Every finding on record at Brooking Park

Based on observation, interview and record review, the facility failed to maintain an effective grievance process for residents and family members to be able to file a grievance verbally or anonymously. This deficient practice had the potential to affect all residents in the facility. The census was 81 with 21 residents in certified beds. Review of the facility's Resident Rights, dated 11/4/19, showed the following resident rights: Resident's right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Review of the facility's Grievance - Informal and Formal policy, dated 6/16/25 showed:-Residents have the right to file a grievance in writing or orally;-Grievance may be filed anonymously. Observation on 6/29/26 through 7/2/26, showed the facility posed three grievance signs. One at the receptionist desk, activity room entrance, and outside the social worker office. The sign identified individuals to contact for grievances and included telephone numbers and email addresses. The facility printed each sign on an 8 1/2 inch by 11-inch sheet of paper using small font (approximately 12-point). There were no grievance forms or a grievance box located at the receptionist area for residents, families or visitors to file grievances anonymously. During the resident group interview on 6/29/26 at 4:00 P.M., conducted with three alert residents, all residents present said they did not know who the grievance officer was including how to file a complaint anonymously. If they had a concern with direct care, they could tell their aide or the nurse. They would prefer to file their concerns anonymously because they do not want the staff to be mad or upset with them. During an observation, interview, and record reveiw on 7/1/26 at 9:35 A.M.: -Receptionist R said he/she was not sure on how a resident would file a grievance anonymously. The residents know they can call the front desk with their grievances, and then the front desk lets the appropriate department know of the resident's concern, they would keep the resident's identity private; -Observation showed the receptionist area located at the entrance of the building with a small table to the left of the receptionist counter. The table contained two black boxes. One box was labeled, Employee Appreciation, and had a stack of blank Extraordinary Employee forms directly in front of it. Next to that box was a slightly larger black box labeled, Outgoing Mail. In front of the outgoing mailbox was a laminated 8 1/2 x 11-inch grievance notice printed in approximately 12-point font. --Review of the notice dated 6/24/26 and addressed Dear Residents and Family Members, informed residents and family members that the facility had changed the manner in which grievance were submitted and provided the names and email addresses of various staff members. The notice did not include information regarding how residents or family members could submit grievances anonymously. During an interview on 7/1/26 at 10:16 A.M., the Director of Nursing (DON) said residents knew they could bring concerns to her or the charge nurses. The facility previously provided grievance forms and a grievance drop box. She was not sure why the new company removed the grievance forms and the box. During an interview on 7/2/26 at 4:15 P.M., the Administrator said the facility posted signs that informed residents and family members how to file grievances. The administrator said the residents could file grievances anonymously by using the grievance box located at the receptionist's desk. 2795937

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL, grooming, eating, oral hygiene) received necessary services when staff failed to provide feeding assistance to two residents (Resident #2 and Resident #10) during meals. Additionally, staff left a dinner tray in one resident's room without attempting to wake the resident up to eat and failed to check his/her mouth after eating for debris and provide oral hygiene to remove debris, as directed in his/her care plan (Resident #1). The sample was 10. The census was 53. Review of the facility's ADLs policy, reviewed/revised date 10/29/2025, showed:-Care and services will be provided for the following activities of daily living: oral care and eating to include meals and snacks;- A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition and oral hygiene. Review of the facility's Meal Supervision and Assistance policy, reviewed/revised date 10/29/25, showed:- The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time;-Encourage the resident to participate with his or her meal as much as possible. When indicated, provide special devices (i.e., two-handed and/or covered cups, hand holder utensils, dishes secured with suction cups, etc.) which will increase independence and participation with meals;-Continue feeding until the resident has had enough food or until the meal is finished;-If the resident wishes to eat later, or cannot eat now, communicate the resident's wishes to your supervisor and other staff members caring for the resident and set a more appropriate time for the resident to receive the meal. 1. Review of Resident #2's Electronic Medical Record (EMR), showed:-admitted [DATE];-Diagnoses included: Chronic fatigue, high blood pressure, oropharyngeal dysphagia (difficulty swallowing that occurs in the throat, involving the oral and pharyngeal (throat) phases of the swallowing process). Review of the resident's clinical admission assessment dated [DATE] at 10:22 P.M., showed the resident weighed 186.4lbs. Review of the resident's progress notes, showed on 8/4/25 at 4:11 P.M., post admission care plan meeting held this date. The resident's family, Interdisciplinary Team (IDT), activities and dietary attended. The family requested speech therapy due to swallowing/choking issues while eating. He/She needed a modified meal plan to meet his/her needs with safe eating. Review of the resident's dietary profile, dated 8/5/25, showed:-Regular diet;-Mechanical soft texture;-Regular fluids;-Small portions;-Poor appetite;-Chewing and swallowing problems;-Partial eating assistance. Review of the resident's Care Plan, in use at the time of survey, showed:-Problem: The resident had gastroesophageal reflux disease (GERD, a chronic digestive disorder where stomach acid frequently flows back into the esophagus) due to hyperacidity;-Interventions: Avoid overeating, small frequent meals, encourage resident to take his/her time eating, alternate sips of fluid with food;-No documented need for feeding assistance. Review of the resident's physician orders dated 9/5/25, showed an order for Ensure plus or house shake three times per day for weight loss. Review of the list of residents who needed to be fed, provided by the facility, showed the resident included on the list. Review of the resident's nutrition/dietary notes, showed:-On 9/16/25 at 3:49 P.M., the resident weighed 136.4lbs., which indicated a significant weight loss for one month. No diet order was in place. Resident had a history of poor appetite/food intake. He/She was started on mirtazapine (used to treat lack of appetite/weight loss) and Ensure plus three times per day. No signs/symptoms of difficulty chewing or swallowing with food. The plan included regular diet order, encourage food/liquid intake and honor food preferences;-On 10/28/25 at 5:35 P.M., the resident weighed 123.4lbs., which indicated a significant weight loss for one month. Staff reported the resident disliked the mechanical soft diet. The dietician recommended Mighty Shakes (a fortified nutritional supplement beverage. It provides extra protein and calories) between meals. The plan included encourage food/fluid intake, set up meals, considered speech therapy (ST) evaluation for diet upgrade. Review of the resident's speech therapy notes dated 11/10/25, showed the resident observed to tolerate consecutive sips of thin liquid. He/She required assistance for holding cup. Discussed strategies to increase alertness during meals. Review of the resident's Speech Therapy Recertification and Updated Plan of Treatment, dated 11/11/25, showed:-The resident tolerated mechanical soft diet and thin liquids with minimal signs/symptoms of dysphagia with feeding assistance and verbal cues to sustain attention;-Goal: The resident would sustain attention during mealtimes to complete 75 percent of meal given verbal cues as needed to increase caloric intake. At previous baseline (10/10/25) the resident required moderate assistance to remain alert during meals. Currently (11/10/25) the resident required maximum assistance to remain alert during meals. Observation on 11/13/25 at 9:13 A.M., showed the resident sat in the dining room. He/She had two Styrofoam cups with lids and straws in them and a small bowl of peach yogurt in front of him/her. He/She picked up the spoon to take bite of yogurt. His/her hand began to shake, and he/she put the spoon down without getting a bite. Then, he/she attempted to pick up the cup and his/her hands began to shake, and he/she put the cup down without getting a drink. At 9:23 A.M., the resident sat at the table with his/her head down. At 9:25 A.M., the resident attempted to pick up the cup. His/her hand shook, and he/she knocked the cup over. Staff Member I picked up the cup, wiped it down, and sat it back on the table. No drink was offered. At 9:28 A.M., the resident dropped his/her cup on the floor. Dining Aide H picked up the cup and threw it away. At 9:30 A.M. the resident dropped his/her spoon on the floor. Certified Nursing Assistant (CNA) B told the resident he/she was coming. At 9:33 A.M., CNA B sat down next to the resident and began feeding him/her the yogurt. At 9:38 A.M., CNA B said the resident ate all the yogurt and offered the resident breakfast. The resident refused. CNA B held the cup while the resident sipped on the straw. Observation on 11/14/25 at 8:18 A.M., showed the resident asleep at the dining room table. During an interview on 11/14/25 at 8:35 A.M., Dining Aide J said the resident needed feeding assistance. The CNA would come back to assist the resident.Observation on 11/14/25 at 8:50 A.M., showed staff served the resident a small bowl of peach yogurt. The resident did not attempt to eat the yogurt. He/She remained asleep. At 8:58 A.M., CNA F told the resident to wake up. The resident opened his/her eyes, and the CNA fed the resident. The resident ate the yogurt. CNA F asked the dietary aide to give the resident pancakes. CNA F fed the resident pancakes. The resident ate 60 percent of his/her breakfast. During an interview on 11/14/25 at 8:30 A.M., Register Nurse (RN) E said staff knew what care the resident required through aide-to-aide verbal report. If they did not know, they could ask the nurse. During an interview on 11/14/25 at 1:56 P.M., CNA F said the nurse tells staff which residents need feeding assistance. The resident's hands shake, and he/she feeds the resident. There is nothing documented to show the resident needs to be fed. The resident gets health shakes between meals. During an interview on 11/14/25 at 2:30 P.M., the Director of Nursing (DON) said she was not sure if the resident needed to be fed. 2. Review of Resident #10's EMR, showed:-admitted [DATE];-Diagnoses included: Alzheimer's disease (a progressive, irreversible brain disease that causes memory, thinking, and language problems), tremors, cognitive communication deficit, depression, chronic kidney disease. Review of the resident's November Physician Orders (POs), showed:-Regular texture diet;- Resident needs to be fed for all three meals, every day and evening shift. Make sure the resident is being fed. Review of the facility's list of residents who need to be fed, provided by the facility, showed the resident was not listed as needing to be fed. Review of the resident's Care Plan, in use at the time of survey, showed:-Problem: The resident has an ADL selfcare performance deficit due to Alzheimer's disease;-Intervention: The family provided cereal for the resident when he/she would not eat his/her meals. The resident was totally dependent on one staff for eating;-Problem: The resident had impaired cognitive function or impaired thought processes due to Alzheimer's;-Intervention: Ask yes/no questions to determine the resident's needs. Cue, reorient and supervise as needed. Observation on 11/13/25 at 8:06 A.M., showed the resident sat at the table in the dining room. He/She was served apple juice, strawberries, one slice of bacon and eggs. He/She ate one strawberry, then used his/her hands to move the strawberries around the bowl. The dietary aide asked the resident if he/she was going to eat the strawberries. The resident did not respond. The dietary aide moved the bowl to the side and told the resident to eat his/her food. He/She used his/her hands to play with the bacon and eggs. He/She took a bite of the bacon and continued to play with the eggs. Staff did not assist the resident with eating. Observation on 11/14/25 at 8:18 A.M., showed the resident sat at the dining room table. Staff asked if he/she wanted to eat. He/She did not respond. He/She was given a bowl of strawberries and a cup of apple juice. He/She did not eat the strawberries or drink the juice. He/She used his/her hand to play with the strawberries. Dining Aide J said the resident did not want to eat. At 9:03 A.M., CNA F asked the resident to eat some strawberries. The resident ignored him/her. CNA F started feeding the resident strawberries. The resident ate all the strawberries. CNA F asked the dining aide to give the resident pancakes and eggs. CNA F fed the resident. The resident ate 100 percent of his/her meal. During an interview on 11/14/25 at 8:35 A.M., Dining Aide J said the resident did not require feeding assistance. During an interview on 11/14/25 at 1:56 P.M., CNA F said the resident only needs encouragement, he/she could feed him/herself. His/her spouse feeds him/her during lunch and dinner. During an interview on 11/14/25 at 2:30 P.M., the DON said she was not aware the resident should be fed at all three meals. 3. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/1/25, showed:-Severe cognitive impairment;-No rejection of care;-Eating: Supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently);-Oral hygiene: Partial/Moderate assistance: (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort);-Diagnoses included: Arthritis, Alzheimer's and non-Alzheimer's dementia, depression, need for assistance with personal care. Review of the care plan in use at the time of survey, showed:-Need: The resident has an ADL self-care performance deficit Alzheimer's, confusion, dementia, limited mobility due to spinal stenosis (narrowing of the spinal canal that puts pressure on the spinal cord and nerves);-Goal: resident will maintain current level in ADL performance through next review;-Interventions included:-Eating: The resident requires assist by one staff to eat. He/She requires encouragement at times. Staff should feed resident at each meal. Regular diet to be provided.-Personal hygiene: The resident requires limited assist by one staff with oral care;-Need: The resident has a swallowing problem and history of holding food in mouth/cheeks (pocketing);-Goal: The resident will have no choking episodes when eating through the review date;-Interventions included: Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris; resident to eat only with supervision and provide cuing as needed. Review of the camera footage, showed on 7/20/25 at 5:13 P.M., the resident was in bed. He/She appeared to be sleeping. Unknown Staff G entered the resident's room with a covered meal tray. He/She said knock, knock, and said the resident's name as he/she sat the tray on the overbed table. Unknown Staff G turned to exit the room as the resident said OK. Unknown Staff G left the room. At 5:16 P.M., the same staff member entered the room, raised the lid off the food and replaced it. Then he/she exited the room. At 5:39 P.M. the same staff member entered the room and collected the meal tray without attempting to wake the resident up. Review of the Medication Administration Record/Treatment Administration Record dated 7/20/25 showed, a physician order to document any episodes of falling asleep during mealtimes in nursing note. If no issues, document that. On 7/20/25 at 6:00 P.M., n/a (not applicable) was documented. Review of the progress notes dated 7/17/25 through 7/24/25, showed there was no documentation for 7/20/25. Review of the order summary report, dated 11/12/25, showed, a physician order to document percent of intake for every meal. Staff to assist resident by prompting/feeding resident. Observation on 11/12/25 at 12:08 P.M., showed the resident sat in the dining room, with mixed vegetables and mashed potatoes on his/her lunch plate. He/She also had two beverages in front of him/her. The resident picked up his/her fork, took a bite, then stopped eating. Dining Aide A cued the resident to take a bite. The resident picked up the fork and took a bite, then stopped. At 12:40 P.M., the resident picked up his/her fork and took a bite, then stopped. At 12:46 P.M., Dining Aide A asked the resident if he/she was done eating, the resident said no, he/she reminded the resident to take a bite. The resident did not pick up the fork. At 1:00 P.M., staff removed the resident's plate. At 1:05 P.M., Dining Aide A propelled the resident into the TV room. Staff did not check the resident's mouth for pocketing, nor did staff provide oral hygiene. Observation on 11/13/25 at 8:37 A.M., showed the resident fed him/herself strawberries. At 8:45 A.M., Dining Aide H cued the resident to pick up his/her fork. The resident picked up the fork and took a few bites then stopped. At 8:53 A.M., CNA D gave the resident a bite of food then he/she walked away to assist another resident. At 8:58 A.M., CNA D cued resident to take a bite. The Resident picked up the fork and took a bite, then stopped. At 9:43 A.M., the Nurse Manager entered the dining room and encouraged the resident to eat a little more, then she walked to the back of the dining room. At 9:46 A.M., staff asked the resident if he/she was done eating and took his/her plate. Observation on 11/13/25 at 12:00 P.M., showed the resident in the dining room with his/her lunch plate in front of him/her. Staff cued him/her to eat. The Resident picked up his/her hamburger and took a few bites, then he/she stopped. The resident ate 50-75% of his/her meal. At 1:10 P.M., the Nurse Manager propelled the resident from the dining room table to the TV room. Staff did not check the resident's mouth for pocketing, nor did they provide oral hygiene. During an interview on 11/13/25 at 10:00 A.M., CNA D said he/she knew what care the resident needed by report. Some days, the resident needed just cueing to eat, and other days he/she needed to be fed. He/She was not aware of any residents who required oral care after they eat. During an interview at 11/14/25 at 2:00 P.M., CNA F said the resident ate three meals daily. He/She needed encouragement and cues to eat because he/she will go off into space. Residents' teeth are brushed in the morning and in the evening. Oral care was not provided in-between. There was only one resident on the hall who used mouth wash. During an interview on 11/14/25 at 2:29 P.M., the DON said staff know what care residents need through shift-to-shift report, or they could ask the nurse. Staff should know which residents require assistance with meals; it should be on their care plan. The facility was not aware of the video from 7/20/25. The facility has talked with the family and instructed them if they see a problem, they need to notify the facility right away so they can address the issue. The family has not provided a video. Mouth care is provided in the morning and in the evening. If a resident needed oral care after each meal, that would be a big ask. 4. During an interview on 11/14/25 at 2:30 P.M., the Administrator and DON said they would expect staff to follow the facility's policies and procedures. The CNAs provide oral care when residents wake up and before they go to bed. They would expect staff to rinse a resident's mouth if it is on the care plan. The dining aides and nurses know which residents require feeding assistance and it should be on the resident's care plan. They would expect the nurse to inform staff which residents required feeding assistance. 2607069

Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and assistance for one resident (Resident #1) who required a mechanical lift (allow a person to be lifted and transferred with a minimum of physical effort) and two-person assistance for transfers when one staff transferred the resident without a mechanical lift. The sample was 10. The census was 53. Review of the facility's Safe Resident Handling/Transfer Policy, dated reviewed/revised 9/25/25, showed:-Policy explanation: 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;-Compliance guidelines:--The interdisciplinary team or designee will evaluate and assess each resident's individual mobilityneeds, taking into account other factors as well, such as weight and cognitive status;--Two staff members must be utilized when transferring residents with a mechanical lift;-Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment;--Resident lifting and transferring will be performed according to the resident's individual plan of care. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/1/25, showed:-Severe cognitive impairment;-Chair/bed-to-chair transfer: dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two helpers is required for the resident to complete the activity);-Diagnoses included: arthritis, Alzheimer's and non-Alzheimer's dementia, depression, need for assistance with personal care and spinal stenosis (the narrowing of the spinal canal that puts pressure on the spinal cord and nerves). Review of the resident's care plan, in use at the time of survey, showed:-Need: Resident and family have requested to have an electronic monitoring device on in his/her room at all times;--Goal: The resident or Power of Attorney (POA) will verbalize understanding of the use of the device and consent to its use through the next review;--Interventions included: a sign will be placed on the door to the resident's room notifying everyone that the room has an electronic monitoring device in place; remind resident of monitoring device prior to providing care; the device needs to be in plain view.-Need: the resident has an Activities of Daily Living (ADL) self-care performance deficit Alzheimer's, confusion, dementia, limited mobility due to spinal stenosis;--Goal: Resident will maintain current level in ADL performance through next review;--Interventions included: The resident requires mechanical lift (sit to stand, assist individuals with limited mobility in transitioning from a seated to standing position) with two staff assistance for transfers. Observation of a two-minute video footage, dated 6/30/25 at 8:59 P.M., showed the resident sat in his/her wheelchair. The wheelchair was positioned parallel to the side of the bed. Staff C put the resident's gown on and lowered the bed down. Staff C asked the resident if he/she was ready. The resident replied yes. Staff C told the resident to give him/her a hug and put his/her arms around the resident. Staff C told the resident your stiff, if you're stiff you are going to make this harder for the both of us and that he/she was going to break the staff member's back. As the resident started to move, he/she was saying oh, oh, my back. Staff C said sit up or he/she would go get another person. The resident said you don't need to do that. As the resident moved forward, he/she said ouch, ouch, my back. Staff C said to come on and give him/her a hug, 1-2-3 and stood the resident up. Staff C told the resident he/she was pushing and told the resident to let that rail go, or he/she would need to put the resident back into the chair. Staff C pivoted and sat the resident on the side of the bed. Staff failed to use the mechanical lift with two-person assistance. During an interview on 11/14/25 at approximately 9:00 A.M., Certified Nurse Aide (CNA) D said he/she knew what care the residents needed through shift-to-shift report. The resident was total care for all ADLs. All lift transfers required two persons assist. During an interview on 11/14/25 at 8:30 A.M., Register Nurse (RN) E said staff knew what care the resident required through aide-to-aide verbal report. Also, they could ask the nurse if they did not know. Lift transfers require two staff. During an interview on 11/14/25 at 2:29 P.M., the Director of Nursing (DON) said staff know what care the resident needed through a verbal report done shift to shift. If the CNA did not know, they should ask the nurse. Mechanical lift transfers require two-person assistance. A bear hug is not a proper way transfer a resident. The DON and Administrator said they were not aware of the above video. During an interview on 11/14/25 at 2:29 P.M., the Administrator said he would expect for the staff to follow the facility's policy and procedures. 2607069

Based on interview and record review the facility failed to ensure acceptable nursing standards of practice when a resident was admitted from the hospital with a wound vacuum (wound vac, a medical device that provides light suction to a wound with high amounts of drainage to pull the excess drainage away from the skin) in place to his/her abdomen for treatment to an open surgical wound. The facility did not verify the wound vacuum treatment orders including wound vacuum dressing changes and needed supplies upon admission to the facility. As a result, the resident did not receive treatments as ordered by the hospital while at the facility. The resident discharged to the hospital on [DATE] for wound evaluation (Resident #1). The sample was 3. The census was 51.Review of the facility's Prevention and Treatment of Skin Breakdown and Other Skin Condition policy, dated 2017, showed:-Policy: properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, to implement preventive measures, and to provide appropriate treatment modalities for wounds according to industry standards of care;-Procedure: A skin/body audit will be done upon admission and weekly during the resident's stay. If a skin concern is noted, complete a wound ID and assessment for each skin condition identified, which will auto create a wound log. Solicit appropriate physician orders;-Treatment: if the resident is admitted with a wound, the following procedure is implemented: Initiate wound care guidelines. Notify the physician and family representative. Solicit appropriate physician orders. Review of Resident #1's hospital Discharge summary, dated [DATE], showed:-Hospital diagnoses included: partial colectomy (removal of part of the colon), severe sepsis with septic shock (systemic blood toxicity) and colon perforation (burst colon);-Hospital wound care notes: Focused assessment of midline (middle) wound vacuum:--Surgery date: 9/27/25. Location: abdomen;--Procedure: re-exploration of the abdomen, partial ileostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall through which waste from the small intestine (ileum) can be discharged into a bag) and negative pressure wound therapy (NPWT, wound vac);--Date wound vacuum initiated: 9/27/25;--Measurements: length 18 centimeters (cm) x width 2.6 cm x depth 1.5 cm, with a small opening proximally (near top of abdomen) and distally (near lower abdomen);--Wound base: 100 percent (%) reddened granular (new tissue growth) tissue and 100 % friable (fragile) tissue throughout wound with two small tunneled areas; --Edges: open and defined;--Drainage: creamy serosanguinous (thin white, blood tinged drainage);--Treatment/interventions: Clean wound with Vashe (antibacterial wound cleanser). Peri wound (outer edge of wound): skin barrier wipe for moisture protection. Vac drape and place Duoderm (a thin transparent material, used as a skin protectant) placed along wound edges for protection from mechanical forces and moisture protection. Foam used, medium black foam. Place two pieces of white foam, one into each tunnel at proximal and distal ends. One piece of black foam to loosely fill wound space and one piece of black foam to cushion [NAME] pad. Pressure setting: 75 (negative pressure setting) mmHG;--Instructions for dressing changes, if wound vac machine is off/fails for greater than two hours or if dressing compromised: Remove the Vac drape and sponges and reconcile the sponge counts with the most recent wound care note. Irrigate the wound gently with normal saline (NS). Lightly pack the wound with NS moistened gauze dressing (wet to dry) and secure with dry dressing. Change wet to dry dressing daily and as needed (PRN) until seen by the physician team or wound care nurse;-Plan: Vacuum changes every Monday, Wednesday and Friday. Discharge to skilled facility. Review of the resident's facility admission physician order sheet, showed:-admitted : 10/23/25;-Shower/bath: every Wednesday and Saturday;-Skin observation: every Saturday;-No wound care orders noted. Review of the resident's progress notes, showed:-On 10/23/25 at 6:20 P.M., an admission note: Arrived by hospital transport. Mental status, able to make needs and wants clearly known. Gastrointestinal: abdomen is tender. A colostomy is present with a stoma. Skin: skin is normal. (The assessment did not address the resident's abdominal surgical wound or wound vac);-On 10/26/25 at 2:05 P.M., a skilled evaluation note: Skin warm and dry, color within normal limits. Skin note: wound vacuum and colostomy area present with no signs of infection, swelling or bleeding. Review of the resident's October Treatment Administration Record (TAR), dated 10/23/25 through 10/28/25, showed no treatment wound care orders for the abdominal wound vacuum. Review of the resident's progress note, showed on 10/27/25 at 5:13 A.M., the resident and family wanted to know the schedule for the wound vac to be changed and the wound cleaned. Currently, had a wound vac to the center of the abdomen at 75 mmHG of pressure. No order located. The physician was contacted to obtain orders to verify and treat. Waiting a call back. The resident stated in the hospital the wound vac had been changed every 72 hours. The orders could not be verified within hospital paperwork. Will continue to monitor. During an interview on 11/04/25 at 11:45 A.M., the Director of Nursing (DON) said the resident was admitted from the hospital with an abdominal wound vac and a new colostomy. The DON was approached by the family on or around 10/28/25 and was notified the resident had not received any wound vacuum changes since he/she was admitted . The resident and family said the wound vacuum was to be changed every Monday, Wednesday and Friday. The facility did not have any wound care supplies, and the resident did not have orders for treatments to the abdominal wound. Upon investigation, the DON discovered the admitting nurse and subsequent nursing staff did not verify hospital discharge wound care orders. The resident did not receive any abdominal wound or wound vacuum care while at the facility. The resident and the family elected to discharge to the hospital for wound evaluation and treatment on 10/28/25. All nurses who cared for Resident #1 were responsible to ensure wound care orders were received from the hospital or call the surgeon to obtain orders for care. During an interview on 11/4/25 at 12:02 P.M., Licensed Practical Nurse (LPN) A said he/she worked part time at the facility and assisted the specialized wound management (SWM) nurse weekly with wound assessments. He/She was asked to assess Resident #1's abdominal wound and wound vacuum on 10/28/25. When he/she approached the resident for consent to enroll into SWM services, he/she was told by the resident and family the resident was going to the hospital for evaluation and treatment of the wound. Prior to the resident discharging to the hospital, LPN A reviewed the physician orders in the computer and did not locate any wound care orders. LPN A expected the admitting nurses to conduct a full head to toe assessment, document any skin impairments and obtain orders. If wound care orders are not clear or provided on discharge paperwork, the nurse should call and verify the orders with the hospital. During an interview on 11/4/25 at 12:17 P.M., the Licensed Practical Nurse Manager said she had worked at the facility for two weeks. On 10/28/25, the resident and family expressed concern that the resident had not received a wound vacuum change since his/her discharge from the hospital several days previously. Upon review of the resident's admission orders, no wound care orders were documented in the medical record. The admitting charge nurse should have verified orders and conducted a full skin assessment. If the admitting staff did not observe hospital discharge wound orders, the staff should have called the hospital for wound orders or clarification. The facility staff could have called the facility medical director for temporary orders until the surgeon was reached. Resident #1 did not receive wound care to his/her abdominal surgical wound since his/her admission on [DATE]. The resident discharged to the hospital per resident and family request on 10/28/25 for wound evaluation and treatment. 2655086

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) C completed and document physical and neurological assessments of Resident #1 after he/she was found unresponsive in his/her room by Certified Nursing Assistant (CNA) A. RN C went to the resident's room and found him/her sitting on the floor with his/her back leaning against his/her recliner. RN C failed to complete and document assessments of the resident after finding the resident on the floor and while waiting on emergency medical services (EMS) to arrive. Once EMS arrived, cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) was initiated. Three residents were sampled. The census was 62. Review of the facility Condition Change (Observing, Recording, and Reporting) policy revised on 2/2019, showed: -Policy Statement: To observe, record, and report any condition change to the attending physician so proper treatment will be implemented; -Equipment: Blood pressure cuff, stethoscope, thermometer, flashlight and pulse oximeter (measures the percentage of oxygen in the blood); -Procedure: 1. After resident falls, injuries, or changes in physical or mental condition, monitor and observe for the following: a. Lacerations; b. Swelling and discoloration; c. Convulsions; d. Headache or pain; e. Bleeding; f. Blood in body fluids; g. Personality changes; h. Alterations in consciousness; i. Incontinence; j. Sensory weakness; k. Generalized weakness; l. Speech disorder; m. Gait (walking), posture, or balance disorder; n. Change in ambulation status; o. Changes in ability to eat or drink; p. Changes in in-put/out-put; q. Stiff neck; r. Proper reflexes (response to painful stimuli); s. Abdominal spasm or pain; t. Bleeding from ears, nose, throat; u. Unequal pupils; v. Variations in respirations (irregular). Measure oxygen saturation; w. Flushing or cyanosis (blue or blue tint skin color); x. Pain; y. abduction (the movement of a limb away from the midline of the body), adduction (the movement of a limb toward the midline of the body), shortening or improper position of extremities; 2. Monitor vital signs; 3. If change of condition is acute, have someone stay with the resident while the nurse is calling attending physician, if necessary; 4. Document observations, assessments and communication related to resident change in condition in the medical record providing objective data; 5. Complete an incident, accident, or task management report per facility policy; 6. Notify resident's responsible party; 7. Monitor resident's condition frequently until stable. Review of the facility's RN Charge Nurse job description, undated, showed: -Summary of Position: Responsible for the general well being of residents on the unit through the delivery of high quality services in a manner consistent with the philosophy of the facility as well as complies with applicable state, federal, and facility policies and regulations. Responsible for the management and supervision of the staff in the unit; -Essential Functions: -Direct the day-to-day functions of the CNAs per facility policy and their respective job descriptions; -Ensure that the written policies and procedures that govern the day-to-day functions of the nursing service department are followed by all nursing personnel assigned to you; -Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, care plan updates, etc., as necessary; -Chart all accidents/incidents involving the resident. Follow established procedures; -Chart nurse's notes in an informative and descriptive manner that reflects care provided to the resident, and resident's response to the care; -Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures; -In the absence of the Administrator or a Department head, the RN Charge Nurse is responsible to lead and direct all staff during an emergency or disaster in a manner consistent with established plans. Review of Resident #1's census report, located in the electronic healthcare record (EHR), showed an admission date of [DATE]. Review of the resident's Nursing Baseline Care Plan, located in the EHR, showed: -Can the resident communicate easily with staff?: Yes; -Does the resident understand the staff?: Yes; -Cognitively intact; -Discharge Planning: Wishes to return home. Review of the resident's medical diagnoses, located in the EHR, showed diagnoses included chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs), congestive heart failure (CHF, the heart does not pump blood efficiently), obstructive sleep apnea (sleep related breathing disorder marked by repetitive pauses in breathing), and diabetes mellitus (low/high blood sugar levels). Review of the resident's progress notes, located in the EHR, showed: -[DATE] at 6:30 A.M., and documented by RN C, showed the resident was found sitting on the floor leaning against recliner. Resident did not respond to stimuli. Called 911 at 6:32 A.M. and physician. After five minutes EMT (emergency medical technician) arrived at 6:44 A.M. and started CPR. Reported to oncoming nurse; -The RN did not document a physical assessment including vitals (temperature, pulse, respirations, blood pressure)), lung sounds, oxygen level, blood glucose level, or neurological assessment including pupil size and response to light, after the resident was found unresponsive, or ongoing assessments as RN C waited for EMS to arrive. During an interview on [DATE] at 2:00 P.M., CNA A said he/she found the resident sitting on the floor with his/her back leaning against the recliner. He/She went and told RN C who came to the resident's room and the resident did not respond. RN C shook the resident, but he/she still did not respond. RN C left the room to call 911 and CNA A remained with the resident. RN C returned to the room after calling 911 and they waited on EMS to arrive. He/She did not see RN C take vitals, listen to the resident's lungs or obtain oxygen saturation levels. RN C did not instruct CNA A to take vital signs. The resident had a snoring type breathing the whole time until EMS arrived. Review of RN C's written statement, dated [DATE], showed the resident was sitting in his/her recliner and received his/her morning medications shortly before 6:25 A.M., when CNA A came to the nurses station and informed RN C the resident was on the floor. The nurse went to the resident's room and observed the resident sitting on his/her bottom in front of the recliner with his/her legs out in front of him/her, drooling. This nurse attempted to arouse the resident by shaking his/her shoulders and calling his/her name. Resident was not aroused. RN C left the room to call 911 and doctor. CNA remained with the resident. RN C returned to the resident's room until the arrival of EMS. RN C reported the resident's condition to EMS. EMT instructed RN C to initiate CPR. Chest compressions were started by RN C. Two person rotation of CPR continued. During a telephone interview on [DATE] at 8:37 A.M., RN C said when he/she and CNA A went into the resident's room, the resident was sitting upright with his/her back resting against the recliner. The resident's head was slumped forward and he/she had a small amount of drool coming from his/her mouth. RN C tried to awaken the resident verbally and when the resident did not respond, he/she shook the resident. The resident remained unresponsive. RN C took the resident's pulse, it was 60 or 80. RN C did not document the pulse in the progress notes. The resident was breathing but RN C did not know how many respirations per minute. The resident's respirations sounded like snoring. RN C and CNA A did not attempt to reposition the resident. He/She left the CNA in the room while he/she went to the nurse's station to call 911. He/She returned to the resident's room after calling 911. The resident continued to have the snoring like respirations. RN C thought he/she checked the resident's pulse after returning from calling, but was not sure. RN C did not check any of the resident's vitals other than the resident's pulse. He/She did not listen to the resident's lung sounds, check the resident's oxygen or blood glucose levels, and did not check the resident's pupils. RN C should have done those things as part of an assessment and documented it in the resident's progress notes, but he/she did not. When EMS arrived, they had him/her begin chest compressions while one of the EMT's started respirations. Review of the EMS report, showed the following: -[DATE]: Call received at 6:32 A.M., at patient at 6:44 A.M.; -Upon arrival on scene entry was made through the front door of the facility. EMS was directed to the patient's room by staff. Upon contact with the patient he/she was found sitting on the floor leaning against his/her chair. Staff stated that he/she had slid out of his/her chair and was not responding appropriately. The patient presented with secretions in his/her airway, no spontaneous respirations, warm, dry and pink, no palpable pulses, and unresponsive. An ALS (advanced life support) assessment was performed. Staff stated that the patient's last known normal was five minutes prior to calling 911. The patient was moved from his/her sitting position to laying supine on the floor and CPR was initiated. Medical control at the hospital was contacted and permission to terminate efforts were granted by the hospital physician. Expired at 7:13 A.M. During an interview on [DATE] at 9:00 A.M., the Director of Nursing (DON) said he/she read RN C's progress note for the resident. The progress note offered very little as to what happened. RN C did not do any vitals at all. He/She did not do any kind of an assessment including vitals, lung sounds, oxygen saturation levels or blood glucose levels. The DON would have expected these assessments to have been completed and on-going until EMS arrived. She would have expected RN C to have documented these assessments in the resident's EHR. She expected staff to follow the facility's policies. During an interview on [DATE] at 9:21 A.M., the resident's physician, who was also the facility Medical Director, said she saw the resident the day after the resident was admitted . The resident had CHF, but was stable. She would expect RN C to have assessed the resident including vitals, lung sounds, oxygen levels and a blood glucose level. She would have expected these assessments to have been ongoing until EMS arrived and documented in the resident's EHR. She expected staff to follow the facility policies. MO00253897

