and reflect professional standards and guidelines. Content shall be reviewed on a regular basis, and updated as needed. 1. Review of the undated Facility Assessment showed the following: -The facility has identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations and technical/hands-on skills; -Refer to Staff Development Training Plan; -Staff are trained on policies and procedures, consistent with their roles; -The facility evaluates policies and procedures that are required in the provision of care on a routine basis through our Quality Improvement Performance Improvement (QAPI) process; -This includes determining if new or updated policies are needed, and ensuring they are developed or updated. 2. Review of the undated Facility Staff Development plan showed the following: -January: dementia management, training on how to care for residents with cognitive impairments, including techniques for managing challenging behaviors and communication strategies; -February: resident abuse prevention, education on identifying, preventing, and reporting abuse. This includes understanding the signs of abuse and the appropriate steps to take if abuse is suspected; -March: areas of weakness, training should address individual areas of weakness identified in nurse aides' performance reviews. This ensures that nurse aides improve in areas where they may be lacking; -April: special needs of residents, training tailored to the unique needs of the facility's resident populations, as determined by the facility assessment and staff; -May: communication skills, effective communication techniques for interacting with residents, families, and other healthcare team members; -June: resident rights and facility responsibilities, education on the rights of residents and the responsibilities of the facility to uphold these rights; -July: QAPI, training on the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program, including how nurse aides can contribute to quality improvement; -August: infection control, training on infection prevention and control standards, policies, and procedures to minimize the risk of infections; -September: compliance and ethics, education on the facility's compliance and ethics program, including understanding ethical practices and regulatory compliance; -October: safety procedures, training on safety procedures, including emergency protocols and proper use of equipment; -November: personal care skills, training on personal care skills such as bathing, dressing, grooming, and assisting with activities of daily living; -December: nutrition and hydration, education on proper nutrition and hydration practices to ensure residents' dietary needs are met; -Other: facility will conduct additional/necessary training's or competencies if needed; -The goals of the facility staff development plan are: enhanced staff competencies, ensure quality care, promote resident safety and rights, improve communication, support continuous improvement, compliance and ethics and personal care and well-being. Overall, the plan aims to create a well-rounded, knowledgeable, and competent staff that can provide exceptional care and support to residents; -The facility staff development plan should be reviewed and updated annually to ensure it remains relevant and effective; -By regularly reviewing and updating the plan, the facility can ensure that staff development remains aligned with the latest best practices and the evolving needs of the residents. 3. Review of the facility's in-service records provided for the period of 06/27/24 through 05/08/25 showed the following education took place: -On 06/27/24: High fall risk/substance abuse and neglect/abuse training, (did not include agenda or time of education); -On 07/25/24: QAPI and Enhanced Barrier Precautions training, (did not include agenda or time of education); -On 08/28/24: Resident rights to primary care provider and pharmacies/UDA's/Hoyer (a mechanical lift for dependent residents) slings/fire safety and handbook updates training, (did not include agenda or time of education); -On 10/18/24: Communication with dementia including behaviors training, (did not include agenda or time of education); -On 01/02/25: Controlled substances and abuse/neglect/exploitation training, (did not include agenda or time of education); -On 02/27/25: Bed bugs/safety and moving equipment/sexual harassment training, (did not include agenda or time of education); -On 03/27/25: Peri-care and hand hygiene training, (did not include agenda or time of education); -On 05/08/25: Evacuation of residents' bed bound during emergencies/hand washing/dignity/aspiration risk and emergency response procedures for fire/tornado/active shooter training, (did not include agenda or time of education); -The time frame reviewed did not include, per the facility Nurse Aide Training Program Policy, the following required in-services: a. effective communication, e. resident rights and facility responsibilities, f. written standards, policies, and procedures for the facility's infection prevention and control program, g. requirements under the facility's compliance and ethics program, i. behavioral health (e.g., mental, psychosocial, or substance use disorders, a history of trauma and or post-traumatic stress disorder, or other behavioral health conditions), j. identification of changes in condition and k. cultural competency. 4. Review of the employee file for CNA H showed his/her hire date as 08/04/23. Review of the facility in-service records, dated 06/27/24 - 05/08/25, showed the following: -CNA H attended the 03/27/25 staff meeting that included neglect/abuse training; -CNA H attended the 05/08/25 staff meeting that included safety procedures and infection control training; -None of the staff meetings documented the hours of training for each meeting. Review of in-service records and employee/education file showed no documentation CNA H attended 12 hours of required training per year. CNA H did not attend training for the following topics: dementia management, resident abuse prevention, areas of weakness, special needs of residents, communication skills, resident rights and facility responsibilities, QAPI, infection control, compliance and ethics, personal care skills and nutrition and hydration as directed by the facility staff development plan. 5. Review of the employee file for CNA F showed his/her hire date as 03/01/24. Review of the facility in-service records, dated 06/27/24 - 05/08/25, showed the following: -CNA F attended the 06/27/24 staff meeting that included neglect/abuse policy training; -CNA F attended the 08/28/24 staff meeting that included resident rights and fire safety training; -CNA F attended the 01/02/25 staff meeting that included abuse/neglect/exploitation training; -CNA F attended the 03/27/25 staff meeting that included infection control and personal care skills training; -CNA F attended the 05/08/25 staff meeting that included safety procedures/resident rights and special needs of residents training; -The in-service records for the staff meetings did not include the number of hours the training entailed. Review of in-service records and employee/education file showed no documentation CNA H attended 12 hours of required training per year. CNA H did not attend training for the following topics: dementia management, areas of weakness, special needs of residents, communication skills, resident rights and facility responsibilities, infection control, compliance and ethics, personal care skills and nutrition and hydration as directed by the facility staff development plan. 6. Review of the employee file for CNA I showed his/her hire date as 11/12/21. Review of the facility in-service records, dated 06/27/24 - 05/08/25, showed the following: -CNA I attended the 06/27/24 staff meeting that included neglect/abuse policy training; -CNA I attended the 10/18/24 staff meeting that included dementia management training; -CNA I attended the 02/27/25 staff meeting that included resident abuse prevention and safety procedure training; -CNA I attended the 03/27/25 staff meeting that included infection control and personal care skills training; -CNA I attended the 05/08/25 staff meeting that included safety procedures/resident rights and special needs of residents training; -The in-service records for the staff meetings did not include the number of hours the training entailed. Review of in-service records and employee/education file showed no documentation CNA H attended 12 hours of required training per year. CNA H did not attend training for the following topics: dementia management, areas of weakness, special needs of residents, communication skills, resident rights and facility responsibilities, infection control, compliance and ethics, personal care skills and nutrition and hydration as directed by the facility staff development plan. 7. Review of the employee file for CNA J showed his/her hired date as 03/01/24. Review of the facility in-service records, dated 06/27/24 - 05/08/25, showed the following: -CNA J attended the 06/27/24 staff meeting that included neglect/abuse policy training; -CNA J attended the 08/28/24 staff meeting that included resident rights and fire safety training; -CNA J attended the 10/18/24 staff meeting that included dementia management training; -CNA J attended the 01/02/25 staff meeting that included abuse/neglect/exploitation training; -CNA J attended the 02/27/25 staff meeting that included resident abuse prevention and safety procedure training; -CNA J attended the 03/27/25 staff meeting that included infection control and personal care skills training; -CNA J attended the 05/08/25 staff meeting that included safety procedures/resident rights and special needs of residents training; -The in-service records for the staff meetings did not include the number of hours the training entailed. Review of in-service records and employee/education file showed no documentation CNA H attended 12 hours of required training per year. CNA H did not attend training for the following topics: dementia management, areas of weakness, special needs of residents, communication skills, resident rights and facility responsibilities, infection control, compliance and ethics, personal care skills and nutrition and hydration as directed by the facility staff development plan. 8. Review of the employee file for CNA D showed his/her hired date as 05/20/24. Review of the facility in-service records, dated 06/27/24 - 05/08/25, showed the following: -CNA D attended the 06/27/24 staff meeting that included neglect/abuse policy training; -CNA D attended the 07/25/24 staff meeting that included QAPI and EBP/infection control training; -CNA D attended the 08/28/24 staff meeting that included resident rights and fire safety training; -The in-service records for the staff meetings did not include the number of hours the training entailed. Review of in-service records and employee/education file showed no documentation CNA H attended 12 hours of required training per year. CNA H did not attend training for the following topics: dementia management, areas of weakness, special needs of residents, communication skills, resident rights and facility responsibilities, infection control, compliance and ethics, personal care skills and nutrition and hydration as directed by the facility staff development plan. During an interview on 06/12/25 at 5:10 P.M. and 7:30 P.M., the Assistant Director of Nursing (ADON) said the following: -She does education with the nursing staff; -The staffing shortage and lack of Director of Nursing (DON) has been a challenge to complete the required 12 hours of CNA training; - To her knowledge, no one has been tracking the CNA education for the 12 hours of required education and is unsure if the requirements have been met or not.