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when providing to perineal care (cleansing of genitalia and buttocks) to one resident (Resident #1). When providing peri care, staff failed to close the door to the resident's room, failed to close the window blinds failed to have a privacy curtain or other draping to prevent the exposure of the resident's genitalia and buttocks. The sample was seven. The census was 63 with 28 in certified beds. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Requires assistance from staff with eating; -Dependent on staff assistance going from lying to sitting position; -Diagnoses included: Diabetes, urinary tract infection in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of video footage, dated 3/9/25 at 12:12 P.M., showed an unidentified staff member entered the resident's room and asked the resident if he/she wanted to get up. The resident said yes. The staff person pulled the resident's blanket off and exposed the resident lying in a top and an adult brief. Without closing the resident's door, the staff member removed the resident's brief and applied a clean one. Observation on 3/19/25 at 2:57 P.M., showed Certified Nursing Aide (CNA) A and CNA B entered the resident's room with the resident and a stand up lift (a medical device designed to help individuals with limited mobility safely transition from a seated to a standing position, or vice versa). Staff told the resident they were going to change his/her brief. They lifted the resident out of his/her wheelchair using the sit to stand lift. Without closing the blinds to the outside and/or moving the resident in the bathroom, CNA A pulled down the resident's pants and removed a soiled brief. CNA B cleaned the resident and applied a clean brief. The resident's room was visible from a walkway outside. The resident's room did not have any privacy curtains so anyone who opened the door would see the resident naked and exposed. During an interview with the Administrator, Director of Nursing (DON), and Regional Nurse Manager on 3/20/25 at 4:05 P.M., the Regional nurse manager said staff should always shut the resident's blinds to the outside when providing personal care. They did not know why the resident's room did not have privacy curtains since the room had tracks for privacy curtains. MO00249872

Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances. The facility also failed to promptly resolve grievances for one resident (Resident #1). The sample was seven. The census was 63 with 28 in certified beds. Review of the facility's grievance policy, reviewed on 12/20/24, showed: -It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of the staff and of other residents, and other concerns regarding their Long Term Care (LTC) facility stay; -The facility will ensure prompt resolution to all grievances, keeping the resident and resident's representative informed throughout the investigation and resolution process; -The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with staff; -The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service and will provide residents, resident representatives, and other information about the mechanisms and procedure to file a grievance. The facility will provide a designated individual to oversee the grievance process, provide a planned systematic mechanism for receiving and prompting action upon issues expressed by residents and resident representatives. The facility will provide an ongoing system for monitoring and trending grievances and complaints; -Procedure: The facility will help promote the grievance process through the organization. This includes notifying residents of their rights related to grievances as well as education to all those affected by potential grievances or concerns on the family grievance processes, including but not limited to: -Resident; -Resident representative; -Employees; -Volunteers; -Vendors; -Other stakeholders. -Grievance Official (Social Services Director): The facility will train and designate an individual who is responsible for: -Overseeing the grievance process in conjunction with facility administration; -Receive and track all grievances through to their conclusion; -Lead any necessary investigations by the facility; -Work with facility staff utilizing root cause analysis processes for resolution of the grievance or concern; -Maintain confidentiality of all information associated with grievances; -Complete written grievance resolutions/decisions to the resident involved; -Resolution: The facility will strive for a prompt resolution outcome for all grievances or complaints rendered. A reasonable timeframe will be agreed upon with all parties involved; -The Grievance Official (Social Service Director) will complete a written response to the resident or resident representative which includes; -Date of Grievance; -Tracking number or identification; -Type of grievance; -Location/Department; -Person assigned to investigation; -Date response letter sent; -Comments/Actions. Review of the facility's Grievance/Concern Form, undated, showed: -Page 1: Space designated for: -Date of occurrence; -Location of occurrence; -Staff or Resident involved; -Summary of concern; -Name of individual filling out the form; -Signature of person filling out the form; -Date form was filled out; -Page 2: Investigation: The investigation will consist of at least the following: -Review of the completed complaint report; -An interview with the person or persons reporting the incident; -Interviews with any witnesses to the incident; -A review of the resident's medical record if indicated; -A search of the resident's room (with resident's permission); -An interview with staff members having contact with the resident during reverent periods or shifts of the alleged incident; -Interviews with the resident's roommate, family members and visitors; -A root cause analysis of all circumstances surrounding the incident; -Summary of investigation; -Page 3: Resolution: Action taken to resolve grievance/complaint; -Spaces designated for date and time, to show if the resident and/or resident's representative, the resident's physician and/or Ombudsman were notified of the resolution (if applicable); -Spaces designated for date and signature of the Director of Nursing (DON), SSD and Executive Director (ED); -The grievance/complaint form did not have a designated space for a tracking number, person assigned to investigate, instructions on who or where the grievance form was to be turned in to, a date or timeframe the grievance should have a resolution or a root cause analysis. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Diagnoses included: Alzheimer's disease and Parkinson's disease (a neurological disease that causes tremors and shaking of the body); -Set up assistance with feeding; -Dependent (helper does all of the work) for toileting hygiene, showers/baths, dressing and transfers. Review of the grievance log showed: -A grievance form filled out by Family Member (FM) S regarding Resident #1; -Signed and dated by FM S on 2/5/25; -Date of occurrence: Multiple in January and February 2025; -Staff involved: Multiple; -Summary of concern: -On Friday night 1/17/25 to 1/18/25, no rounds from 9:21 P.M., eight hours no staff checked on resident; -Saturday 1/25/25, whole uncrushed pills given at 5:15 A.M., and at 9:00 P.M., causing choking, against physician's orders; -On Tuesday 1/28/25, missed breakfast hours, left in bed, breakfast tray brought later, there were 16 hours between meals; -On Saturday 2/1/25: -Whole uncrushed pills provided at 5:30 A.M.; -No shower provided; -At 11:32 A.M., the staff turned the camera (in the resident's room) and left it (turned) intentionally all night; -Staff called the resident boy; -On Sunday 2/2/25 to 2/3/25, no rounds from 8:35 P.M., to 5:48 A.M. (nine hours); -On Tuesday 2/4/25, evening medications not given until after midnight; -Page 2. Investigation sheet: Not with grievance packet and not provided to surveyor; -Resolutions: -Social Worker (SSD) called and left a message for daughter to address these concerns. Social Worker (SSD) will wait for a return phone call (no date and/or time, the call was placed); -No tracking number or identification; -No person assigned to investigation; -No date when response letter was sent; -A grievance filled out by FM S regarding Resident #1; -Dated 2/7/25, -Date of occurrence; 2/6 to 2/7/2025; -Staff or Resident involved: multiple; -Summary of concern: -Night rounds did not occur between 7:30 P.M. and 2:12 A.M., nearly seven hours between rounds; -Wheelchair still dirty; -Staff turned camera during lift; -Signed and dated by FM S; -No investigation page; -Resolution: -SSD called and left a message for FM S to address these concerns, this SSD will wait for return phone call (no date and/or time provided); -SSD spoke with FM S on 2/21/25, (no time provided); SSD set up a care plan meeting; -No resolutions; -No tracking number or identification; -No person assigned to investigation; -No date the response letter sent; -Space designated for resident and/or resident representative, physician and the Ombudsman notified of resolution: Left blank; -Grievance form signed only by SSD on 2/10/25. During interviews on 3/19/25 at 2:30 P.M., and 3/20/25, at 1:30 P.M., FM S said he/she discussed his/her concerns on the most recent grievance forms with the DON. The DON told FM S it would be very difficult for her to figure out which staff were involved with the allegations. FM S did not understand this because he/she provided very specific dates and times of the alleged concerns. There was supposed to be a meeting with the DON about his/her concerns on 3/7/25, but the DON did not show up for the meeting. When FM S asked to speak with the DON, he/she was told the DON was busy. FM S had never been told the results of the two grievances he/she filed in February. He/She visited the resident almost daily and had never missed a scheduled care plan meeting. FM S asked the facility to text and/or email him/her, but they continued to call his/her cell phone. FM S's preference for communication with the facility was by email or text. His/Her concerns had been an ongoing issue with the facility. The facility was not following their plan of correction from December 2024. He/She was not asking for anything above or beyond the basic nursing services he/she was paying for. There was no reason his/her family member should ever miss a meal, be left to lay in a soiled brief for extended periods of time, not be bathed or not provided routine personal hygiene. FM S had voiced his/her concerns in the past and still nothing had improved in regard to the care of the resident. The facility had grievance forms all over the facility. The form did not include who to turn the report into, when a response should be expected and/or who the grievance officer was. FM S asked to see the facility's policy concerning grievances, but the facility would not provide one. During an interview on 3/20/25 at 2:50 P.M., the SSD said he/she was the Grievance Officer. If he/she received a written grievance he/she would give it to the department head the grievance pertained to. Nursing complaints would go to the DON and dietary complaints would go to the Dietary Manager. He/She would expect the department heads to follow through with the investigation of the grievance and return it to him/her after it was completed. He/She maintained the grievance log. After she had gotten a summary of the grievance solution, he/she would notify the person who filed the grievance. He/She was not sure if or what the response time was for a grievance. The process should take no longer than one month. During an interview on 3/19/25 at 1:00 P.M., the DON said she had tried to set up a meeting with the resident's family member. The family member would not return her calls. A care plan meeting was set up, but the family member failed to show up. She was not able to provide an investigation regarding the specific allegations on the grievance forms. She did not interview any staff about the resident being left in bed for extended periods of time or receiving medications whole and/or late. She did not address moving the resident's camera with staff so the resident's care could not be monitored. She did put several agency staff on the do not return list because of the family member's complaints. The SSD was the Grievance Officer for the facility. The resident's family member had been very challenging. FM S expected too much from the facility and did not have realistic expectations for the resident's care. During an interview on 3/20/25 at 4:30 P.M., the ED said he was not the official Grievance Officer. The Grievance Officer for the facility was the Social Worker (SSD). Any staff person could take and try to resolve any grievances filed. He expected staff and department heads to address grievances in a timely manner. He should be notified of any grievance and the outcome of the investigation because he had to sign the completed grievance forms. MO00249872

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL, bathing, dressing and toileting) received the necessary services to maintain adequate personal hygiene. Staff failed to assist one resident with personal hygiene and failed to provide physician ordered showers. (Resident #1). The sample was seven. The census was 63 with 28 residents in certified beds. Review of the facility's Bathing policy, dated February 2019, showed: Policy: -To cleanse the skin on micro-organisms (small bacteria) thus preventing infections and preserving the integrity of the skin; -To provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion (ROM) and improve self-esteem through appearance; -Bath days and the type of bath to be given will be assigned by the Charge Nurse. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Diagnoses included: Alzheimer's disease and Parkinson's disease (a neurological disease that causes tremors and shaking of the body); -Dependent (helper does all of the work) for toileting hygiene, showers/baths, dressing and transfers. Review of the resident's physician order sheet, in use at time of the onsite visit, showed an order for the resident to receive a shower/bath twice weekly on Wednesday and Saturday on the evening shift. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a history of urinary tract infections (UTIs, infection of the urinary tract); -Intervention: Resident/Family/Caregiver teaching should include good hygiene practices; -Need: The resident has an ADL self-care performance deficit; -Intervention: The resident requires extensive assist by one staff member for showering and bathing twice weekly and as needed (PRN). Observation on 3/19/25 at 2:28 P.M., showed the resident seated in a wheelchair. Certified Nursing Aide (CNA) A and CNA B, used a stand up lift (mechanical lift to assist residents with standing) to stand the resident up and change his/her brief and provide perineal care (peri-care, cleansing of the genitals). The resident's hair appeared very oily, flat and stringy. The resident had long facial hair including a mustache. The resident had a strong body odor. CNA A and CNA B placed the resident back in his/her wheelchair and propelled him/her to the dining room. During an interview on 3/19/25 at 2:30 P.M., Family Member S said he/she did not think the resident had had a shower since the end of last month. The resident always looked disheveled and his/her hair was oily. It was a struggle to get staff to bathe the resident twice weekly. The resident never had a beard and/or mustache prior to admission. The resident always smelled of urine and body odor. During an interview on 3/19/25 at 2:40 P.M., CNA B said residents were supposed to get showers twice weekly. The shower sheets were posted at the nurse's station. Sometimes the nurse would write it down on the assignment sheets. During an interview on 3/20/25, at 7:08 A.M., Licensed Practical Nurse (LPN) C said residents were supposed to be showered at least twice a week. CNAs gave the showers and nurses signed off on the shower sheets. Review of the shower/bath schedule on 3/19/25, showed the resident was to have a shower/bath on Wednesdays and Saturdays on the evening shift. Review of the resident's shower sheets for February 2025, showed: -Shower sheet dated 2/13/25, -Shower sheet dated 2/19/25; -Shower sheet dated 2/22/25; -Shower sheet dated 2/26/25; -No additional shower sheets were provided. Review of the resident's shower sheets for March 2025. Showed the facility provided one shower sheet dated 3/19/25. No additional shower sheets were provided. During interviews on 3/20/25 at 1:00 P.M. and 4:00 P.M., the Director of Nurses (DON) said she did not have any additional shower sheet documentation for the resident. The residents should receive showers twice a week. The nurses should sign off on the shower sheets. Any skin issues that were new or old should be marked on the shower sheets. Staff should shave residents on the residents' shower days and as needed. MO00249872

Based on observation, interview and record review, the facility failed to follow their policy and the resident's care plan by ensuring two staff members safely assisted a resident who required a sit-to-stand mechanical lift for transfers (Resident #1). Staff failed to have two staff present at each transfer and failed to secure the safety belt around the resident's waist during a transfer. The sample size was seven. The census was 63 with 28 residents in certified beds. Review of the facility's Sara lift (a type of sit-to-stand mechanical lift) policy, dated September 2017, showed: -Purpose: To provide a safe transfer for all residents who are unable to be transferred by staff due to a physical condition; -Procedure: -Two nursing persons must be used for a Sara lift transfer; -Position sling around resident's back so it is approximately two inches above the waistline; -Fasten safety belt around the resident's waist; -Unclasp sling from lift, remove safety belt from the resident; -Note: Nursing staff not using two nursing personnel for a Sara lift transfer will begin counseling process for failure to follow facility policy and procedures for safe transfer. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Diagnoses included: Alzheimer's disease and Parkinson's disease (a neurological disease that causes tremors and shaking of the body); -Dependent (helper does all of the work) for toileting hygiene, showers/baths, dressing and transfers. Review of the resident's care plan, in use at the time of the survey, showed: -Need: The resident has an activities of daily living (ADL) self-care performance deficit; -Interventions: The resident requires max of two staff assistance to move between surfaces as necessary. The resident requires mechanical lift sit-to-stand with two person staff assistance. Review of video footage dated 2/1/25 at 8:02 A.M., showed the resident lay in bed. An unidentified Certified Nurse Aide (CNA) could be seen using the sit-to-stand lift, with no other assistance, the CNA transferred the resident from the bed to the wheelchair. The belt from the lift was not secured around the resident's waist and hung unattached at the resident's side. Review of video footage, dated 2/1/25 at 6:47 P.M., showed the resident sat in a wheelchair. An unidentified CNA entered the resident's room alone with the sit-to-stand lift. The CNA turned the camera away from view and said, I am not having you watch me, sorry. During the audio portion of the video, the staff member can be heard talking to the resident. The resident can be heard saying ouch, ouch. Approximately five minutes later, the CNA put the camera back in view. The resident lay in bed. At no time during the audio, could a second staff person be heard entering the room to assist with the sit-to-stand transfer. Observation on 3/19/25 at 2:28 P.M., showed the resident seated in a wheelchair. CNA A and CNA B entered the resident's room with a sit-to-stand lift. CNA A assisted CNA B with applying the lift belt. Neither CNA clasped the belt around the resident's waist. CNA A lifted the resident to a semi-standing position. CNA B pulled down the resident's pants down, removed his/her adult brief, provided perineal care (cleansing of the genital area and buttocks), applied a clean brief, pulled up the resident's pants and lowered him/her back into the wheelchair. CNA B removed the belt from around the resident's waist by pulling the belt and releasing the Velcro. CNA A then propelled the resident to the activity room. During an interview on 3/19/25 at 2:38 P.M., CNA B said it was policy for two people to be present when using a sit-to-stand lift. He/She thought the belt had been clasped during the transfer. He/She knew the Velcro was attached but didn't think about the buckle [NAME] being secured. During an interview on 3/20/25 at 3:00 P.M., the Director of Nursing said she expected staff to use two person assistance when using the mechanical sit-to-stand lift with a resident. The belt should be secured with Velcro and the belt should be clasped with the buckle provided with the belt. The sit-to-stand lift required two people in case the resident's knees buckled or the machine began to topple over. MO00249872

Based on observation and interview, the facility failed to ensure one treatment cart remained locked when left unattended with medications on top of the cart. This practice could affect all residents residing in the facility. The census was 63 with 28 in certified beds. Review of the facility's Medication Administration-General Guidelines policy dated July 2021, showed all medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. Observation on 3/19/25 at 11:00 A.M. to 11:17 A.M., showed the treatment cart on the Avalon unit unattended and unlocked. Multiple medications sat on top of the cart. Residents were seated and stood in the hallway near the cart. There were two Exelon patches (used for the treatment of dementia) and one Tamiflu (used to treat flu symptoms) tablet on top of the cart. All the drawers were able to be opened. The cart contained treatment supplies and various medications. During an interview on 3/19/25 at 11:18 A.M., the Director of Nursing said she expected all treatment and medication carts to be locked and secured. No medications should ever be left unsupervised on a medication/treatment cart.

Based on observation, interview, and record review, the facility failed to ensure one resident was served meals in a timely manner when staff served meals outside the timeframes designated by the facility (Resident #1). The sample was seven. The census was 63 with 28 in certified beds. Review of the facility's mealtimes showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. -Review on 3/19/25 at 10:05 A.M., of the meal service logbook, showed the space for each day to record the start and stop time for each meal service. There were multiple days staff failed to document any times in the designated dates and/or times for each meal services The dates and times the staff did document showed they documented the start and end of each meal on each day mirrored the facility's mealtimes showing that Breakfast was started at 7:30 A.M. and ended at 9:00 A.M., lunch was started at 11:30 A.M. and ended at 1:00 P.M., dinner started at 4:30 P.M. and ended at 6:30 P.M. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 1/3/25, showed: -Severe cognitive impairment; -Requires moderate assistance from staff with eating; -Diagnose included: Diabetes, urinary tract infection in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has Activity of Daily Living (ADL) deficit related to Alzheimer's; -Interventions: Eating-regular diet, requires set up assistance and encouragement at times. Review of camera footage dated 3/9/25 from 12:15 A.M., until 12:12 P.M., showed the resident lay in bed. At no time did the motion activated camera show staff brought a breakfast tray for the resident. Observation on 3/19/25 at 9:30 A.M., showed the resident lay in bed. Certified Nursing Assistant (CNA) A and CNA B provided the resident assistance with dressing and getting out of bed. At 9:57 A.M., the resident was assisted out of bed and placed in his/her wheelchair. CNA A propelled the resident into the dining room and served the resident breakfast. During an interview on 2/19/24 at 2:25 P.M., Family Member (FM) S said the resident was frequently left in bed for breakfast or until after breakfast. The resident was able to feed himself/herself but was totally dependent on staff to get him/her out of bed for meals. Staff frequently let 14 to 16 hours elapse between dinner and breakfast. It had been an ongoing issue. FM S had a camera in the resident's room, and could see when the resident was gotten up and taken out for meals. At times staff would bring a tray to the resident's room and just leave it sitting on the over the bed table without sitting the resident up and/or assisting with set up of the meal. There had been multiple occasions when the resident was not fed a meal all day. Staff at the facility were not organized and had no system in place to make sure every resident was served a meal at every mealtime, every day. During an interview on 3/19/25 at 10:00 A.M., Dietary Aide F said the resident was served breakfast late because staff failed to bring the resident to the dining room prior to 9:00 A.M. Nursing staff frequently brought residents to the dining room after scheduled mealtimes. Nursing staff were responsible to let dietary staff know which residents would be eating meals in their rooms. Nursing staff took trays to resident rooms. During an interview on 3/19/25 at 9:55 A.M., Dietary Manager E said the facility had an open meal plan. Breakfast could be served from 7:30 A.M., to 9:00 A.M. Dietary staff served off of a steam table in the unit dining rooms. All residents should have their meal no later than 9:00 A.M. Dietary staff would remain on the unit with the steam table until all residents were served. There were times the meals were served late because there could be a problem with dietary staff and/or nursing staff. The dietary department was open from 7:00 A.M. until 7:00 P.M. Dietary staff should use dietary tickets to assure each resident was served a meal. He/She did not know how a resident would not be served a tray. There was no other system to make sure each resident received a tray at each meal. Dietary tickets were printed by the dietary department. The resident received his/her meal late because nursing staff got the resident up late. During an interview on 3/19/24 at 1:00 P.M., the Director of Nursing said she would expect meals to be served timely. There were a lot of agency nursing staff, and they were not familiar with the residents and the mealtime process. During an interview on 2/19/25 at 1:30 P.M., the Executive Director said he would expect meals to be served timely and within the times listed on the menus. He would expect nursing and dietary staff to work together to serve the residents meals. During an interview on 3/20/25 at 2:30 P.M., the Regional Corporate Nurse said residents should receive a meal tray within the designated meal timeframes. Dietary staff were supposed to keep a log to show when meals were served outside of the designated mealtimes. She did not know why the log was not updated and/or accurate when staff documented all meals for the month had been served within the timeframes. MO00249872

Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and to promptly resolve grievances for one resident (Resident #1). The facility failed to follow-up on concerns expressed at Resident Council meetings. In addition, the facility failed to identify a Grievance Official responsible for overseeing grievances in their policy. The failure has the potential to affect all residents. The census was 52 with 25 in certified beds. Review of the facility's grievance policy, dated 2017, showed: -Preface: It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furbished, the behavior of the staff and of other residents, and other concerns regarding their Long Term Care (LTC) facility stay; The facility will ensure prompt resolution to all grievances, keeping the resident and residents representative informed throughout the investigation and resolution process; The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with staff; The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service and will provide residents, resident representatives, and other information about the mechanisms and procedure to file a grievance; The facility will provide a designated individual to oversee the grievance process, provide a planned systematic mechanism for receiving and prompting action upon issues expressed by residents and resident representatives; The facility will provide ongoing system for monitoring and trending grievances and complaints; -Procedure: -The facility will help promote the grievance process through the organization; This includes notifying residents of their rights related to grievances as well as education to all those affected by potential grievances or concerns on the family grievance processes, including but not limited to: -Resident; -Resident representative; -Employees; -Volunteers; -Vendors; -And other stakeholders. -Grievance Official: The facility will train and designate an individual who is responsible for: -Overseeing the grievance process in conjunction with facility administration; -Receive and track all grievances through to their conclusion; -Lead any necessary investigations by the facility; -Work with facility staff utilizing root cause analysis processes for resolution of the grievance or concern; -Maintain confidentiality of all information associated with grievances; -Complete written grievance resolutions/decisions to the resident involved; -Resident Council: -The facility will review the grievance policy and procedure with the resident council on an annual or as needed basis; The Grievance Official will attend the resident council meeting as agreed upon in the resident council charter; All grievances identified during the resident council meeting will be submitted immediately to the Grievance Official for investigation and resolution; Reporting of resolution outcome will be given to the resident council per protocol; -A grievance or concern can be expressed orally to the Grievance Official or facility staff or in writing using a grievance form; -Grievances may be give to any staff member who will forward the grievance to the Grievance Office, or they may file the grievances anonymously in the designated box; -Response: An employee of the facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority; If a compliant cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official. -The policy did not address the name or title of the facility Grievance Official. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -An admitted [DATE]; -Severe cognitive impairment; -Diagnoses included: Alzheimer's disease and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of e-mails provided by Family Member K showed: -An email, dated 11/15/24 at 5:19 P.M., to the Director of Nursing (DON) from Family Member K with questions related to the resident's care, physician appointments and medications; -An e-mail, dated 11/19/24 at 8:34 A.M. to the DON from Family Member K, asking the DON if she had received his/her previous e-mail; -An e-mail, dated 11/30/24 at 4:07 P.M. to the DON from Family Member K, providing dates and times that Family Member K would be in town and a request to meet with the DON. -There were no responses or to the e-mails sent to the DON by Family Member K or an out of office e-mail automated response. During an interview on 12/5/24 at 10:55 A.M., Family Member K said he/she lives out of town and the resident was admitted to the facility on [DATE]. He/She had some concerns about the resident and the resident's care. He/She was provided the DON phone number by a staff member. Family Member K said he/she left two voicemails on 11/8/24, one voicemail on 11/12/24, and two voicemail messages on 11/14/24. After getting no response, Family Member K e-mailed the DON on 11/15/24 at 5:19 P.M.,with his/her concerns. Family Member K said he/she still did not get a response and e-mailed the DON again on 11/19/24 at 8:34 A.M. questioning the DON if she had received his/her messages. On 11/21/24, Family Member K said he/she called the front desk, and the person who answered the phone said that the DON was on vacation and that the facility recently had their phone system redone and that the facility was working out the kinks. The person who answered the phone did not offer any other staff member who he/she could speak with or offer to take a message with his/her concerns. Family Member K left one voicemail message on 11/26/24. Family Member K still did not get a response from the voicemails and e-mailed the DON on 11/30/24 at 4:07 P.M., stating in the e-mail that Family Member K was going to be in town on 12/2/24 and would like to meet with the DON. The DON called Family Member K on 12/4/24 and left a message requesting a time to meet with Family Member K. Review of the facility's grievance log for June 2024 through December 2024, showed two grievances, dated, 8/14/24 and 8/23/24. During an interview on 12/6/24 at 11:00 A.M., the Administrator said that the two grievances filed in August 2024 were the only ones of which he was aware. 2. Review of the Resident Council meeting minutes, dated 11/27/24, Start time: 2:08 P.M., End time: 2:40 P.M., showed: -Residents in attendance: Blank; -Resident comments, concerns or recommendations: The residents asks questions, have concerns and never get answers. During an interview on 12/9/24 at approximately 10:00 A.M., the Life Enrichment Director said she e-mails all department heads the Resident Council meeting minutes and what specific things need to be addressed for their specific department. She never gets a response. There is no follow through on resident grievances. There are only a couple of residents who come to the Resident Council meetings. They feel it is useless because nothing every gets resolved. She thought the Grievance Officer was the Social Worker but wasn't sure. 3. During an interview on 12/6/24 at 8:42 A.M., Licensed Practical Nurse (LPN) F said there was very little follow through on resident complaints. There used to be Unit Managers who would assist the nurses and smooth things over when resident issues came up. Resident care was a lot better and there were less complaints when there were Unit Managers available. LPN F said he/she will try to solve resident issues him/herself or inform the Assistant Director of Nursing (ADON) or the DON about the residents' issues. LPN F does not who the Grievance Officer is. 4. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said he/she receives complaints all the time from the residents and resident's family members about resident care and staff issues. RN G said she tries to address their concerns, but if he/she cannot solve the problem, he/she will try to call the DON. There are two phone numbers for staff to call the DON, and they will always go to voicemail. There is no follow through on resident issues and complaints. There are no Unit Mangers to assist with resident issues or complaints. It all lands on the shoulders of the floor nurse to solve the problems the residents are having, in addition to all the other tasks that the nurses have to do. Most of the nursing staff are agency staff and are only in the building working a couple of shifts a month and do not follow through on resident complaints or issues. RN G thought the Grievance Officer was the Administrator or the Social Worker but wasn't sure. 5. During an interview on 12/9/24 at approximately 11:30 A.M., the Social Service Director (SSD) said there is 100% lack of communication between administration and managers and the residents who have grievances and complaints. She is not the Grievance Officer but will try to handle resident issues to the best of her ability. She does not have a grievance log or book. She thought the Social Worker who recently left had a grievance book, and that the Administrator may have it now. 6. During an interview on 12/9/24 at 1:00 P.M., the DON said she was on vacation 11/15 through 11/25/24. She did not review her e-mails while on vacation. They recently had a new phone system installed and the were some issues initially, but they are resolved now. She receives some of the Resident Council meeting minutes via e-mail. She would expect staff to call her or the ADON directly on their cell phone for resident concerns. The Administrator or Social Worker can also address resident concerns and issues. 7. During an interview on 12/9/24 at 1:30 P.M., the Administrator said he is not the official Grievance Officer. He thought it was the Social Worker. The DON and ADON were on vacation at the same time, which was approved without his knowledge and it should not have occurred. He encouraged the DON to have her e-mail say she was out of the office but didn't think she did so. The Resident Council meeting minutes are not always provided to him and thought the activity staff forget to give the minutes to him. He expects staff and department heads to address residents grievances to the best of their ability in a timely manner. He would expect managers to answer e-mails and voicemails in a timely manner. He would expect non-management staff members to try to assist residents and their representatives if no one is readily available. This is the residents' home, and they should be happy and satisfied with the care they receive at the facility. MO00246155

Based on observation, interview, and record review, the facility failed to ensure the residents were served meals in a timely manner, which included two sampled residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 in certified beds. 1. Review of the facility's menus labeled Bistro 307 showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. 2. Review of Resident #1 's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires moderate assistance from staff with eating; -Dependent on staff assistance going from lying to sitting position, -Diagnose included: Diabetes, urinary tract infection in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a nutritional problem due to his/her need for a therapeutic diabetic diet. -Interventions: Provide and serve therapeutic diet. Observation on 12/5/24 at 9:36 A.M., showed the resident lay in bed. Certified Nursing Assistant (CNA) A and CNA B provided the resident assistance with dressing and getting out of bed. At 10:00 A.M., the resident was assisted out of bed and placed in his/her wheelchair. CNA A propelled the resident into the dining room. Staff served the resident a bowl of oatmeal in a Styrofoam cup and a glass of juice. During an interview on 12/5/24 at 10:25 A.M., Family Member K said the resident was frequently left in bed until after breakfast and served cold food or whatever was left over. 3. Review of Resident #2's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Requires moderate assistance from staff with eating; -Dependent on staff for bed to chair transfers; -Diagnoses included arthritis, Alzheimer's disease, anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a potential nutritional problem related to his/her dementia, with need for cueing and a history of swallowing difficulties; -Interventions: Provide and serve meal as ordered. Observation on 12/9/24 at 9:40 A.M., showed staff in the resident's room getting the resident dressed and into a wheelchair. Staff brought the resident to the dining room in his/her wheelchair. At 9:46 A.M., staff served the resident juice and coffee. At 9:48 A.M., staff served the resident fresh fruit in a bowl that the resident ate with his/her fingers. 4. During an interview on 12/5/24 at 7:48 A.M., Dietary Aide L said breakfast was always served late because dietary staff run late for their shifts. 5. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said the meals were always served late. There was not enough staff in the kitchen. There is a lot of nursing agency staff who show up late to their shift, are not familiar with the residents and do not get the residents up in a timely manner to go out to the dining room for meals. Sometimes residents will miss meals. 6. During an interview on 12/9/24 at 12:25 P.M., CNA H said meals were usually served in the residents' rooms because the residents were not out of bed yet or the food comes to the hall late. 7. During an interview on 12/9/24 at 11:40 A.M., the Director of Culinary Services said he is aware the meals are late because they have a shortage of staff and the staff come in late for their shifts. He is new to the role and is working on getting staff and providing meals in a timely manner. 8. During an interview on 12/9/24 at 1:00 P.M., the Director of Nursing (DON) said she would expect meals to be served timely. There are a lot of agency nursing staff, and they are not familiar with the residents and the meal time process. 9. During an interview on 12/9/24 at 1:30 P.M., the Administrator said he would expect meals to be served timely and within the stated times on the menus. He would expect nursing staff and dietary to work together to serve the residents meals. MO00245478 MO00246155

Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs, bathing, dressing and toileting) received the necessary services to maintain adequate personal hygiene when staff did not provide showers to two residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Bathing policy, review date February 2019, showed; Policy: To cleanse the skin on micro-organisms (small bacteria) thus preventing infections and preserving the integrity of the skin; To provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion (ROM) and improve self-esteem through appearance; Bath days and the type of bath to be given will be assigned by the Charge Nurse. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires substantial assistance for staff with toileting hygiene, shower and bathing, upper body dressing; -Requires moderate assistance from staff for personal hygiene; -Dependent on staff assistance going from lying to sitting position, sitting to standing position, chair to bed and bed to chair transfers; -Has indwelling urinary catheter (a tube that drains the bladder); -Diagnoses included: Diabetes, urinary tract infection (UTI) in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a history of UTIs; -Interventions: Resident/Family/Caregiver teaching should include good hygiene practices. -Need: The resident has an ADL self-care performance deficit; -Interventions: The resident requires extensive assist by one staff member for showering and bathing. Observation on 12/5/24 at 9:36 A.M., showed the resident lay in bed and Certified Nursing Assistant (CNA) A and CNA B provided perineal care (peri-care, cleansing of the genitals) and assisted the resident change his/her clothing. The resident's hair appeared very oily, flat and stringy. The resident raised his/her arms up and CNA A removed the resident's shirt. The resident had a strong body odor. CNA A applied roll-on deodorant and placed a clean shirt on the resident. CNA A and CNA B placed the resident in his/her wheelchair and propelled him/her to the dining room. During an interview on 12/5/24 at 10:25 A.M., Family Member K said he/she did not think that the resident has ever had a shower since admission on 11/1/24. The resident always looks disheveled and his/her hair is oily. The only time the resident's hair was washed was when the beautician did it, which was only two times. The staff just keep adding deodorant to cover up the smell. During an interview on 12/9/24 at 1:00 P.M., the Director of Nurses (DON) said she did not have any shower sheet documentation for the resident. 2. Review of Resident #2's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, bathing, and bed to chair transfers; -Always incontinent of bowel and bladder; -Diagnoses included arthritis, Alzheimer's disease, anxiety, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Need: The resident had an ADL self-care deficit related to Alzheimer's disease; Interventions: The resident requires maximum assist for staff with showering twice weekly and as needed; Provide a sponge bath when a full bath or shower cannot be tolerated; The resident is to be shaved on shower days. Observations on 12/5/24 at 7:48 A.M., showed the resident in his/her room with very oily hair and had approximately one fourth of an inch beard. At 2:20 P.M., the resident was in the activities room with very oily hair and had approximately one fourth of an inch beard. Observation on 12/9/24 at 9:40 A.M., showed the resident sitting in the dining room on Aspen Hall with very oily hair and approximately one half an inch of a beard. Review of the shower sheets, dated October, 2024 showed: -On 10/23/24 and 10/31/24 showers were completed. During an interview on 12/9/24 at 1:00 P.M., the DON said that was all the shower sheets she had for the resident. There were no shower sheets for November, 2024 or December, 2024. 3. During an interview on 12/6/24 at 8:15 A.M., CNA M said he/she was the shower aide for the day. There normally was not a shower aide for the Aspen and Birch Halls. Staff fill out shower sheets once the showers are completed. Staff should shave residents when requested or as needed. 4. During an interview on 12/6/24 at 11:15 A.M., CNA A said showers should be completed twice a week. There is a schedule that is followed at the nurses' station for the showers. Staff fill out shower sheets when the showers are completed and give the sheets to the Assistant Director of Nursing (ADON). 5. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said the showers are rarely completed for residents twice a week. The CNAs do what they want, and the nurses do not check to make sure the showers are done. There has not been a nursing manger for the nursing units for a couple of months, and the care has really gone downhill because there is no accountability for the staff from management. 6. During an interview on 12/9/24 at 1:00 P.M., the DON said the residents should receive showers twice a week. The nurses should sign off on the shower sheets. Any skin issues that are new or old should be marked on the shower sheets. Staff should shave residents on the residents' shower days. MO00246155

Based on observation, interview and record review, the facility staff failed to ensure one resident (Resident #1) who developed a newly acquired pressure ulcer (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) had weekly skin assessments completed, according to the resident's care plan. Facility staff also failed to notify the physician of the new pressure wound and obtain new treatment orders in a timely manner. In addition, the facility staff failed to complete weekly skin assessments, according to facility policy, on one resident (Resident #2) who had a history of pressure ulcers. The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Prevention and Treatment of Skin Breakdown and Other Skin Conditions policy, dated 2017, showed: Policy: -It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcer/injuries; To implement preventative measures and to provide appropriate treatment modalities for wounds according to industry standards; -Procedure: -Prevention of pressure ulcers or injuries: -A skin body audit will be done weekly during a resident's entire stay; -Skin will be observed daily with care of the nursing assistant; -If any skin concerns are noted, they are to reported promptly to the designated nurse; -Weekly skin audits on the bath/shower day will be performed by the licensed nurse and documented in the electronic medical record (EMR). 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -An admitted [DATE]; -Severe cognitive impairment; -Requires substantial assistance for staff with toilet hygiene, shower and bathing, upper body dressing; -Requires moderate assistance from staff for personal hygiene and rolling left to right; -Dependent on staff assistance going from lying to sitting position, sitting to standing position, chair to bed and bed to chair transfers; -Has indwelling urinary catheter (a tube that drains the bladder); -The resident is at risk for developing pressure ulcers; -Diagnoses included: diabetes, urinary tract infection (UTI) in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a potential for impairment to skin integrity related to incontinence, history of weight loss, and need for assistance with mobility, positioning and transfers; -Interventions: Elevate the resident's heels off of the bed; Encourage good nutritional and hydration: Follow facility protocol for treatment of injury; weekly skin documentation of any new areas, documentation to include measurement of each new areas of skin breakdown's width, depth, type of tissue and drainage and any other notable changes; Turn and position during rounds and as needed. Review of the resident's Braden Scale (an assessment tool completed by nursing staff that predicts pressure ulcer risk), dated 11/18/24, showed the resident's score was 13, moderate risk for developing a pressure wound. Review of the resident's skin observations under the assessment tab in the electronic medical record showed: -On 11/8/24 at 2:25 P.M., skin intact; -No documented skin assessments between 11/9/24 and 11/27/24; -On 11/28/24 at 12:39 P.M., no new skin issues at this time; -On 12/6/24 at 4:41 P.M., Site: Sacrum (tailbone); Type: Pressure; Notes: Cleansed, educated and teaching was done with resident to decrease redness to his/her sacrum. Observation and interview on 12/5/24 at 9:36 A.M., showed the resident lay in bed on his/her back. Certified Nursing Assistant (CNA) B assisted CNA A turn the resident to his/her left side. The resident had two quarter-sized deep red maroon-colored circles to the right and left of his/her sacrum and the two circles merged to the center of the sacrum. The areas were not opened and did not have drainage. CNA A cleansed the resident's rectal area and applied Zinc (a cream used to prevent or treat skin irritations). Family Member K was at the bedside and asked CNA A why the resident's sacrum was red. CNA A said to Family Member K that it was due to the resident lying in one spot for too long, and it is not supposed to occur. The resident needs to be turned and repositioned by staff because the resident cannot do it him/herself. Repositioning the resident is to prevent the redness from occurring. The resident said his/her bottom hurt. Observation on 12/6/24 at approximately 10:00 A.M., showed the resident lay in bed on a regular mattress, and CNA D assisted the resident with getting dressed. The resident had two quarter-sized deep red, maroon-colored circles to the right and left of his/her sacrum, and the two circles merged to the center of the sacrum. The areas were not opened and did not have drainage. During an interview on 12/6/24 at 10:25 A.M. and at 1:15 P.M., Licensed Practical Nurse (LPN) E said the CNA did not inform him/her that the resident had a red area on his/her sacrum on 12/5/24. LPN E said he/she examined the resident's sacrum and said the area was a pressure wound. During an interview on 12/6/24 at 11:15 A.M., CNA A said the resident had the red areas on his/her sacrum about a week ago and he/she told the nurse at that time but did not inform the nurse on 12/5/24. Review of the resident's progress notes, dated 10/31 through 12/9/24, showed no documentation that the resident's physician was notified of the new pressure area or new treatment orders or interventions put in place for the resident's sacrum. Review on 12/9/24 at 8:29 A.M. of the resident's physician order sheets (POS), dated December 2024, showed no orders related to the resident's newly acquired pressure wound. During an interview on 12/5/24 at 2:00 P.M., LPN N said skin observations should be documented on the skin observation tool. Even if there are no skin issues, the skin assessment tool was required to be filled out. If a new area is assessed, the nurse should measure it and describe how it looks. Staff should obtain orders immediately. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said the resident has dementia and would not understand being educated about a newly acquired pressure wound. Any nurse can stage a wound. They have cards attached to their badges for reference on how to stage the wound. The nurse needs to describe the wound to the best of his/her ability to the physician. The minimum that should be done for a newly acquired pressure wound, is obtain an order for a low air loss (LAL) mattress immediately. The facility always has the LAL mattresses in the building. 2. Review of Resident #2's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, bathing, and bed to chair transfers; -Always incontinent of bowel and bladder; -At risk of developing a pressure wound; -Diagnoses included arthritis, Alzheimer's disease, anxiety, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Need: The resident has an actual and potential impairment to skin integrity related to a history of Stage 2 pressure ulcer (partial thickness skin loss, presenting as shallow open ulcer) on his/her sacrum; -Interventions: Weekly treatment documentation to include measurement of each new area of skin's breakdown's width, length and type of tissue, drainage and any other notable changes or observations. The resident's Braden score, dated 11/6/24 at 2:04 P.M. was 14, moderate risk for developing pressure wounds. Review of the resident's skin observations in the assessment tab in the resident's EMR showed: -On 10/9/24 at 11:07 P.M., Site: Right buttock; Type: pressure; Site: left buttock; Type: Pressure; Notes: Stage 2 pressure ulcer, redness and irritation noted. -No further skin assessments were documented. Review of the resident's progress notes showed: -On 10/18/24 at 1:41 P.M., sacral wound healed, no open areas noted at this time. Review of the shower sheets, dated October, 2024 showed: -On 10/23/24 and 10/31/24 showers were completed. During an interview on 12/9/24 at 1:00 P.M., the Director of Nursing (DON) said that was all the shower sheets she had for the resident. There were no shower sheets for November, 2024 or December, 2024. Observation on 12/5/24 at 7:48 A.M., showed the resident lay in bed and CNA C was assisting the resident applying socks, shoes, and pants. CNA D entered the room and assisted CNA C with a mechanical lift transfer of the resident into his/ her wheelchair. Once the resident was finished using the toilet, CNA C raised the resident off the toilet with the use of the mechanical lift. The resident had no skin issues to the sacrum or buttocks. 3. During an interview on 12/6/24 at 11:15 A.M., CNA A said showers should be completed twice a week. There is a schedule that is followed at the nurses' station for the showers. Shower sheets are filled out when the showers are completed and given to the Assistant Director of Nursing (ADON). Any new skin issues are circled on the shower sheets and reported to the nurse. 4. During an interview on 12/9/24 at 10:35 A.M., RN G said skin assessments should be completed on every resident, especially if the resident previously had a pressure wound or is at a higher risk of developing one. Staff were not completing skin assessments. RN G knows that the assessments are not being done because the system will alert you in the computer if the skin assessments are past due, and he/she sees that occur frequently. There are no managers or regular staff to follow up and ensure that skin assessments are being completed. 5. During an interview on 12/9/24 at 1:00 P.M., the DON said the nurses were expected to sign off on the shower sheets and review the sheets for any new skin issues. Any skin issues that are new or old are to be marked on the shower sheets by the person completing the shower. Licensed nurses should complete residents' weekly skin assessments and document them in the assessment tab. An RN is the only nurse that can stage wounds. Newly acquired skin conditions should be reported to the physician and family immediately. MO00246155 MO00245478

Based on observation, interview and record review, the facility failed to follow their policy and the resident's care plan and ensure two staff members assisted residents who required a sit-to-stand mechanical lift for transfers (Resident #2). The sample size was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Sara lift (a type of sit-to-stand mechanical lift) policy, dated September, 2017, showed: Purpose: To provide a safe transfer for all residents who are unable to be transferred by staff due to a physical condition; Procedure: Two nursing persons must be used for a Sara lift transfer; Note: Nursing staff not using two nursing personnel for a Sara lift transfer will begin counseling process for failure to follow facility policy and procedures for safe transfer. Review of Resident #2's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 10/4/24, showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, bathing, and bed to chair transfers; -Always incontinent of bowel and bladder; -Diagnoses included arthritis, Alzheimer's disease, anxiety, and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Need: The resident has an activities of daily living (ADL) self-care performance deficit; -Interventions: The resident requires max of two staff assistance to move between surfaces as necessary. The resident requires mechanical lift sit-to-stand with two person staff assistance. Review of video footage, dated 10/23/24 at 7:40 A.M., showed the resident lay in bed. Certified Nursing Assistant (CNA) A assisted the resident with peri-care (cleansing of the genitals) and getting dressed. CNA A assisted the resident to the side of the bed and applied the Sara lift belt to the resident's upper torso and attached the belt to the lift. CNA A then left the resident's room for approximately one minute while the resident was attached to the lift. CNA A returned to the resident's room and Unknown Staff Member I entered the room and stood at the doorway. CNA A transferred the resident into the wheelchair using the Sara lift while Unknown Staff Member I stood at the door. Review of video footage, dated 10/25/24 at 10:12 A.M., showed the resident lay in bed. CNA A assisted the resident by providing peri-care and help with dressing. CNA A assisted the resident to the side of the bed and applied the Sara lift belt to the resident's upper torso and attached the belt to the lift. CNA A then left the resident's room for approximately one minute while the resident was attached to the lift. When CNA A returned to the room, he/she transferred the resident into his/her wheelchair. CNA A did not have a second staff member in the room. Observation on 12/5/24 at 7:48 A.M., showed the resident lay in bed and CNA C assisted the resident applying socks, shoes, and pants. CNA D entered the room and assisted CNA C with applying the Sara lift belt. CNA C and CNA D placed the resident into his/her wheelchair, and CNA D transferred the resident into the bathroom and positioned the resident on the toilet. CNA D left the room. Once the resident was finished using the toilet, CNA C raised the resident off the toilet with the Sara lift. CNA C cleansed the resident, applied Desitin (barrier) cream to the resident's buttocks and applied a new brief. CNA C transferred the resident from the bathroom, approximately 25 feet across the bedroom using the Sara lift, to the resident's wheelchair. CNA C then lowered the resident into the wheelchair with the use of the lift. CNA C transferred the resident by himself/herself from the bathroom to the bedroom. During an interview on 12/6/24 at 9:05 A.M., Physical Therapist (PT) J said he/she has been working with the resident, and the resident's current transfer status was a two person transfer utilizing the Sara lift. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said staff should use two staff to assist residents with mechanical sit-to-stand lift transfers. The resident should never be left unattended in the lift, and the second staff member should be next to the resident during the transfer, in case the resident's legs buckle and they begin to fall. During an interview on 12/9/24 at 12:25 P.M., CNA H said two staff members are to assist the resident when utilizing a mechanical sit-to-stand lift. The staff member should remain with the resident when attached to the lift. A staff member standing in the doorway does not count as the second person. The second staff member should be standing very close and assisting with the transfer, in case the lift stops working or the resident begins to fall. During an interview on 12/9/24 at 1:00 P.M., the Director of Nursing (DON) said she expected staff to use two persons assistance when using the mechanical sit-to-stand lift with a resident. The resident should not be left unattended when attached to the lift, and the second person should be hands on with the transfer, not standing at the doorway. The Sara lift required two persons in case the resident's knees buckle or the machine began to topple over. MO00245478 MO00246155

Based on observation, interview and record review, the facility failed to provide one resident (Resident #1) with proper urinary catheter (tube that drains the urine from the bladder) care by failing to have catheter supplies readily available to ensure the resident's catheter was changed, and failed to obtain a urine specimen, according to physician orders, in a timely manner. The staff failed to place the resident's urinary catheter below the resident's bladder during a transfer, which put the resident at greater risk for infection. The sample was eight. The census was 52 with 25 in certified beds. Review of the facility's catheter policy, review date February 2019, showed: -Catheter Care should be given every shift and as needed; -Never lift bag above bladder level (source of infection); -Change drain bag and tubing every 30 days; -Change indwelling Foley catheter as indicated based on assessment or per physician order. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires substantial assistance for staff with toilet hygiene, shower and bathing, upper body dressing; -Requires moderate assistance from staff for personal hygiene; -Dependent on staff assistance going from lying to sitting position, sitting to standing position, chair to bed and bed to chair transfers; -Has indwelling urinary catheter; -Diagnoses included: Diabetes, urinary tract infection (UTI) in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a history of UTIs; -Interventions: Resident/Family/Caregiver teaching should include good hygiene practices; Obtain and monitor lab and diagnostic work as ordered; -Need: The resident has a urinary catheter related to his/her diagnosis of urinary retention (inability to empty bladder completely); Interventions: Catheter care and treatment per current physician orders; Position catheter bag and tubing below the level of the bladder. Review of the resident's urologist (a kidney and bladder specialist) physician orders showed: -An order dated, 12/4/24 at 1:21 P.M., catheter needs to be changed 12/4/24 using a 16 french (fr) indwelling Foley catheter and filling the balloon with 10 milliliters (mls) of sterile water; -After the exchanged foley, obtain a urine culture (a test to check the urine for an infection)from the new exchanged Foley. Review of the resident's progress notes showed: -On 12/5/24 at 8:28 A.M., Foley catheter to be changed today but the supplies are not available, this nurse will order the 16 fr, 10 mls and it will be done tonight; -On 12/5/24 at 3:43 P.M., the resident's Foley was not changed today; The Nurse Practitioner (NP) at the hospital clinic was called to advise how to proceed; The catheter is to be changed now every 30 days using a 16 fr indwelling Foley filled with 10 mls of sterile water; The resident is to have a urine culture with every new exchange; -On 12/6/24 at 12:47 P.M., order clarification for Foley catheter per NP; May use a 16 fr, 5 ml indwelling catheter and fill with 10 mls of sterile water; -On 12/7/24 at 9:11 A.M., the resident's catheter was changed, urine specimen was obtained, was informed by the lab that there was no coverage for lab to pick up specimen on the weekend; The nurse will schedule specimen pick up on 12/9/24 at 6:00 A.M. During an interview on 12/5/24 at 10:25 A.M., Family Member K said the resident returned from a urologist visit on 12/4/24, and Family Member K gave the new urinary catheter related orders to the nurse on duty. During an interview on 12/5/24 at approximately 12:00 P. M., the Central Supply Technician O said he/she did not have the correct Foley catheter supply for the resident. His/Her computer was down so he/she could not check to see if he/she could order it. He/She thought the nurse was going to call the physician and see if they could use the catheter the facility had on hand. During an interview on 12/6/24 at 8:42 A.M. and on 12/9/24 at 1:42 P.M., Licensed Practical Nurse (LPN) F said the facility did not have the Foley 16 fr, 10 ml balloon and only had the Foley 16 fr, 5 ml balloon. LPN F said the nurse did not change the catheter on 12/6/24. LPN F said he/she changed the catheter on 12/7/24 between 12:00 A.M. and 2:00 A.M., and a urine specimen was obtained. He/She called the lab to have the specimen picked up, but they said there was not enough lab staff to pick the urine up on the weekend. LPN F said the urine specimen was rescheduled for 12/9/24. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said the facility does not have adequate supplies for the nurses to do their jobs. The residents should get the services, products and supplies they need. The facility should have the supplies readily available. The resident's catheter orders should have been reviewed immediately and physician's office should have be called that day on 12/4/24 for clarification. The resident should not have to wait three days to have his/her catheter changed and a urine specimen sent. During an interview on 12/9/24 at 1:00 P.M., The Director of Nursing (DON) said that the resident's catheter exchange and urine specimen took way to long to complete. She would expect staff to problem solve with the physician's office in a timelier manner, and she would expect the facility to have the correct supplies available. 2. Observation on 12/5/24 at 9:36 A.M., showed the resident lay in bed on his/her back. Certified Nursing Assistant (CNA) A assisted the resident by providing perineum care (peri-care, cleansing of the genitals and rectal area). At 9:37 A.M., CNA B entered the room and assisted CNA A with getting the resident dressed and to apply a Hoyer lift (a specialized lift to assist with transfers) by turning the resident side to side. CNA A and CNA B raised the resident up in the Hoyer lift, and CNA A hung the resident's catheter bag on the hooks on the Hoyer lift approximately 12 inches above the resident's bladder. CNA A and CNA B placed the resident in his/her wheelchair. CNA A assisted the resident by adjusting the resident's clothing and raised the resident's catheter bag approximately 12 inches above the resident's bladder while he/she was sitting in his/her wheelchair. During an interview on 12/9/24 at 10:25 A.M., RN G said the resident's urinary catheter and bag should always be kept below the resident's bladder, so the urine does not go back into the bladder and cause a UTI. During an interview on 12/9/24 at 12:25 P.M., CNA H said the resident's catheter bag should be positioned below the waist so that the urine does not go back into the bladder. During an interview with on 12/9/24 at 1:00 P.M., the DON said she would expect staff to position the resident's urinary catheter below the resident's bladder, to prevent a UTI from occurring. MO00246155