Based on interview and record review, the facility failed to maintain a system to ensure four discharged residents' (Residents #101, #102, #103 and #28) personal funds were not maintained in the facility's operating account when the facility did not reimburse the residents and/or their responsible parties after the residents were discharged from the facility. The facility census was 25. Review of the facility policy, Resident Trust, revised 06/12/25, showed the following: -Upon admission, an Authorization to Hold Resident's Funds form (Attachment M in the admission Contract) must be presented to the resident, guardian, or legal representative and must be signed by them if they choose to have the facility manage the resident funds; -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete and separate accounting principles, which precludes any commingling of resident funds with facility funds; -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance and personal possessions; -The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge. The Resident Trust Clerk shall provide a complete accounting record of the funds along with the check. 1. Review of Resident #101's face sheet showed he/she discharged from the facility on 04/27/25. Review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 06/09/25, showed the resident maintained a balance of $741.60 in the facility operating funds account. 2. Review of Resident #102's face sheet showed he/she discharged from the facility on 03/05/25. Review of the facility maintained A/R Aging Report, dated 06/09/25, showed the resident maintained a balance of $349.22 in the facility operating funds account. 3. Review of Resident #103's face sheet showed he/she discharged from the facility on 02/03/25. Review of the facility maintained A/R Aging Report, dated 06/09/25, showed the resident maintained a balance of $144.00 in the facility operating funds account. 4. Review of Resident #28's face sheet showed he/she discharged from the facility on 05/01/25. Review of the facility maintained A/R Aging Report, dated 06/09/25, showed the resident maintained a balance of $51.00 in the facility operating funds account. 5. During an interview on 06/12/25 at 9:19 A.M. and 3:50 P.M., the Business Office Manager (BOM) said the following: -She was responsible for reviewing the A/R Aging Report; -She reviews the report to see if any residents are owed a refund; -The regional office is responsible for releasing those funds back to the resident or their representative/family; -She knew there was a certain amount of time to issue a refund, but she was not sure what the timeframe was; -Resident #101's refund was requested on 06/09/25, but had not yet been issued. During an interview on 06/12/25 at 7:30 P.M., the Administrator said he would expect for the resident funds to be kept separately from the facility operating funds and that refunds would be issued per the facility policy.

Based on observation, interview and record review, the facility failed to update and revise problems and interventions on resident care plans to reflect current care needs for three residents,(Resident #4, #14 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; -The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of the facility policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed the following: - The MDS 3.0 with the Care Area Assessment Summaries is a much more user friendly assessment tool that addresses the holistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident; -The Plan of Care should then address these factors: A. Improvement where possible; B. Maintenance and prevention of avoidable declines and all Care Area Triggers; -There are twenty areas that can become triggered areas for concern and must be addressed with individualized interventions on the plan of care for the resident. 1. Review of Resident #4's face sheet showed the following: -The resident was his/her own responsible party; -Diagnoses of chronic obstructive pulmonary disease (COPD) (lung disorder), type two diabetes, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), unspecified dementia, delusional disorders, retinopathy (eye disorder), generalized osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of the bones wear down), major depressive disorder, and dizziness and giddiness (feeling dizzy or about to pass out). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Set-up assistance for eating; -Supervision for shower/bathing; -Independent for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, able to walk 50 feet with two turns and to walk 150 feet. Review of the resident's care plan, revised on 02/04/25, showed the following: -Performance bed mobility: independent; -Performance dressing: independent; -Performance eating: independent; -Performance locomotion off unit: independent; -Performance locomotion on unit: independent; -Performance personal hygiene: independent; -Performance toilet use: independent; -Performance transfer: independent; -Performance walk in corridor: independent; -Performance walk in room: independent. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Supervision for eating (decrease in ability to perform independently); -Supervision for oral hygiene (decrease in ability to perform independently); -Supervision for toileting hygiene (decrease in ability to perform independently -Supervision for upper body dressing (decrease in ability to perform independently -Supervision for lower body dressing (decrease in ability to perform independently); -Supervision for putting on/taking off footwear (decrease in ability to perform independently); -Supervision for personal hygiene (decrease in ability to perform independently); -Supervision to walk 50 feet with two turns (decrease in ability to perform independently); -Supervision to walk 150 feet (decrease in ability to perform independently). Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate assistance for shower/bathing (decrease in ability to perform independently); -Supervision for rolling left and right in bed (decrease in ability to perform independently); -Supervision for sitting on side of bed to lying flat on the bed (decrease in ability to perform independently); -Supervision for lying flat on the bed to sitting on the side of the bed (decrease in ability to perform independently); -Supervision for sitting to standing (decrease in ability to perform independently); -Supervision for chair/bed-to-chair transfers (decrease in ability to perform independently); -Supervision for toilet transfers (decrease in ability to perform independently); -Supervision to walk 10 feet (decrease in ability to perform independently). Review of the resident's care plan showed revisions made on 05/16/25 and 06/05/25, but no revisions made to activities of daily living (ADL's). 2. Review of Resident #14's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/17/24, showed the following: -Moderate cognitive impairment; -Diagnosis: stroke with hemiplegia (weakness or paralysis to one side of the body), end stage renal disease, and traumatic brain injury; -Independent with toileting hygiene, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, wheel 50 feet, and wheel 150 feet; -Set up or clean up assistance from staff for eating, and oral hygiene ; -Requires partial/moderate assistance from staff for shower/bathe, upper body dressing, lower body dressing, and putting on/taking off footwear; -Occasionally incontinent of bladder, and continent of bowel. Review of the resident's care plan, last revised 02/04/25, showed the following: -Current functional performance: -Resident's functional status will progress towards personal discharge goal during stay; -Resident is independent for locomotion, personal hygiene, and transfers; Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was not independent with any activities of daily living (ADL's); -Requires supervision/touching assistance from staff members for eating, oral hygiene, personal hygiene, roll left and right, and chair/bed-to-chair transfer, -Requires partial/moderate assistance from staff for toileting hygiene, sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, wheel 50 feet -Dependent on staff for wheeling 150 feet; -Frequently incontinent of bladder and bowel. Review of the resident's care plan showed the plan was not updated after the resident had changes to his/her need for assistance with declining ADL's and worsened incontinence. 3. Review of Resident #15's Care Plan, last updated 02/04/25, showed the following: -Resident's functional status will progress towards personal discharge goal; -Independent with locomotion -Resident requires set up/supervision for eating -Resident requires limited assist of one staff member for bed mobility -Resident requires extensive assist of one staff member for dressing, personal hygiene, toilet use, transfers. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/12/25, showed the following: -Severe cognitive impairment; -Diagnoses included peumonia, arthritis, Alzheimer's disease, dementia, seizure disorder, anxiety disorder, and hallucinations; -Inattention and disorganized thinking, fluctuates; -Delusions; -Requires supervision/touching assistance from staff members for oral hygiene, roll left and right, sit to lying, and lying to sitting on side of bed; -Dependent on staff for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, chair/bed-to-chair transfer, tub/shower transfer, able to wheel 50 feet, and wheel 150 feet. Review of the resident's care plan showed it was not updated after the resident had a decline in ADL's and was dependent for toilet hygiene, shower/bathe, dressing, personal hygiene, transfer and locomotion. 4. During an interview on 06/12/25, at 7:30 P.M., the Assistant Director of Nursing said the following: -Nursing administration, charge nurses, and the department heads for dietary, activities and social services complete and update the residents' care plans; -When there are changes in the resident's condition or needs, the care plan should be updated immediately. During an interview on 06/12/25, at 7:30 P.M., the Director of Nursing said care plans should be completed and updated according to direction in the RAI manual, be person centered and include all care areas. During an interview on 06/18/25 at 3:09 P.M., the Regional MDS Coordinator said the following: -She started doing MDS's at the facility at end April beginning of May 2025; -The facility has had a couple different MDS coordinators and now she was doing the MDS's for four facilities; -Facility staff are expected to follow the RAI manual for completion of the care plans; -Facility staff are expected to complete the comprehensive care plan and should customize the care plan for each resident.

Based on interview and record review, the facility failed to complete required employee background screenings including criminal background checks (CBC) and employee disqualification list (EDL) checks, prior to employment for four of ten newly hired employees (Housekeeper P, Certified Medication Technician F, Assistant Director of Nurses, and Certified Nurse Aide J -hired since the last survey). The facility also failed to check the Nurse Aide Registry for the Administrator as directed in the facility policy. The facility census was 25. Review of the facility's policy Background Investigations, last revised 12/27/24, showed the following: -Criminal conviction record checks are conducted on all personnel making application for employment with this company; -The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied. -For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing. -If the background investigation(s) disclose any material misrepresentation or omissions by the applicant or employee on the application form or reveal information indicating that the individual may not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or, if already employed, will be terminated. -The facility will not employ individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. b. Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. c. Have a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation or resident property. Review of the facility policy Screening - Applicant, Employee, Volunteer and Vendor (Missouri), dated 05/14/24, showed the following: -Human Resources department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied. -HR staff will conduct screens on potential employees prior to hire including criminal history. Using the Request for Criminal Records Check, a criminal background check should be done through the Missouri Highway Patrol's Missouri Automated Criminal History Site (https://www.machs.mshp.dps.mo.gov/ MocchWeblnterface/home.html). A copy of the results must be printed with the original initiated. And dated by the person who conduct d the check. If a check is made through the Family Care Safety Registry showing that the applicant is registered and a no finding letter is received and printed, that will satisfy the Missouri Criminal background check requirement and no check needs to be done with the Missouri Highway Patrol. -If the applicant has not resided in the State of Missouri for five consecutive years prior to the date of his/her application for employment or has no employment history with a licensed Missouri facility during that five year period, then a nationwide (FBI) criminal history check must be performed. This nationwide criminal history check can be made under the Missouri Highway Patrol's Missouri Volunteer and Employee Criminal History Service (VECHS) program (http://www.mshp.dps.missouri.gov/ MSHPWeb/PatrolDivisions/CRID/MoVECHSProgram.html). -No applicant may be hired if they have been convicted of, pled guilty or nolo contendere to a crime which under Missouri law would be a felony in violation of the following Missouri codes listed in this policy (list in the policy is not pertinent to findings so is not included). -If the individual has obtained a written exception from the Exceptions Committee of the Missouri Department of Mental Health or a Good Cause Waiver from the Department of Health and Senior Services, the Executive Director of Human Resources must be consulted and approve the hire. -Family Care Safety Registry - Log in to the Missouri Department of Health and Senior Services website, Family Care Safety Registry (FCSF) section. This screening will check the sex offender, employee disqualification list, and other Missouri databases automatically. The company should ensure that the applicant submits the paperwork and the fee to the FCSR. Registration and background check must be completed within fifteen days of the first date of employment. -Employee Disqualification List - The Missouri Employee Disqualification List (EDL) must be checked for every applicant. If a record is found, the applicant is on the EDL and may not be hired. If no record is found, the applicant may be hired. The results must be printed with the original initialed and dated by the person who conducted the check. -CNA Registry - The CNA Registry must be checked for all applicants regardless of the position for which they are applying. Any applicants listed with background problems or a federal indicator may not be hired for any position. -The results of each background check must be printed with the original initiated and dated by the person who conducted the check. This original must be maintained in the applicant's Background File. 1. Review of Housekeeper P's employee file showed the following: -Date of hire 06/14/24 ; -The employee file did not contain a FCSR letter; -No documentation of a CBC check prior to hire, or after hire; -No documentation of an EDL check prior to hire. 2. Review of Certified Medication Technician (CMT) F 's employee file showed the following: -Date of hire 3/14/24; -FCSR letter date 01/09/25 (after hire, requested on 01/08/25); -No documentation of a CBC check prior to hire; -No documentation of an EDL check prior to hire. 3. Review of Assistant Director of Nursing's employee file showed the following: -Date of hire 03/01/24; -FCSR letter date 01/08/25 (after hire, requested on 01/08/25); -No documentation of a CBC check prior to hire; -No documentation of an EDL check prior to hire. 4. Review of Certified Nurse Assistant (CNA) J's employee file showed the following: -Date of hire 3/01/24; -FCSR letter date 01/09/25 (after hire, requested on 01/09/25); -No documentation of a CBC check prior to hire; -No documentation of an EDL check prior to hire. 5. Review of the Administrator's employee file showed the following: -Date of hire 04/28/25; -No documentation of a Nurse Aide Registry check. 6. During an interview on 06/10/25, at 04:55 P.M., the Human Resources (HR)/Business Office Manager (BOM)said the following: -The facility was purchased by the current owners in January 2025, and did not have access to full employee files that were electronically kept but have some information that was printed; -Many of the employee files are not complete; -She was responsible for Nurse Aide registry check, FCSR letter, EDL check, Missouri criminal background check if the employee is not registered with FCSR prior to their hire date, it is part of onboarding; -She has not completed a full audit. During an interview on 06/11/25, at 10:30 A.M., the Administrator said HR/BOM was responsible to complete the FCSR, CBC, NA registry, and EDL checks prior to the start date for new employees. The facility had changed owners and HR directors. The employee files were not fully complete and had been no full audit of the files. Some of the hire dates were not correct.

Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan for four residents (Resident #5, #11, #23 and #4), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives; -Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization; -The care planning process will include an assessment of the resident's strengths and needs in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will describe, at a minimum, the following: A. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; B. Any services that would otherwise be furnished, but are not provided due to the residents exercise of his or her right to refuse treatment; C. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations; D. The resident's goals for admission, desired outcomes, and preferences for future discharge; E. Discharge plans, as appropriate; F. Resident specific interventions that reflect the resident's needs and preferences; G. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident; -The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: A. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan; B. A registered nurse with responsibility for the resident; C. A nurse aide with responsibility for the resident; D. A member of the food and nutrition services staff; E. The resident and the resident's representative, to the extent practicable; F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: The RAI Coordinator, Activities Director/Staff, Social Services Director/Social Worker, Licensed therapists, Family members, surrogate, or others desired by the resident, Administration, Discharge Coordinator, Mental health professional, and Chaplain; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of the facility policy, Trauma Informed Care, revised 05/14/24, showed the following: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization; -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 1. Review of Resident #5's face sheet showed the following: -Diagnoses included chronic obstructive pulmonary disease/COPD (a group of lung diseases that block airflow and make it difficult to breathe), chronic osteomyelitis (a long-term bone infection), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and epilepsy (also called seizure disorder, a disorder in which nerve cell activity in the brain is disturbed). Review of the resident's April 2025 Physician's Order Sheet (POS) showed the following: -May use grab bars as needed for mobility/positioning, upon assessment, education and consent with an order start date of 04/29/25; -Oxygen at two liters per nasal cannula (prongs that go into the nares to deliver oxygen) to maintain oxygen saturations (the amount of oxygen in the blood) above 90 percent (%) for COPD with an order start date of 04/22/25. Review of the resident's care plan, revised on 05/02/25, showed no documentation to address activities of daily living (ADL), identify the use of bed rails, or identify oxygen use. Review of the resident's quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/20/25, showed the following: -Cognitively intact; -Substantial/maximum staff assistance for oral hygiene; -Dependent on staff for toileting hygiene, personal hygiene, bathing, tub/shower transfer, toilet transfer, upper and lower body dressing, putting on/taking off footwear, rolling left and right, lying to sitting on side of the bed, sit to stand transfer, chair/bed-to-chair transfer and wheelchair mobility 50 and 150 feet; -Indwelling urinary catheter (a tube inserted into the bladder for urine drainage); -Always incontinent of bowel; -Oxygen not indicated as used. Observation on 06/09/25 at 2:38 P.M., showed the resident lay in bed awake with bilateral 1/8th side rails in the raised position and oxygen running at two liters (L)/NC. Observation on 06/10/25 at 6:41 A.M., showed the resident lay in bed awake with bilateral 1/8th side rails in the raised position and oxygen running at two L/NC. Observation on 06/10/25 at 11:35 A.M., showed the resident sitting up in her wheelchair with oxygen running at two L/NC. Observation on 06/12/25 at 7:56 A.M., showed the resident lay in bed awake with bilateral 1/8th side rails in the raised position and oxygen running at two L/NC. 2. Review of Resident #11's face sheet showed the following: -He/She had a responsible party/Power of Attorney (POA); -Diagnoses of dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, major depressive disorder, generalized anxiety disorder, other specified depressive episodes, adult failure to thrive and muscle weakness. Review of the resident's Physician Order Sheet, dated 04/04/25, showed an order to admit to hospice. Review of the resident's care plan, revised on 05/16/25, showed no documentation to address the resident was on hospice. During an interview on 06/10/25 at 8:57 A.M., the resident's responsible party/POA said the resident was put on hospice about two months ago due to refusing to eat. 3. Review of Resident #23's face sheet showed the following: -He/She was his/her own responsible party; -Diagnoses of alcohol abuse, schizoaffective disorder (mental illness), depression, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and primary insomnia. Review of the resident's Pre-admission Screening/Resident Review (PASARR) Level II, dated 1/29/25, showed the following: -He/She had serious mental illness; -His/Her needs can be met in a nursing facility; -Supports and services to be provided by the facility include: -Behavioral Support Plan; -Structured Environment; -Crisis Intervention Services; -Medication Therapy; -Activities of Daily Living (ADL) Program; -Personal Support Network; -Diagnoses of major depressive disorder, schizoaffective disorder, depressive type, PTSD, adjustment disorder with mixed anxiety and depressed mood, alcohol dependence, and polysubstance abuse; -Per psychiatric evaluation on 07/15/24, the resident had a history of special education and attention deficit hyperactivity disorder (ADHD) in childhood; -Resident had increased auditory hallucinations in December 2024; -Resident was being seen by counseling services on an outpatient basis; -Resident had PTSD related to witnessing his/her parent's murder; -Resident had recent symptoms of suicidal ideations (thoughts of harming or killing ones self), anhedonia (the inability to feel pleasure), depression, command auditory hallucinations (hearing voices that give specific instructions), delusions (a type of mental health condition in which a person can't tell what's real from what's imagined), restlessness, paranoia (a way of thinking that involves feelings of distrust and suspicion of others), and excessive worry; -The resident did not have any family support; -The resident was chronically homeless prior to hospitalization in July 2024; -The resident continued to have auditory hallucinations at times. Review of the resident's care plan, revised 06/09/25, showed the following: -The resident uses psychotropic medications related to behavior management; -Monitor and record occurrence of behavior symptoms and document per facility protocol; -No documentation to address the resident's PTSD or PASARR status. During an interview on 06/11/25 at 11:04 A.M., the resident said the following: -He/She had a diagnosis of PTSD, along with depression, anxiety, and schizophrenia; -He/She did virtual counseling every Wednesday; -Triggers for his/her PTSD included large crowds and loud noises. 4. Review of Resident #4's face sheet showed the following: -He/She was his/her own responsible party; -Diagnoses of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disorder and anxiety, delusional disorders, major depressive disorder recurrent moderate, and acute stress reaction. Review of the resident's care plan, revised 06/05/25, showed the following: -Impaired social interaction, dementia; -Resident will embrace positive thinking statements; -Encourage resident to participate in recreational activities; -Encourage resident to participate in social situations. During an interview on 06/09/25 at 1:10 P.M., the resident said he/she did not like to participate in activities, but preferred to stay in his/her room. Review of the resident's care plan, revised on 06/05/25, showed no documentation to address the resident did not like to participate in activities, but preferred to stay in his/her room. 5. During an interview on 06/12/25 at 3:02 P.M., the SSD said she was not aware PTSD should be included on the care plan. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said all departments were responsible for their portions of the care plan. Social Services completes a portion, activities has a portion, and nursing has a portion. The care plan should be updated as soon as changes occur. During an interview on 06/12/25 at 7:30 P.M., the Director of Nursing (DON) said all comprehensive care plans should be person centered and include all pertinent care areas.