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multi drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for one resident with a urinary catheter (a tube that drains the bladder) for one resident (Resident #1). The facility failed to ensure staff used acceptable infection control practices with one resident when providing perineal care (peri-care, cleansing of the genitals) (Resident #1). In addition, the facility staff failed to use acceptable infection control practices when administering medications for one resident (Resident #2). The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Enhanced Barrier Precautions policy, dated April, 2024, showed: -Policy statement: It is the policy of this facility that EBP, in addition to standard contact precautions (a set of infection control practices used regardless of if the resident appears ill)will be implemented during high-contact resident care activities when caring for residents who have an increased risk for acquiring MDRO, residents with wounds, indwelling medical devices or residents with infection or colonization (organism that is in the body but does not produce symptoms) with an MDRO. -Purpose: The purpose of EBP is to prevent opportunities for transfer of all MDROs to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids; -High contact resident care activities include: -Dressing; -Bathing or showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: Central line (a thin tube surgically inserted into a large vein used for medications and fluids),urinary catheter, feeding tube (a surgically inserted tube place in the abdomen to provide liquid nutrition and medications), and tracheostomy tube (a tube surgically inserted into the windpipe to assist with breathing); -Wound Care: Any skin opening requiring a dressing; -Procedure: -EBP are to be implemented in addition to other standard precautions; -Post clear signage on the door/wall outside the resident's room with the type of precautions to be used: -Personal protective equipment (PPE, isolation gowns and gloves) is required by all staff providing high-contact resident care activities; -EBP will be in place for the duration of the resident's stay or until a wound is resolved or the indwelling medical device is discontinued. Review of the facility's policy for Hand Hygiene, undated, showed: -Policy: It is the policy of this facility that hand hygiene (handwashing and or alcohol-based hand rub (ABHR), also known as alcohol-based hand sanitizer (ABHS)), is to be performed consistent with accepted standards of practice in order to reduce the potential of the spread of pathogens; Hand hygiene continues to be the primary means of preventing the transmission of infection. -Procedure: -ABHS are the most effective for reducing the number of germs on the hands of healthcare employees, it is the preferred method of use in most clinical situations and are the most effective products for reducing the number of germs on the hands of healthcare providers; ABHS should be used: Immediately prior to touching a resident; before performance of an aseptic procedure (technique of preventing an infections) or handling invasive medical devices; -When caring for a resident, when moving from a soiled body site to a clean body site of the same resident; -After touching a resident or the resident's immediate environment; -After any contact with blood, body fluids or contaminated surfaces; -Immediately upon removal of gloves and PPE. Review of the facility's Medication Administration policy, dated July, 2021, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Procedures: The person administering medications adheres to good hand hygiene; Hands are washed before putting on examination gloves and upon removal for administration of typical, ophthalmic, injectable, enteral (medications that are administered into the gastrointestinal tract by a feeding tube and by mouth), rectal and vaginal medications. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires substantial assistance for staff with toilet hygiene, showers and bathing, upper body dressing; -Requires moderate assistance from staff for personal hygiene; -Dependent on staff assistance going from lying to sitting position, sitting to standing position, chair to bed and bed to chair transfers; -Has indwelling urinary catheter; -Diagnoses included: MDRO, diabetes, urinary tract infection (UTI) in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a history of UTIs; -Interventions: Resident/Family/Caregiver teaching should include good hygiene practices. -The care plan did not address the use of EBP precautions. Review of the resident's physician order sheets (POS), dated December, 2024, showed: -An order, dated 10/31/24 for EBP. Observation on 12/5/24 at 9:36 A.M., showed no EBP sign posted outside the resident's room. The resident's door had a caddy hanging on it with PPE supplies. The resident lay in bed on his/her back. Licensed Practical Nurse (LPN) F was at the resident's bedside changing the resident's catheter bag with gloved hands. After LPN F changed the catheter bag,Certified Nursing Assistant (CNA) A with gloved hands, removed the resident's covers and lowered the resident's brief. CNA A cleansed the resident's peri-area and around his/her catheter. At 9:37 A.M., CNA B entered the room with no isolation gown and applied gloves, without washing hands or applying hand sanitizer. CNA B assisted CNA A turn the resident to his/her left side. CNA A cleansed the resident's rectal area and applied Zinc (a cream used to prevent or treat skin irritations). CNA A then removed a peri-area cleansing wipe out of a container that was located on the resident's bedside table. CNA A then used the wipe to remove excess Zinc cream off his/her gloved hands. CNA A readjusted the resident's clean brief, pulled the resident's pants up and apply the Hoyer lift (a mechanical device used to transfer residents) pad by turning the resident side to side with the same gloved hands. CNA A and CNA B transferred the resident into the resident's wheelchair by utilizing the Hoyer lift. CNA A continued to assist the resident by adjusting the resident's clothing and catheter with the same gloved hands. CNA A removed his/her gloves and did not perform hand hygiene. CNA A propelled the resident into the dining room. LPN F, CNA A, and CNA B did not wear an isolation gown while providing care to the resident. During an interview on 12/6/24 at 8:40 A.M., LPN F said he/she should have been wearing an isolation gown when he/she changed the resident's catheter bag. During an interview on 12/9/24 at 12:25 P.M., CNA H said EBP are used when there is a sign and PPE is located outside of the door. Staff should wear gown and gloves when providing care. 2. Review of Resident #2's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included arthritis, Alzheimer's disease, anxiety, and depression. Observation on 12/5/24 at 9:02 A.M., on Aspen/Birch Hall, showed LPN E stood at the medication cart and popped multiple pills out of different bubble packs, by placing the medications in his/her hands. LPN E then crushed the medications and mixed the medications with applesauce and administered them to Resident #2. Observation on 12/5/24 at 8:45 A.M. and 9:21 A.M., showed LPN E removed multiple bubble packs out of the cart and popped the medication into his/her hand and then placed them into a medicine cup. LPN E then took the cup of pills and walked down the Birch Hall into a resident's room, and after several minutes LPN E exited the resident's room without the cup of pills. 3. During an interview on 12/9/24 at 10:35 A.M., Registered Nurse (RN) G said gloves should be changed when completing peri-care, and hand washing or hand sanitizer should be used before applying new gloves. The resident, the resident's clothing or catheter should not be touched with soiled gloves. EBP are for residents who have MDROs, catheters or wounds. Staff are to wear gown and gloves when providing direct care. A sign should be placed outside of the room and staff should wear gowns and gloves when providing care. Medications that are in a bubble pack should be popped directly into the medicine cup. 4. During an interview on 12/9/24 at 1:00 P.M., the Director of Nursing (DON) said she would expect there to be a sign on the door for residents requiring EBP. Staff are to use gown and gloves for residents who have catheters, wounds,or any indwelling medical device. The staff are expected to change gloves and use hand sanitizer after providing peri-care. Staff should not be touching the resident with soiled gloves. Staff are expected to use hand sanitizer or wash hands before and after providing care. Medications that are in a bubble pack should not be directly popped into the staff member's hand. The medications should be directly popped into the medicine cup. MO00245478