Based on observation, interview, and record review, the facility failed to ensure safety and adequate monitoring were provided to prevent falls and failed to consistently implement and modify interventions as necessary, in accordance with current standards, that resulted in falls for two of the 12 sampled residents (Residents #3 and #8). Resident #3 fell five times with multiple injuries between 10/2/13 and 1/15/14. Resident #8, who had a history of [REDACTED]. 1. Record review of the facility's Falls Prevention/Reduction Protocol, dated as revised on 12/4/12, showed the following: -Purpose: To assess all residents for being at risk for falls upon admission to the facility, quarterly, with any change in condition and after any incident or accident. If identified at risk for falls, the following protocol will be followed; -Protocol: Any resident admitted to the facility will automatically be flagged "at risk for falls" and "Falls Interventions" will be initiated by the admitting nurse; -Quarterly assessment of falls risk will be completed by the Care plan team as part of the MDS process; -When a resident falls,they are at risk for additional falls, therefore the "Falls Interventions" will be initiated at the time of the fall by the nurse in charge. The "Interventions" will be kept with the "Week at a glance" for at least seven days, so all shifts/staff will be aware of any new care issues; -Within 72 hours of a fall, a Post-Fall Evaluation, utilizing the Care Area Assessment "Review of Indicators of Fall Risk", will be conducted by the MDS Coordinator or designee. Based on the evaluation, the care plan will be updated within seven days; -All accidents/incidents will be reviewed by the Falls Committee on a weekly basis to identify possible causes and explore additional options, not already in place, to reduce accidents/injury; -The Falls Committee Meeting Minutes will be reviewed monthly at the Quality Assurance meeting to monitor the effectiveness and timeliness of care plan updates. 2. Record review of Resident #8's quarterly MDS, dated [DATE], showed the following: -Cognition moderately impaired; -Independent with bed mobility, transfer, walk in room and corridor, and locomotion on and off the unit; -Required extensive assist of one staff for toilet use and personal hygiene; -The resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, or surface-to-surface, but able to stabilize without staff assistance; -The resident had functional limitation in range of motion of lower extremity on one side; -The resident used a walker as assistive device; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -Had one fall with injury since last assessment (7/24/13); -Received antidepressant and diuretic during the look back period; -Received no restorative or therapy services during the look back period. Record review of the resident's care plan, dated 10/22/13, showed the following: -Ambulation: I am using a walker since I broke my foot, I do get short of air and may need frequent rest breaks. I position myself. I will be independent with my mobility through the next meeting; -Bowel and Bladder: I am needing more help with my hygiene related to urinary incontinence. Assist me as needed. I toilet myself and I am incontinent frequently. I do dribble sometimes and/or miss the toilet. Make sure you check the bathroom for urine and bowel movement spills and mop up immediately to prevent slips and falls. Also check the handicap bathroom as well, as I use it too; -Falls and Safety: I am at risk for falls. I sometimes stumble and I get short of air when walking. This is what I need you to do: Place call light in easy reach and answer promptly; keep bed in the lowest position; keep area clean and clutter free; make sure has appropriate footwear to prevent slips and falls; -On 6/20/13 was at the hospital for outpatient services, attempted to step onto the sidewalk and fell to the ground, face first. Abrasion to forehead, bridge of nose, chin and swelling of left ankle/foot, was taken to the emergency room for evaluation. He/she needs to be transported outside of the facility in a wheelchair. He/she is compulsive and is not observant of safety issues; -On 6/22/13 the resident was trying to transfer self from recliner to wheelchair, found sitting on the floor. No injury noted. Different wheelchair with elevated cushion given to the resident to use; -On 6/30/13 the resident was in the handicap bathroom, found sitting on the floor holding onto grab bar, stated "I just fell backwards." Wearing his/her walking boot on his/her left leg, need to encourage to request assist with toileting. Has had an increase of bowel and bladder incontinence; -On 8/23/13 the resident said, "I stood up too fast and my feet came out from under me and I fell ." Was found in the front foyer, he/she sustained a head laceration. No changes in plan of care; -Positioning: I position myself; -Transfers: I transfer myself; -Program information: Program name: Active Range of Motion Program; Start date: 10/10/13; End date: 11/21/13; Priority: High; Program test: Bilateral lower extremity exercises doing 15 reps times two sets using 3 pound ankle weights. Marching, squats, up on toes, kicking out to the side, and step ups on carpeted box; Frequency: None. Record review of the resident's nurse's notes, dated 12/12/13 untimed, showed the following: -While the resident was getting a shower the shower aide noticed some bruises on the resident's face and chest area, when questioned the resident what happened, he/she stated, "I fell around 2:00 A.M., getting out of bed to go to the bathroom, my feet got tangled." He/she denied reporting to the nurse because he/she was afraid he/she would be in trouble. The writer informed the resident not to feel afraid of being in trouble and make sure he/she let someone know and use his/her call light from now on. The resident said he/she would, denies any pain from the fall and has range of motion without pain. Record review of the resident's nurse's notes, dated 12/13/13 untimed, showed the resident could not tell time, spoke to the nurse that wrote the previous entry (12/12/13) to clarify what was said. Record review of the resident's nurse's notes, dated 12/13/13 at 9:00 A.M., showed the resident complained of left ankle pain, stated he/she twisted his/her ankle on 3-11 shift on 12/12/13. Left ankle is swollen, Resident using wheelchair to ambulate, physician notified, order received for an X-ray and then to go see the physician. Record review of the resident's nurse's notes, dated 12/13/13 at 10:00 A.M., showed an order received to wear a boot for two weeks to left lower leg/ankle. Boot applied at the physicians's office. May ambulate with walker and boot on. Resident X-ray showed a sprain. Record review of the resident's nurse's notes, dated 12/13/13 at 5:40 P.M., showed the resident in his/her wheelchair for comfort and safety. Boot in place to left ankle, denies pain at present. Record review of the resident's current medical record showed no indication staff changed or implemented new interventions to reduce the likelihood of another fall. Record review of the resident's nurse's notes, dated 12/14/13 at 2:00 A.M., showed the resident in recliner with feet elevated. Boot in place to left ankle. No complaints of pain at this time. Was assisted to the bathroom via wheelchair and returned to the recliner. Will continue to monitor. Record review of the resident's nurse's notes, dated 12/14/13 at 2:35 P.M., showed the boot to left foot, denies any complaints of pain or discomfort at this time. Sitting up in recliner with feet elevated. Record review of the resident's nurse's notes, dated 12/15/13 at 2:30 A.M., showed the following: -The resident complains of pain in the left leg that goes down to ankle area, given extra strength Tylenol (nonopioid analgesic) two tablets. The