Based on interview and record review, the facility failed to assess one of four sampled residents (Resident #1) for risk of entrapment from a bed rail and failed to ensure the bed rail did not pose a risk of entrapment when staff installed bed rails with a low air loss mattress. The resident was at risk for a serious adverse outcome when staff failed to assess the use of bed rails with the addition of a new low air loss mattress. On [DATE] at 9:40 P.M., staff found the resident on the floor with his/her head stuck between the rail and the mattress. The resident's buttocks were on the floor, his/her neck was stuck between the rail and the mattress, and his/her face was blue. The resident expired at the hospital. The census was 58. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. Facility staff were inserviced and a system was immediately put in place to evaluate and remove bed rails. The IJ was corrected on [DATE]. Review of the facility's Adaptive/Assistive Device and Potential Restraints Policy, review date ,d+[DATE], showed: -Policy Statement: To ensure that physical restraints and adaptive/assistive device will be used only when it has been determined through an evaluation process that it is necessary to treat a resident's medical condition or as a therapeutic intervention to enhance the resident's functional abilities to promote the resident's highest level of wellbeing and after evaluation of risks; -Procedure: --A physical restraint and adaptive/assistive device will be used only when it has been determined through an evaluation process that it is necessary to treat a resident's medical condition or as a therapeutic intervention to enhance the resident's functional abilities; --Adaptive/assistive devices such as geri-chairs (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility), Broda chairs (tilt-in-space positioning wheelchairs), siderails and assist bars, low air loss mattresses (made up of many inflatable air tubes that inflate and deflate in an alternating pattern. This mimics the movement of a patient shifting in bed, and relieves pressure on the body, especially in areas like the hips, shoulders, elbows, and heels), canoe/scoop mattresses (designed with raised edges or contoured sides that 'scoop' upward, creating a barrier to help prevent users from rolling off the bed), alarms and other devices and/or combination of devices that are not assessed as a restraint will be evaluated for necessity and risk prior to being placed, quarterly, upon significant change of condition, and when a mattress is changed; --Siderail(s) and assist bars will be evaluated in combination with the mattress prior to placement of a mattress or siderail(s) upon admission, quarterly, upon significant change in condition, and each time the mattress is changed; --A low air loss mattress will not be routinely placed by hospice. Low air loss mattresses will only be used when conventional pressure reduction mattresses are inadequate to heal or prevent pressure ulcers, or when other means of providing comfort and pain control have proven inadequate; --Low air loss Mattresses that are not the communities' stock conventional pressure reduction mattress will only be placed after approval by the Director of Nursing (DON) or his/her designee and only after evaluation if the device (low air loss mattress or non-stock conventional pressure reduction mattress) using Adaptive/Assistive Device and Potential Restraint Evaluation form. The resident will not be placed on the mattress until it has been examined by the DON or his/her designee stated above; --Consent will be obtained from the resident (when appropriate) or responsible family member/legal guardian/durable power of attorney (DPOA) for adaptive devices such as siderails and assist bars, low air loss mattresses and other devices and/or combination of devices placed near, next to, or in contact with the resident's body (excluding braces, splints, casts, canes, walkers, and other devices that pose minute risk of harm) prior to placement if the device assessed to be a restraint. Consent will be obtained for siderails and bed-assist bars whether or not they serve as restraints; --For residents who have been newly admitted to the community and deemed appropriate for the implementation of assist/mobility bars, nursing will provide frequent monitoring for the first 48 hours the resident has the assist bars in place to ensure safety and proper utilization. This will include monitoring the resident every hour for the first 24 hours, then every two hours thereafter for the next 24 hours. If after 48 hours, there is no evidence of possible injury/negative outcome and resident is utilizing assist bars appropriately, then monitoring will cease unless otherwise indicated; -Clarification: --The DON or designee must evaluate restraints, low air loss mattresses, and non-stock pressure reduction mattresses used in combination with side rails; --Licensed nurses who have been educated in evaluation may evaluate other adaptive/assistive devices including side rails when used in combination with non low air loss and stock community pressure reduction mattresses, as approved by the DON. Review of Resident #1's medical record, showed: -admitted to the facility on [DATE]; -Weight 301 pounds on [DATE]. Review of the resident's baseline care plan, dated [DATE], showed: -Vision and hearing adequate; -Understands and can easily communicate with staff; -Required substantial/maximal assist with toileting hygiene, showering and upper body dressing, rolling left to right in bed, moving from a sitting position to a lying positions, moving from a lying position to a sitting position, and moving from a sitting position to a standing position; -Dependent on staff for lower body dressing, putting on and taking off footwear, chair to chair and chair to bed transfers, toilet transfers, and tub/shower transfers; -Required a walker and/or wheelchair; -Alert but cognitively impaired with fluctuations with moderate cognitive impairment; -Had a history of falls within the previous month prior to admission: -Used a positioning assistance bar. -Had a fall on [DATE] without injury. -Offer to assist the resident with toileting every two hours. Review of the resident's Fall Risk Assessment, dated [DATE], showed: -One to two falls in the past three months; -Alert and oriented times three (alert and oriented to person, place and time); -Chair bound and incontinent; -No noted drop in blood pressure between lying and standing; -Vision adequate; -Did have a change in condition in the last 14 days; -Recent hospitalization in the last 30 days; -Balance problems while standing and walking; -Decreased muscular coordination; -Requires use of assistive devices (i.e. cane, walker, wheelchair, furniture). Review of the resident's progress notes, showed: -[DATE] at 6:21 A.M.: Fall Risk Evaluation: Resident is alert. History of ,d+[DATE] falls within the last three months prior to admission. Chair bound and incontinent. Balance problem while walking. Decreased muscular coordination. Requires assistive devices for mobility. Fall score 16, indicating a high risk for falls. Review of the resident's Physician Order Sheet, dated [DATE], showed an order for a low air loss (LAL) mattress which will help distribute the patient's body weight over a broad surface area and help prevent skin breakdown. Wedge pillow is ok to use as needed for position rotation. During an interview on [DATE] at 3:45 P.M., Certified Occupational Therapist Assistant G said: -He/She was aware of the resident's need for a LAL mattress because they talked about it during interdisciplinary team meetings; -He/She got the resident out of bed for therapy, noticed the wound on his/her sacral area was bleeding, saw the mattress on the floor and said they should get that mattress on his/her bed; -The LAL mattress had been delivered and was sitting in the resident's bedroom floor for a couple of days at that time; -Therapists G and H placed the LAL mattress on the bed and secured it to the frame; -Therapist H went to the nurse's station and told the nurse they had placed the mattress; -The nurse said ok and he/she was not aware they needed to notify anyone else or that there was a procedure to follow; -He/She does not remember what day it was placed, but believes it was the Tuesday or Thursday before the incident; -He/She was not aware of any protocol for placing a LAL mattress to a bed with siderails, because it was not something they typically did; -He/She wasn't aware of any policy, procedure or protocol. During an interview on [DATE] at 3:09 P.M., the Therapy Director said: -Therapy does not typically place LAL mattresses on the residents' beds; -The therapist knew the resident had an order for the LAL mattress due to discussions during interdisciplinary team meetings; -Therapist G and Therapist H were in the room with the resident, saw the mattress on the floor and decided to help out and put it on the bed. Review of the resident's progress notes, showed: -[DATE] at 7:37 A.M.: On [DATE] at 6:24 A.M., upon staff making rounds, patient was found on the floor lying in side-lying position. No new wounds. Nurse tried to reach out to resident's responsible party, but hasn't got ahold of them. Nurse reached out to fire department to pick the resident up and put him/her back in the bed. Resident is in stable condition, bed in the lowest position, patient is non-compliant with using the call light. Nurse asked the resident what he/she was trying to do. The resident said he/she was trying to take himself/herself to the bathroom. Nurse notified telehealth. Staff will continue to monitor resident for safety and activities of daily living (ADLs). Call light within reach. Vital signs are in stable condition; -[DATE] at 8:03 A.M.: Resident's physician and family made aware of the fall. Review of the resident's progress notes, showed: -[DATE] at 10:40 P.M.: At 8:20 P.M., this writer gave the resident his/her Lipitor (treats high cholesterol). At 9:40 P.M., the Certified Nursing Assistant (CNA) came to this Licensed Practical Nurse (LPN) for assistance due to resident fall out of bed. Upon arrival, the resident was found with his/her legs on the floor and head stuck between the rails. Attempted to get his/her head out of the rail. Staff could not completely get it out. RN called 911 at 9:55 P.M. At 10:00 P.M., the Emergency Medical Technicians (EMTs) and police arrived. CPR was perform. After performing CPR, at 10:15 P.M., pulse was responding. This writer called the Administrator at 10:12 P.M. At 10:23 P.M., the resident was sent out to the hospital. At 10:28 P.M., the resident's family was called and informed; -No progress note that the resident was assessed/evaluated for the use/placement of an assistive grab bar and/or the use of a LAL mattress with the assistive grab bar. Review of CNA B's Witness Statement, dated [DATE], showed: -Reported to the facility for the evening shift at 2:30 P.M., on [DATE]; -Went to find the aide on duty to get report and do rounds; -Aide was in the resident's room changing his/her brief and putting him/her into bed; -The call light was in reach, his/her head was elevated at a 45 degree angle and he/she was watching TV; -He/She went back into the room at approximately 5:15 P.M., to deliver his/her evening dinner tray; -The resident stated that he/she was not hungry; -Asked resident if he/she would like a soda and he/she said yes; -He/She didn't talk much, just yes or no answers; -Checked on the resident again around 7:30 P.M. He/She was asleep. His/Her brief was changed. Call light was within reach and TV was on; -Went back to his/her room at approximately 9:45 and upon entering the room, the resident was sitting on his/her bottom, back towards the mattress and head stuck between the mattress and the assist bar. His/Her tongue was sticking out; -He/She instantly ran to get help; -He/She ran up the hall to get the nurse and also asked CNA E for help; -All three ran back into the room, but all three staff could not move the resident, he/she was too large; -LPN A went to call for help while CNA B and CNA E stayed in the room and continued to attempt to get the resident loose; -When he/she found the resident, he/she was sitting in about a 45 degree angle but was trapped; -He/She had been on an air mattress; -CNA B then moved the mattress; -By that time, the police came and were able to get him/her loose. Review of LPN A's Witness Statement, dated [DATE], showed: -He/She arrived at the facility at 2:31 P.M. on [DATE], to begin his/her shift; -At 3:20 P.M., he/she received report from the day nurse and laid eyes on the resident and was told he/she had a fall early that morning; -At 7:37 P.M., the resident was sitting up in bed watching TV; -He/She refused his/her evening meal at that time; -CNA B was also in the room at that time; -Th resident was provided with a soda and staff left the room; -At around 8:20 P.M., the resident was sleeping. His/Her medication was provided at that time and he/she went back to sleep; -At 9:40 P.M., CNA B asked for assistance because the resident fell out of bed; -When we arrived in the room, the resident was noted on his/her buttocks on the floor and his/her neck was stuck between the mattress (bed) and the rail; -He/She had a faint pulse; -Staff attempted to get his/her neck out of the rail, but could not get it completely out; -Staff moved the mattress to get his/her neck out as much as possible. RN C called 911; -The police and EMT arrived around 10:00 P.M.; -The police got his/her neck free and started CPR; -The Administrator was called around 10:12 P.M.; -At 10:15 P.M., the EMT got a pulse; -At 10:23 P.M., the EMTs took the resident to the hospital. Review of RN C's Witness Statement, dated [DATE], showed: -He/She was sitting at the nurse's station completing his/her charting and round 9:40 - 9:45 P.M., the CNA came to the nurse's station saying there was a resident stuck in the bedrail by his/her neck. The resident was blue in color and hanging off the bed; -The nurse on that assignment ran to the resident's room with the assigned aide to assist the resident; -Based off the statement the aide made about the resident being blue in color, he/she called 911 and was attempting to obtain a code status; -After that, he/she called the police at 9:50 P.M.; -He/She called the resident's physician and the administrator after that. During an interview on [DATE] at 2:443 A.M., CNA E said: -The agency aide came out of the resident's room and asked for assistance getting the resident off the floor; -Upon entering the room, it was noted that the resident was sitting on the floor with the bed rail over his/her head and holding his/her throat on the bar. Only his/her nose and mouth was sticking through. He/She was still breathing and his/her eyes were open, but not moving. CNA E got in the resident's face and yelled the resident's name. They tried to undo the mattress and get him/her out, but was unable to get him/her out due to his/her size; -The nurse entered the room; -The EMTs came into the room and got the resident out and resuscitated him/her. The EMTs said he/she still had a pulse when they left with the resident. -The bed was not in the low position when he/she entered the room, but it should have been. During an interview on [DATE] at 3:33 P.M., RN C said: -The aide came down to the nurse's station close to 9:50 P.M. and said the resident was blue and not breathing, and his/her head was stuck in the bed rail; -RN C called 911 while the resident's nurse went down to the resident's room with the aide. By the time he/she hung up, the police and EMS were running in the door; -The police and EMS were able to get the resident out from between the bed and the rail and started CPR. Review of the EMS run sheet, dated [DATE], showed: -The 911 call was received on [DATE] at 9:45 P.M.; -Resident's level of distress was severe; -Signs and symptoms were cardiac arrest; -While responding to the scene, 911 dispatch advised that the patient was unconscious with breathing status unknown, possibly in cardiac arrest; -Assessment time was 10:08 P.M.; -The resident was found in cardiac arrest on the floor with CPR being performed by the police department; -The resident had no spontaneous breaths and no pulses; -The resident was still warm and his/her color was pale; -No lividity (discoloration of the skin that occurs after death, caused by blood pooling in the body's veins and capillaries) or pooling was noted; -Nursing home staff reported that the resident was wedged between the bed and the wall when he/she fell , and it is believed that he/she asphyxiated; -Nursing home staff was unable to provide a detailed history reporting the resident was new to the facility; -Due to the resident having high ETCO2 (a measurement of the amount of carbon dioxide in exhaled breath) readings and periods of an organized rhythm with a pulse confirmed with ultrasound the decision was made to transport to the closest hospital; -A pulse was regained at 10:13 P.M. and lost at 10:25 P.M., with CPR initiated and pulse regained at 10:31 P.M., and maintained throughout transport; -Due to low cardiac output and low pulse, the resident was give two doses of push (a process of introducing a medication or fluid substance directly into the bloodstream via the venous system) dose epinephrine (a hormone and medication used to treat a number of conditions, including low blood pressure, and cardiac arrest). Review of the resident's hospital emergency room record, dated [DATE], showed: -Present illness: -The resident was Pulseless Electrical Activity (PEA, indicates a serious cardiac arrest situation where the heart is displaying electrical activity but isn't effectively pumping blood, resulting in no pulse and requiring immediate medical intervention) on arrival; --The resident was immediately placed on a ventilator (a machine that helps you breathe or breathes for you); --Norepinephrine drip (used to raise blood pressure in patients with severe, acute hypotension (short-term low blood pressure)) was initiated as he/she got his/her pulse back; --He/She went from PEA to regular rhythm around ,d+[DATE] with a pulse; --He/She lost his/her pulse twice but got it back fairly quickly; --No purposeful movement during all of this; --Pupils somewhat dilated and fixed; -Decision making: --Resident will be admitted to the intensive care unit (ICU); -Reason for visit: --Resident was found between the wall and the bed when EMS arrived; --No pulse with CPR for 13 minutes; --Blood pressure low for EMS and oxygen low upon arrival' --Resident had pulse upon arrival; -Upon arrival to ICU, the resident: --Does not follow commands; --Does not withdraw to pain; --Has a cough; --Pupils were reactive; --Overbreathing the ventilator (the patient and the ventilator are not in sync and the patient breathing faster than the rate set on the ventilator); --Would occasionally, spontaneously open eyes. Review of the resident's Unwitnessed Fall Report, dated [DATE], showed: -Incident description: Resident found on the floor in his/her room. Resident found with his/her buttocks on the floor with his/her neck stuck in the rail. His/Her head was lying to the left. Resident had a faint pulse. Two aides and the nurse attempted to get the resident to the floor but were unsuccessful. Staff was able to get the resident's neck out of the assist rail by pushing the mattress back; -Immediate action taken: Resident sent to the hospital; -Injuries note at the time of the incident: No injuries noted at the time of the incident; -Level of consciousness: Comatose (a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness); -Mobility: Wheelchair bound; -Injuries reported post incident: No injuries observed post incident; -Predisposing environmental factors: Other (no description); -Predisposing physiological factors: Confused, impaired memory, and weakness/fainted; -Predisposing situation factors: admitted in the last 72 hours and siderails up; -Other information: Resident was lethargic; -Statements: No statements found; -Agencies/People notified: Physician and family. Review of the resident's medical record, showed: -No Assistive Device Audit tool; -No Adaptive Device/Potential Restraint form; -No assessment or evaluation of the resident for the use of assistive devices or assistive devices with the use of a LAL mattress. During an interview on [DATE] at 10:11 A.M., the CPSO/CCO said: -At approximately 9:40 P.M., last Thursday, [DATE], the resident was found sitting on the floor with his/her head stuck between the mattress and the assist bar on the bed; -The resident had a pulse but was not breathing; -Staff attempted to dislodge his/her head, but was unable to due to the resident's size; -911 was called and the police were here within ,d+[DATE] minutes; -The police and EMS were able to get the resident dislodged and began CPR; -He/She arrived at the facility at approximately 10:30 to 10:40 P.M.; -The Administrator was also there; -Witness statements were obtained from all pertinent staff; -Investigation began; -Friday, [DATE], they started to evaluate what happened and analyze the incident; -They pulled four critical pathways they feel may be involved in the incident; -The resident had a bed with a U shaped grab bar and a LAL mattress was put on the bed without an assessment/evaluation performed; -They found the facility needed a process for assessing the need for specialty devices and mattresses and for assessing the safety and fit after the mattress is placed; -They are also looking at the mattress and overlay placement process; -The investigation showed that some assessments, mattress checks after placement and consent form were not getting done; -The facility kept in contact with the hospital and the first couple of reports showed the resident to be in critical but stable condition, then moved to ICU and told he/she was stable. On Sunday, they were told he/she was on a ventilator. They were informed the resident passed away on [DATE]. During an interview on [DATE] at 3:09 P.M., the Therapy Director said: -At the time of the incident, he/she was not aware of any protocol related to placing mattresses on beds with side rails. During an interview on [DATE] at 11:13 A.M., the CPSO/CCO said: -There was a break in protocol on assessing residents before equipment placement and equipment after placement. During an interview on [DATE] at 8:40 A.M., the Administrator said: -The resident had a history of falling at home; -The resident was found on the floor earlier that day without injury; -The resident would try to get up and take him/herself to the bathroom without asking for assistance; -At approximately 10:00 P.M., on [DATE], nursing called him and said the resident had fallen and was trapped between the mattress and the assist rail; -The staff where unable to dislodge the resident due to his/her size; -Staff had already called 911 and they arrived within approximately three minutes; -EMS were able to dislodge the resident and start CPR; -The Administrator went to the facility immediately to check on the residents and begin the investigation; -Based on the investigation, it was approximately 40 minutes from the last time the resident was checked to when the resident was found trapped; -He does not feel staff followed policy/procedure when placing the LAL mattress on the bed with the assist rails; -He does feel nursing staff followed policy/procedure and acted responsibly when the resident was found trapped; -The CNA and nurse were both agency staff; -Agency staff are provided a binder with all policy and procedures in it for review and must sign a document that they were provided the information and read it; -He called the hospital several times and got updates on the resident. One day he was informed they were going to extubate (removal of an endotracheal tube (or ETT) from the throat and windpipe. An ETT is used to help breathe when one can't breathe on their own either due to surgery, injury or illness) and turn off all machines. The next time he called back, the resident had expired (died ); -It was a terrible situation and they tried to be proactive and quickly get procedures in place so it would never happen again. MO00245555

Based on observation, interview, record review, and facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1. open food items were labeled with a description of the food item and an open or expiration date; 2. food items were not stored beyond their use-by-dates and moldy onions were discarded; 3. dishware was allowed to airdry prior to use for meal service; 4. prepared foods were stored in a manner to prevent potential cross-contamination; and 5. the food preparation area and dietary equipment were maintained in a clean and sanitary manner, and the ceiling did not drip water onto the steam table used for meal service hot holding when it rained. Findings included: 1. An undated facility policy titled, Labeling and Dating revealed, Prepared or Opened Food -All prepared or opened foods will be wrapped or covered and labeled with the following 1. The date the product was prepared or opened and put into a container 2. A description of the item in the container. An undated facility policy titled, Food Storage revealed, 6. Leftover contents of cans and prepared foods shall be stored in covered, labeled, and dated containers in refrigerators and/or freezers. On [DATE] beginning at 9:29 AM, a tour of the kitchen was conducted with the Executive Chef. At 9:30 AM, a white container with a clear sliding door was observed to be filled with a white unknown substance that appeared to be flour. The container was labeled as onions and was not dated. At 9:31 AM, a second white container with a clear sliding door was observed to be filled with 15 purple onions. The container was not dated. On [DATE] beginning at 9:34 AM, the following open items were observed in the reach-in cooler without a date: a cucumber cut in half and wrapped in plastic-wrap, a bulk container of applesauce, a container of beef base, a container of sweet pickle relish, and bulk containers of Italian dressing, [NAME] dressing, ranch dressing, coleslaw dressing, and mayonnaise. At 9:38 AM, the Executive Chef stated he was responsible for making sure open items were dated. On [DATE] at 9:42 AM, an open, pint-sized container of baking extract was observed in a drawer below the food preparation table. The container was not labeled with an open date. At 9:43 AM, open containers of vegetable oil and teriyaki sauce were observed under the food preparation table. The containers were not labeled with open dates. On [DATE] at 9:46 AM, an opened, resealable bag of blue cheese was observed in the walk-in cooler. The bag was not dated. On [DATE] at 9:49 AM, a gallon of strawberries and a metal container of waffles were observed in the walk-in produce cooler. The items were not dated. On [DATE] beginning at 9:51 AM, the following open items were observed in the walk-in freezer, not labeled with an open date: corned beef hash in a resealable bag, beef brisket in a resealable bag, a metal container of salmon, sausage in a resealable bag, pepperoni in a resealable bag, and a bag of fries. On [DATE] at 9:56 AM, an undated container of brown sugar was observed in the food preparation area. Undated, opened bags of nacho chips and potato chips were also observed. On [DATE] beginning at 10:03 AM, the following open items were observed without dates in the dry storage area: corn meal, pecans in a resealable bag, spaghetti noodles wrapped in plastic wrap, a plastic bag of almonds, a five-pound bag of spaghetti, and a five-pound bag of egg noodles. On [DATE] at 10:06 AM, the Executive Chef stated he was responsible for dating and labeling the items in the kitchen. The Executive Chef said he had no excuse; it should have been done. On [DATE] at 8:28 AM, the Director of Dining Services (DDS) reported that all dietary staff were responsible for dating food items in the kitchen. The DDS said all food items in the walk-in cooler and reach-in cooler should be dated. The DDS further stated the Executive Chef was responsible for the dating of food items and should be checking every day to ensure items were labeled appropriately. On [DATE] at 3:28 PM, the Director of Nursing (DON) stated that as soon as food was opened, it should be labeled and dated. On [DATE] at 4:25 PM, the Administrator said the Executive Chef was responsible for dating and labeling foods. 2. An undated facility policy titled, Labeling and Dating revealed, Perishable Foods -All perishable foods will be dated upon delivery and used before their expiration date. Any food that is past its expiration date will be discarded immediately. An undated facility policy titled, Expired Foods revealed, -Make sure all foods are within the expiration date. Check all dates before using the product. If the date is expired discard the product. Make sure to let the chef know before throwing the product away. On [DATE] at 9:31 AM, a container was observed with 15 onions and what appeared to be mold stored under the food preparation table. At 9:32 AM, a container of 11 onions and what appeared to be mold was observed on top of the food preparation table. At 9:33 AM, the Executive Chef stated he needed to contact the food vendor because the onion order was delivered last Monday, and the onions were molded. The Execuitve Chef said dietary staff had already shown him the onions, but he had not discarded them. He stated he should have discarded them and that was his fault. On [DATE] at 9:36 AM, a container of extra-hot horseradish sauce, with a use-by-date of [DATE], was observed in the reach-in cooler. On [DATE] at 9:38 AM, the Executive Chef stated he was responsible for making sure expired items were discarded. On [DATE] beginning at 9:46 AM, the following expired items were observed in the walk-in cooler: three pounds of cream cheese with an expiration date of [DATE], two containers of low-fat cottage cheese with an expiration date of [DATE], two gallons of skim milk with an expiration date of [DATE], and three gallons of whole milk with an expiration date of [DATE]. On [DATE] at 8:32 AM, the Director of Dietary Services (DDS) stated expired or moldy food items should have been thrown away. On [DATE] at 3:28 PM, the Director of Nursing (DON) stated the DDS should perform frequent monitoring and throw items away. 3. An undated facility policy titled, Dishwasher/Catcher Policy, revealed, -All pots and pans must come from the machine straight onto the drying rack. Once the pans are dry, they can then be put away on their usual spot. Under no circumstance are any pots, pans, smallwares, silverware, or place mat's [sic] to be put away wet or even damp. On [DATE] at 11:37 AM, eight bases for the residents' meal trays were observed wet. The Director of Dietary Services (DDS) used them while wet for residents' trays during the lunch meal service. At 11:38 AM, the Executive Chef stated staff pulled the lids from the dishwashing area quickly, and that was why they were still wet. On [DATE] at 8:28 AM, the DDS said dishes were supposed to air dry, but sometimes for lunch they did not get trays back until 10:45 AM, and staff had to hurry to do the dishes before the lunch meal service. On [DATE] at 3:28 PM, the Director of Nursing (DON) stated lids and bases for meal trays should not be wet when used during meal service. On [DATE] at 4:25 PM, the Administrator said dishes should be air dried before use. 4. On [DATE] at 9:42 AM, five uncovered pans of cookies, 24 on each pan, were observed on a cart next to a trash can with no lid. On [DATE] at 8:28 AM, the Director of Dietary Services (DDS) stated he did not think the uncovered pans of cookies should have been sitting next to the trash can. The DDS indicated staff should have placed parchment paper over the cookies. 5. An undated facility policy titled, Food Preparation Area revealed, It is the policy of this facility to maintain a clean, sanitary, and safe food preparation area. A facility policy titled, Cleaning Rotation, copyright 2020, revealed, Equipment and utensils will be cleaned and sanitized according to the following guidelines or manufacturer's instructions. The policy specified, 2. Items cleaned daily: included -kitchen and dining room floors and -microwave oven, and 5. Items cleaned annually: included -ceilings. On [DATE] at 9:44 AM, trash, including a potato and noodles, was observed on the floor in the area behind the cooking equipment. The Executive Chef stated the floors were normally cleaned each Sunday, but a staff member was out, and it was not done. On [DATE] at 9:50 AM, the ceiling vent outside of the walk-in cooler in the food preparation area was observed with an excessive amount of dust accumulation. The Executive Chef stated maintenance staff were responsible for cleaning the vents. On [DATE] at 9:55 AM, the microwave was observed with food debris and a rust-like substance under the microwave plate. On [DATE] at 10:01 AM, the ceiling vent near the entrance/exit door to the kitchen was observed with an excessive amount of dust. On [DATE] at 11:02 AM, water was dripping from the ceiling in the food preparation area above the steam table used for hot holding during meal service. The Executive Chef stated the water came from the ceiling every time it rained. On [DATE] at 8:28 AM, the Director of Dietary Services (DDS) stated the floors were to be cleaned every night, and a company came to power wash the floors every other month. The DDS stated the microwave needed to be cleaned every day. The DDS indicated the dietary department needed a new microwave but had not gotten one yet. The DDS said the closing servers should be cleaning the kitchen each night. The DDS further stated the ceiling was leaking due to it raining outside. He stated housekeeping and kitchen staff should clean the ceiling vents. On [DATE] at 9:02 AM, the Maintenance Manager stated the kitchen staff usually called to let them know if there were any issues in the kitchen. The Maintenance Manager said that any issues should be reported to maintenance by way of their electronic system and by word of mouth. According to the Maintenance Manager, the ceiling in the kitchen had leaked previously and was addressed and checked. The Maintenance Manager said the kitchen got steamy when it was humid out. On [DATE] at 3:28 PM, the Director of Nursing (DON) stated floors in the kitchen should be cleaned as needed, and the microwave should be put out of use until the issues were addressed or the microwave was replaced. The DON reported she was not aware of the ceiling leaking. On [DATE] at 4:25 PM, the Administrator stated the floors in the kitchen should be cleaned daily and as needed. The Administrator reported he expected the microwave to be clean. The Administrator further stated they had issues with the ceiling in the kitchen previously, and maintenance staff looked at it; however, the Administrator did not know the details.