resident was in bed for awhile and then wanted to go to the recliner in the television area. The resident is resting comfortably at this time; -No documentation staff notified the physician of the pain in the left leg that radiated down to the ankle area. Record review of the resident's nurse's notes, dated 12/15/13 at 10:00 A.M., showed the boot on left foot, assist times two for transfers, tolerated well. Very unsteady gait. Record review of the resident's nurse's notes showed the next entry, dated 12/18/13 at 10:00 A.M., noted the resident's moon boot on left ankle and leg. Assisted with all ADL's, incontinent of urine and bowel at times. Record review of the resident's nurse's notes, dated 12/19/13 (Seven days after the resident said he/she fell ) at 10:50 A.M., showed the following: -Took the resident to the parallel bars to ambulate due to order received on 12/13/13 for weight bearing as tolerated and facility staff stating the resident is refusing to ambulate. This writer noted the resident's left foot turning in, rotating medially, left leg appears bowed out. When questioned the resident where his/her pain was and how bad it got, he/she stated "Really bad," and then pointed to his/her left groin. Sat the resident down in wheelchair and called his/her physician to request an X-ray of his/her hip. Record review of the resident's nurse's notes, dated 12/19/13 at 1:00 P.M., showed the resident was transferred per wheelchair and facility van to the hospital for X-ray. Record review of the resident's nurse's notes, dated 12/19/13 at 2:30 P.M., showed the writer was notified by the resident's physician that the resident had a fractured left hip and was being transferred to an outlying hospital for treatment. Record review of the resident's nurse's notes, dated 12/23/13 at 12:55 P.M., showed the the resident returned from an outlying hospital after undergoing partial left hip surgery on 12/20/13. The resident still has moon boot to his/her left lower leg. Ambulates with one assist and gait belt. The resident did ambulate with one assist and walker, his/her gait steady and slow. Record review of the resident's falls prevention/reduction interventions, dated 12/23/13, showed the following: -Personal alarms: Specify type: Non-applicable written in; -Make sure has appropriate footwear. Specify: Shoes non-slip socks; -Staff education: Do not tell the resident to do something without being there; -Resident education: Do not get up without assistance; -Any medication changes or dosage changes in the past 30 days? Yes, started heparin (anticoagulant); -Change in mental status, mood, or behavior in the last seven days? None; -Change in functional status or requires more assist with ADL's? None; -Date Care plan revised of any changes: Blank; -Falls committee reviewed: Blank. Record review of the resident's nurse's notes, dated 12/23/13 at 8:40 P.M., showed the resident was found on the floor in his/her room. The resident states that he/she stood up to put his/her jacket on and fell forward landing on his/her elbows. The resident denies hitting his/her head or left hip. Denies any complaints of pain or discomfort. Dressing still intact to left hip. Record review of the resident's current medical record showed no indication staff changed or implemented new interventions to reduce the likelihood of another fall. Further review of the resident's care plan, dated 1/13/14, showed the following: -Ambulation: The resident needs to have standby assist to contact guard assist with ambulation. Make sure you put a gait belt on him/her and he/she is to use his/her walker. Physical therapy is working with the resident. Goal: The resident will be independent with ambulation by next review, goal newly set and ongoing; -Falls and Safety: Unchanged from previous care plan on 10/22/13. -On 12/16/13 the resident had a fall on 12/12/13 without reporting to nursing staff. Bruising was noted during bath, when questioned admitted to falling earlier that morning trying to go to the bathroom. He/she requires more assist with ADL's. He/she is progressively getting worse related to his/her kidney function. Need to assist him/her every two hours to the bathroom during the day and check on him/her during the night for his/her toileting needs. Do not scold the resident for incontinence, he/she cannot help it. He/she is to wear a moon boot on his/her left foot for two weeks. Can be weight bearing as tolerated. Goal: The resident will not sustain any injury related to falls through next review, goal set on 12/16/13; -Pain: The resident had a fall and sustained a fractured left hip. He/she has an as needed pain pill he/she can take; -Skin: I had surgery on my left hip. Make sure I move around every two hours; -Transfers: I need the assist of one staff member for transfers. I am unsteady and am at risk for falls. I will need to be reminded to wait for assistance. I am used to being independent. Goal: The resident will be able to transfer self by the next review, goal newly set on 1/13/14; -Staff failed to update after resident's recent fall (12/23/13) and did not plan or implement new interventions to prevent future falls. There was no mention the resident had a recent fall with fracture to left hip. During a telephone interview on 1/29/14 at 9:50 A.M., the resident's physician, said the following: -He saw the resident in his office on 12/13/13 and the resident was in a wheelchair at that time. The resident was only complaining of pain in his/her left ankle; -He never heard from the facility again until 12/19/13, when the Director of Nursing (DON) contacted him about her assessment of the resident; -If the facility would have contacted him about the left leg pain that went all the way down the resident's leg and the fact the resident was refusing to walk, then he would have ordered an x-ray of the resident's hip at that time, but the facility failed to notify him until 12/19/13. 3. Record review of Resident #3's care plan, dated 11/11/13, showed the following previous fall history: -On 3/18/13 the resident was found on the floor between the recliner and bed on his/her knees, stated "I missed a step and went down", he/she did have on non-skid socks; -On 5/20/13 the resident was found sitting on the bathroom floor with his/her back against the door and holding onto the sink. He/she stated "The toilet stool is facing the wrong way and the bathroom is too small." He/she sustained a dime sized abrasion to the outer right elbow. He/she did have on non-skid socks and was incontinent of urine; -On 10/2/13 the resident was found on the floor in his/her bathroom, had taken self to bathroom. Remind the resident to use call light for toileting needs and make sure it is where he/she can locate it. Also, provide with a urinal at bedside, if desired; -On 10/11/13 the resident was found on the floor twice on this date. He/she had been eating meals, was pushing the overbed table away and fell to the floor. This is the third fall thus far this month. Labs were drawn and medications adjusted. Continue same interventions. Record review of the resident's nurse's notes, dated 10/2/13 at 1:40 A.M., showed the following: -The resident was found on the bathroom floor by roommate, when he/she got up to use the restroom. The resident has a skin tear to his/her right upper arm. The resident stated, "I am okay, I didn't hit my head." Resident education on importance of compliance with call light for activities of daily living (ADL)'s. Call light within reach. No complaints of pain at this time. The resident was using a walker at the time of the fall. Review of the resident's care plan showed: -On 10/2/13 the resident was found on the floor in his/her bathroom, had taken self to bathroom. Remind the resident to use call light for toileting needs and make sure it is where he/she can locate it. Also, provide with a urinal at bedside, if desired. Record review of the resident's nurse's notes, dated 10/11/13 at 8:15 A.M., showed the following: -Found laying on the floor, slid down wall (slowly). Went to the bathroom and then to recliner after the fall. Call light within reach. Record review of the resident's nurse's notes, dated 10/11/13 at 4:00 P.M., showed the resident ambulating in his/her room with wheeled walker. Denies pain or discomfort from previous incident. Record review of the resident's nurse's notes, dated 10/11/13 at 6:15 P.M., showed the following: -The resident's roommate called staff to the room to report the resident was on the floor beside his/her bed against the wall with the window. Noted the resident had a V-shaped skin tear to his/her right elbow. The resident was moving all extremities, noted an orange size hematoma (blood filled swelling) to right anterior lower leg. Returned to chair per two staff assist, elevated lower extremity and ice bag applied. Noted two golf ball size purple bruises to his/her right buttocks. Review of the resident's care plan showed: -On 10/11/13 the resident was found on the floor twice on this date. He/she had been eating meals, was pushing the overbed table away and fell to the floor. This is the third fall thus far this month. Labs were drawn and medications adjusted. Continue same interventions. Goal: I will not sustain any injury related to falls through next review. Sustained injury to right leg with his/her last fall. Goal is ongoing. Record review of the resident's nurse's notes, dated 10/12/13 at 1:15 A.M., showed the following: -Right elbow bandage intact. Right hip area with a bruised area. Right lower leg, shin area has a large approximately 8 centimeter (cm) by 4 cm raised hematoma. Resident stated he/she became dizzy when trying to ambulate to his/her recliner. The resident was advised to either sit in his/her recliner for his/her meals or on the side of his/her bed closest to his/her recliner. He/she was told that the bedside table could be brought to him/her instead of him/her walking from his/her recliner to the opposite side of his/her bed to eat. He/she was agreeable to this request. He/she was also advised to use his/her call light if he/she needed to ambulate. Call light was within reach. Record review of the resident's nurse's notes, dated 10/12/13 at 9:30 A.M., showed the following: -The resident sitting in his/her chair beside the bed with feet down. Noted multiple small bruises on the resident. Hematoma to right lower leg 5 cm by 4 cm raised area and tender to the touch. Ice applied. Four plus pitting pedal (foot) edema noted Ambulates per walker and side by side assist, he/she does complain of dizziness when moves head side to side, and/or moves position. The resident has fallen three times in the last one week. Reiterated to the resident the need for him/her to use the call light. The resident verbalized understanding. Call light placed in the resident's hands and encouraged the resident to elevate his/her feet. Record review of the resident's nurse's notes, dated 10/12/13 at 11:40 A.M., showed the the facility received orders from the resident's physician for labs, urinalysis, and Antivert (antiemetic, antihistamine, anticholinergic) 25 milligram (mg) three times a day for five days. Record review of the resident's care plan showed the care plan was not updated to reflect the resident's new orders for medication following multiple falls or monitoring for symptoms (dizziness). Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment, completed by facility staff, dated 11/6/13, showed the following: -Moderate cognitive impairment; -Active [DIAGNOSES REDACTED]. -The resident required extensive assist of one staff for bed mobility, transfer, dressing, personal hygiene, and bathing; -The resident required limited assist of one staff to walk in room and corridor, locomotion on and off the unit, and toilet use; -The resident was not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, or surface-to-surface, but able to stabilize without staff assistance; -Functional limitation in range of motion of upper and lower extremity on one side; -Occasionally incontinent of bladder; -Always continent of bowel; -Had one fall with no injury since last MDS (8/7/13); -Had one fall with injury since last MDS (8/7/13); -The resident received an antidepressant, hypnotic, anticoagulant, and diuretic during the look back period; -The resident received no therapy or restorative during the look back period. Record review of the resident's care plan, dated 11/11/13, showed the following: -Ambulation: I need assistance with walking to and from the bathroom. I am unsteady. I sometimes will take myself without waiting for assistance. I have fallen in the past. I prefer a wheelchair for long distances. I get short of breath and my knees really bother me. Assistive Devices: wheelchair/walker. Goal: I will walk at least one time daily with staff assistance thru the next review. I will continue to be independent with my mobility through the next review; -Bowel and Bladder: The resident is incontinent of urine. He/she has a history of prostate problems and he/she takes a water pill that increases his/her need to urinate. Due to his/her impaired mobility, he/she often cannot get to the bathroom on time without being incontinent. His/her physician ordered an external catheter to be used to manage his/her incontinence. It is to be applied, as he/she desires, in the morning. It is attached to a leg bag during the day and if he/she wishes to wear it to bed, attach it to a bedside drain bag; -Dressing/Grooming: The resident needs help with dressing daily. It will require one staff for assist. He/she is on a blood thinner. He/she is to wear edema wear and derma sleeves to both legs daily. Encourage to elevate his/her legs as much as possible to reduce swelling; -Falls and Safety: I am at risk for falls. I am unsteady and have poor balance. I use a cane to ambulate. Make sure my room is clutter free. Make sure I have proper footwear on when I am out of bed. May use 1/2 side rails on both sides of the bed. I can use a wheelchair for long distances. My goal: I will not sustain any injury related to falls thru next review. 11/8/13-Goal not met. Sustained injury to right leg with last fall. Goal is ongoing; -Pain: I have pain in my knees and/or legs related to osteoarthritis (pain in joints). Assess my pain and administer medications as ordered; -Positioning: I need assist of one staff for getting in and out of bed, rolling around in bed, etc..; -Reason here: I had a stroke that affected my right side. My speech is most affected. I am very soft spoken. I have [DIAGNOSES REDACTED](rapid irregular heart beat) that I take a blood thinner to prevent clots. I also have heart failure and sometimes get swelling in my feet and/or legs. I take a diuretic and may have trouble controlling my bladder. I have an open area related to a fall. Record review of the resident's nurse's notes, dated 11/12/13 at 5:20 A.M., showed the following: -The resident was found on the floor between his/her bed and the wall. He/she was laying on his/her back. His/her right arm by the elbow and lower part of the upper arm had an old hematoma that opened. No skin tear noted. One area near thereabout 1 cm with the skin off. The wrist area on the right side has an old healing skin tear that re-opened. He/she stated that he/she had no more pain than usual. Small bruising on his/her right knee. He/she stated when he/she fell had he/she had become dizzy and couldn't avoid falling. Resident was left in his/her recliner with his/her feet elevated and call light within reach. Record review of the current medical record showed no indication staff changed or implemented new interventions to reduce the likelihood of another fall. Record review of the resident's nurse's notes, dated 12/24/13 at 6:30 A.M., showed the following: -The resident was found on the floor beside his/her bed on his/her stomach and his/her neck area was on top of the trash can. Stated he/she just fell forward while waiting for the aide to get a new pad for his/her bed. The aide had just walked out of the room when he/she fell forward. Bruises noted to both knees with the right knee slightly scraped. Bruise noted on the right upper chest area and a reddened area under his/her chin and around the right side of his/her neck. He/she had non-skid socks on and there was no spills or debris on the floor. Will continue to monitor. Record review of the resident's falls prevention /reduction interventions, dated 12/24/13, showed the following: -Make sure has appropriate footwear. Specify: non-skid socks written in (intervention of appropriate foot wear was listed on the care plan, dated 11/11/13); -Use adaptive/assistive devices. Specify: non-applicable written in; -Use mechanical lift for transfers: Specify: non-applicable written in; -Staff education: non-applicable written in (The resident fell while sitting on the side of her bed and staff left the resident unattended); -Resident education: if resident felt dizzy to put on his/her call light (intervention dated 10/2/13, listed on the current care plan); -Any medication changes or dosage changes in the past 30 days? No; -Change in mental status, mood, or behavior in the last 7 days? No; -Change in functional status or requires more assist with ADL's? No; -Date Care plan revised of any changes: Blank; -Falls committee reviewed: Blank. Review of the resident's current medical record showed no indication staff changed or implemented new interventions to reduce the likelihood of another fall. Record review of the resident's nurse's notes, dated 12/26/13 at 7:30 A.M., showed the resident laying on top of his/her walker. Skin tear noted to the resident's right forearm 3 cm, treatment done per policy. Record review of the resident's falls prevention/reduction interventions, dated 12/26/13, showed the following: -Personal alarm: Specify type: None written in; -When to use: None written in; -Positioning aides: None written in; -Make sure appropriate footwear. Specify: Non-skid socks written in; (intervention listed on the current care plan since 10/2/13) -Use adaptive/assistive devices: Specify: None written in; -Use mechanical lift for transfers: Specify: None written in; -Staff education: Check every two hours written in; -Resident education: Use call light for assistance with ADL's and transfers written in; (intervention listed on the current care plan since 10/2/13) -Any medication changes or dosage changes in the past 30 days? None written in; -Change in mental status, mood, or behavior in the last 7 days? None written in; -Change in functional status or requires more assist with ADL's? Need assist written in; (Intervention listed on the current care plan, dated 11/11/13) -Date Care plan revised of any changes: Blank; -Falls committee reviewed: Blank. Review of the resident's current medical record showed no indication staff changed or implemented new interventions to reduce the likelihood of another fall. Observation on 1/13/14 at 1:00 P.M., showed the resident in his/her bathroom with door open and by self, had wheeled self in with wheelchair and transferred self onto the toilet. The resident wore non-skid socks. The call light was not engaged, no staff present. Observation on 1/13/14 at 2:20 P.M., showed the resident laying in his/her bed with head of bed flat. Call light was still on the recliner, not within reach. Observation on 1/14/14 at 5:45 A.M., showed the resident sitting on the edge of his/her bed. The resident's wheeled walker out in front of the resident, call light on the left side of the bed attached. The call light was not engaged, no staff present. Record review of the resident's nurse's notes, dated 1/15/14 at 12:00 P.M., showed the following: -Called to the resident room by aide, the resident found sitting on the floor in front of the toilet and leaning against the wall. Right elbow with bleeding noted. Skin tear re-opened on right elbow. Assisted the resident to standing position with assist of two staff and gait belt. Balance very poor, leans backwards, feet slide, assisted to wheelchair. Range of motion in all joints okay without complaints of pain. During an interview on 1/15/14 at 12:10 P.M., the resident's responsible party said the following: -He/she was very concerned with all the falls the resident was having and was afraid the resident would end up fracturing something; -Had talked to the facility about moving the resident closer to the nurse's station, (as he/she is in the last room furthest from the nurse's station), but the facility said they did not have a room closer at this time; -He/she understood the resident doesn't remember to use the call light and when he/she has to go to the bathroom does not like to wait as he/she was afraid he/she might have an accident. Record review of the resident's nurse's notes, dated 1/15/14 at 1:00 P.M., showed the following: -Durable power of attorney here to visit with the resident, he/she questioned the possibility of moving the resident closer to the nurse's station, was informed there were no rooms available at this time. Pressure alarm in place and attached to call light. Resident has multiple bruises on arms black and blue in color and his/her skin is thin. Call light handed to the resident and instructed to use, he/she verbalized understanding. Record review of the resident's falls prevention/reduction interventions, dated 1/15/14, showed the following: -Personal alarm: Specify type: Body alarm; -When to use: At all times; -Make sure appropriate footwear. Specify: Had non-skid socks on, really needs shoes on when out of bed; (intervention of appropriate foot wear was listed on the 11/11/13 care plan) -Resident education: He/she doesn't remember to ask for help; -Change in functional status or requires more assist with ADL's? Yes; -Date Care plan revised for any changes: Blank; -Falls committee reviewed: Blank; -Nursing to therapy referral form completed and give copy to therapy. Observation on 1/15/14 at 1:30 P.M., showed the resident sitting up in recliner, bedside table in front of the resident, television on, call light attached to the right side of the recliner, non-skid socks on. No body alarm attached to the resident at the time of observation. Further review of the plan of care showed staff did not record updates after the resident's falls on 11/12/13, 12/24/13, or 12/26/13 and did not plan or implement new interventions to prevent future falls/injuries. 4. During interview on 1/16/14 at 9:10 A.M., the Director of Nursing (DON), said the following: -Falls risk is identified on admission, through general observation, and periodically throughout the resident's stay; -The facility has a fall tracking system they utilize and the MDS Coordinator is in charge of that; -The facility is reviewing interventions after falls to monitor the effectiveness of safety measures; -The facility makes modifications to safety prevention measures by reviewing after falls and periodically; -Falls should be looked at and evaluated as to why a resident fell and what can be done to try and prevent future falls/injuries. During interview on 1/16/14 at 10:20 A.M., the MDS Coordinator said the following: -She is on the falls committee; -She is the one that updates the care plans; -Standard things, such as call light in reach, room clutter free, etc. is not necessarily placed on the care plan, the facility tries to individualize more; -The facility does a post fall evaluation, based off of the Falls Care Area Assessment (CAA) from the Resident Assessment Instrument (RAI. From this they can usually determine why the resident fell and if the resident may need further work up to d