Based on interview and record review, the facility failed to follow their policies for vital signs and change in condition by failing to immediately notify physicians when residents' blood pressures (BP) were low, thoroughly assess the residents and monitor the resident's until their BP returned to normal limits (120 (systolic/80(diastolic). One of eight sampled residents (Resident #17) had a low BP that exceeded the facility parameters of when to notify the physician. In addition, the facility failed to ensure the resident received the correct medications as listed on the After Visit Summary that accompanied the resident upon admission. That resident passed away at the facility two days after admission. Thirty residents from an expanded sample of past and present residents residing in certified beds were reviewed. Two of those 30 had low BPs exceeding the facility parameters and problems were found with both. (Residents #167 and #126) The census was 61 with 17 in certified beds. Review of the facility Vital Signs-When to report and Assessments to Obtain policy, undated, showed the following: Report Stat (immediately): -Systolic BP of less than 90 (the top number of the BP represents the systolic, the heart at work, and the bottom number represents the diastolic, the heart at rest); -Assess and request orders for: Orthostatic BP (a drop of BP that occurs when you stand up from a sitting or standing position) and check medication administration records (MARs) for missed medications; -The policy had no parameters for low diastolic BP's. Review of the facility Change in Condition Reporting policy, dated 2/17, showed the following: Policy: -The resident's primary physician (or designated alternate) will be notified immediately under the following circumstances: Change in resident condition that requires immediate medical attention. Any circumstance in which immediate communication with the physician is deemed by the nurse to be essential to the health and welfare of the resident; The Nurse will: -Assess the resident's condition as warranted which may include, but is not limited to checking vital signs, completing a physical assessment as indicated, speaking with the resident about their symptoms and noting the presence or absence of pain; -The charge nurse or other licensed nursing team member will notify the physician promptly of the change in condition/incident/unusual occurrence and assessment findings. If the physician determines intervention is necessary, the charge nurse will then carry out any interventions designated by the physician; -Attempts to notify physician should take place in the following order: Attending physician, attending physician's designated alternate, medical director; -If the physician determine intervention is necessary, the charge nurse will carry out any interventions designated by the physician; -Changes in condition/incidents/accidents/unusual occurrences may be reported to the physician via fax, unless the resident's condition is unstable or for any reason requires an immediate response from the physician; -The charge nurse or other licensed nursing team member will then contact the resident's representative/interested family member of any significant change in the resident's condition/incident/accident/unusual occurrence involving the resident promptly after the condition change or situation is noted, physician has been contacted and any immediate interventions necessary have been performed; -The charge nurse will then document in the nurse's notes: A description of the change in condition/incident/accident/unusual occurrence. Results of any assessment performed. Description of any care or emergency measures performed. Notification of the physician including what was reported to the physician and physician response including whether new orders were received. Notification to resident and/or resident's representative. Follow up assessment and care as appropriate; -The Director of Nurses (DON) or Assistant Director of Nurses (ADON) or designee will assess each resident's change of condition daily by reviewing 24 hour daily log, interviewing staff, and monitoring clinical documentation. Follow up will be completed as necessary. Review of WebMD's definition for symptoms of low blood pressure, include the following: -Dizziness, lightheadedness, unsteadiness, dimming or blurring of vision, weakness, fatigue, nausea, cold/clammy skin, [MEDICAL CONDITION] and pale skin. 1. Review of Resident #17's hospital records, pages 1-46, showed the following: -admission date of [DATE] to intensive care unit (ICU); -discharge date from ICU: 6/12/19 (to post-acute rehabilitation at the hospital); -Last update documented on the form: 7/1/19 at 4:31 P.M.; -Chief complaint: [MEDICAL CONDITION] ([MEDICAL CONDITION], the heart does not pump blood efficiently); -Admission data: Resident was recently admitted with shortness of breath and bilateral lower extremity [MEDICAL CONDITION] (excess fluid/swelling). Resident was treated with diuresis (removing excess fluid out of the body) and the resident's course was complicated by poor oral intake, functional decline, and [MEDICAL CONDITION] (low BP). Resident was deemed stable and medically appropriate for comprehensive rehabilitation; -6/13/19 at 2:21 P.M.: Diuretics were adjusted for relative [MEDICAL CONDITION], mental status returned to baseline and patient was followed by dietician for moderate protein calorie malnutrition. He/she was seen in consultation by physical and occupational therapy and transferred to acute rehabilitation at the time of discharge (resident was admitted to intensive care for the first two days of his/her hospitalization ); -During his/her admission, resident was treated in ICU for 2 days for metabolic [MEDICAL CONDITION] (abnormalities of the water, electrolytes (essential for cells, organs and body systems to work properly), vitamins and other chemicals that adversely affect brain function) and acute (sudden) [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen level) thought to be secondary to medications versus [MEDICAL CONDITION] (low sodium). Metabolic [MEDICAL CONDITION] resolved prior to discharge; -Resident was hypotensive this admission, therefore [MEDICATION NAME] held. Due to history of [MEDICAL CONDITION], resident to be discharged on [MEDICATION NAME] (blood pressure medication) 12.5 milligrams (mg) daily and [MEDICATION NAME] (a diuretic used to treat high blood pressure and/or excess fluid) 40 mg daily, both with holding parameters of do not give if systolic BP below 100; -Pertinent discharge [DIAGNOSES REDACTED]. -Page 26 showed: Medication list, continue taking these medications (the medication list included): [MEDICATION NAME] 60 mg two times a day (BID), [MEDICATION NAME] 25 mg BID; -Discharge condition: Improving; -Prognosis: Good. Review of the After Visit Summary, provided to the facility by the hospital with a print date of 7/2/19 at 2:18 P.M., showed the resident's medications included: -[MEDICATION NAME] (anti-biotic) 100 mg BID for 7 days; -[MEDICATION NAME] (appetite stimulant) 2.5 mg BID; -[MEDICATION NAME] (to treat [MEDICAL CONDITION]) 25 micrograms daily; -[MEDICATION NAME] (diuretic used to treat high blood pressure and/or fluid retention) 2.5 mg daily before lunch; -[MEDICATION NAME] 12.5 mg daily, hold if systolic BP is less that 100; -[MEDICATION NAME] (antibiotic) 500 mg every 8 hours (TID) for 5 days; -[MEDICATION NAME] (constipation) one packet daily; -No order for [MEDICATION NAME] or [MEDICATION NAME] sulfate (iron supplement). Review of the resident's medication profile/physician order [REDACTED]. -[MEDICATION NAME] 60 mg BID; -[MEDICATION NAME] 25 mg BID (no order to hold if the systolic BP was low); -[MEDICATION NAME] sulfate 325 mg daily; -No order for [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME]. Review of the resident's admission care plan, dated 7/2/19, showed the following: -Discharge to community; -Cognition: Confused; -Communication: Verbal; -Therapy Services: Physical, Occupational and Speech; -Oxygen: 3 Liters per nasal cannula; -7/3/19: Physician in to visit with family and discuss palliative (comfort) care and Hospice, with family in agreement after the holiday. Review of the resident's BP, recorded in the electronic medical record vital signs section, showed: 7/2/19 at 4:37 P.M. BP of 116/69. Review of the nurse's progress notes, located on the 24 hour report, showed the following: -7/2/19 at 7:19 P.M.: Resident admitted to facility from hospital via ambulance. Resident is alert and oriented x 1 (person). Unable to make needs known. Requires assistance of one or two with activities of daily living (ADLs), transfers and mobility in wheelchair. Resident is on antibiotic for two more days; Review of the resident's MAR, dated 7/1/19 through 7/4/19, showed the following: -7/2/19: Staff administered [MEDICATION NAME] 60 mg and [MEDICATION NAME] 25 mg at the hour of sleep (HS); -No BP documented at the time the medications were administered; -No order for [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME]. Review of the resident's BP, recorded in the electronic medical record vital signs section, showed the following: -7/3/19 at 2:07 A.M.: 99/54 and at 1:37 P.M. 99/64.; -No follow-up BPs were documented after either BP; -No BPs documented in the medical record on the evening shift . Review of the resident's MAR, dated 7/1/19 through 7/4/19, showed the following: -7/3/19: Staff administered [MEDICATION NAME] 60 mg and [MEDICATION NAME] 25 mg in the A.M. and at HS; -No BP documented at the time the medications were administered in the A.M. or HS; -No order for [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME]. Review of the resident's skilled progress note Q (every) shift form, dated 7/3/19 at 2:14 A.M. and completed by Nurse F, showed the following: -Oxygen: 3 liters via nasal cannula; -BP 99/54; -Resident resting in bed with head of bed elevated. No complaints of pain or shortness of breath. No acute distress. Requires assist x 1 with ADLs and assist of 1 or 2 for transfers. Will continue to monitor throughout the shift; -No further documentation regarding the resident's BP. Review of the resident's skilled progress note Q shift form, dated 7/3/19 at 1:43 P.M., showed a BP of 99/64 and no narrative note. No further documentation regarding the resident's BP. Review of the nurse's progress note, located on the 24 hour report, showed the following: -7/3/19 at 3:06 P.M.: Resident is alert and oriented x 2 (person and place). Able to make needs known with soft speech. Mood includes little interest, sleeping too much, feeling tired, poor appetite and little energy. Resident and spouse would like for resident to go back home when the time comes. Review of the resident's facility physician's progress note, pages 1-14, dated 7/3/19 and completed by the resident's facility physician, showed the following: -Medication list at the end of visit as of 7/3/19 at 9:12 P.M.: [MEDICATION NAME] one tablet BID for 7 days (start date: 7/2/19, end date: 7/9/19), [MEDICATION NAME] 2.5 mg BID (start date: 7/2/19, end date: blank), [MEDICATION NAME] 2.5 mg daily before lunch (start date: 7/2/19, end date: blank), [MEDICATION NAME] 12.5 mg daily, hold if systolic BP is less than 100 (start date: 7/2/19, end date: blank), [MEDICATION NAME] 500 mg TID (start date 7/2/19, end date: 7/7/19), No order for [MEDICATION NAME] sulfate 325 mg daily. These medications were listed a second time on pages 5 through 7 of the progress note; -Resident was hospitalized from [DATE] through 6/12/19 (ICU) and then rehabilitation at the hospital from 6/12/19 through 7/2/19; -Resident transferred to current nursing facility on 7/2/19 for continued recovery, and the potential therapy if applicable; -Had conversation with nursing staff and therapy since his admission yesterday. He/she was not doing well. Physically he/she is very weak, very sleepy and less responsive. Needed two maximum assistance to get out of bed. Very poor oral intake; -According to spouse, prior to recent incidents, the resident lived at home. At baseline (what is normal for that resident) he/she ambulates with a walker for short distances, independent for most ADLs and does need minor assistance; Assessment and plans: -Physical debility, generalized weakness; -Declining functional status: At this time his/her rehabilitation potential is unclear. Continue to monitor his progress; -Heart failure: At the present time, he/she is taking [MEDICATION NAME] 60 mg BID and [MEDICATION NAME] 25 mg BID. Continue to monitor symptoms. Monitor BP; -More than 70% of the time was spent on conversation mainly with spouse and the family regarding his/her past medical history, current medical condition, prognosis, current medications, treatment plans, etc. He/she has had a generalized declining in the past several months. Hospital record indicated there were palliative care discussion, both the resident and the spouse declined. Major discussion regarding palliative care and especially hospice care, for the best benefit of the resident. Spouse had a lot of questions regarding hospice. Spouse seems interested now; -Physical examination: BP 103/65. BP readings from the last three readings: 7/3/19 103/65, 7/2/19 99/65 and 7/1/19 76/53 Review of the resident's BP, recorded in the electronic medical record vital signs section, showed the following: -7/4/19 at 1:00 A.M.: 71/42 (recorded by Nurse F); -No follow-up BPs recorded. Review of the resident's skilled progress note Q shift form, dated 7/4/19 at 1:06 A.M., showed the following: -BP 71/42; -Resident resting in bed with HOB elevated for comfort and bed in lowest position for safety. No complaints of pain or shortness of breath. No signs or symptoms of acute distress. Will continue to monitor throughout the shift. The note did not address the resident's 71/42 BP. No physician notification, no assessment, no follow-up BPs. The note did not address the resident's large loose bowel movement. Review of the resident's MAR, dated 7/1/19 through 7/4/19, showed the following: -7/4/19: Staff administered [MEDICATION NAME] 60 mg and [MEDICATION NAME] 25 mg in the A.M.; -No BP documented prior to administering the medications in the A.M.; -No order for [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME]. Review of the resident admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/19, showed the following: -admission date of [DATE]; -Clear speech - distinct intelligible words; -Sometimes understands; -Usually understood; -Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of 11, indicates moderate cognitive impairment); -Total dependence of one person required for bed mobility, locomotion on/off the unit, dressing, toilet use and bathing; -Independent - set-up help only required for eating; -Mobility device: Wheelchair; -[DIAGNOSES REDACTED]. -Shortness of breath: No; -Prognosis, does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?: No; -Weight: 148 pounds; -Weight loss of more than 5% in the last month or 10% in the last 6 months? No or unknown; -Diuretic (removes excess water) 3 of the last 7 days; -Receiving speech, occupational and physical therapy; -Hospice: No. During an interview on 7/10/19 at 6:56 A.M., Certified Nursing Aide (CNA) [NAME] said he/she was assigned to the resident on the night shift of 7/2/19 into 7/3/19 and again on 7/3/19 into 7/4/19. He/she obtains vitals around 10:30 P.M. every shift. On the 7/2/19 into 7/3/19 shift, he/she checked on the resident about every two to three hours. The resident was pleasant and was oriented to person and place. The resident turned himself/herself with his/her assistance. He/she could not recall the resident's BP that night, but he/she gave a copy of the completed vitals to the charge nurse when he/she finished. The CNAs do not enter the vitals in the electronic records, the nurse's do that. There was nothing unusual about the resident that night that he/she could recall. Review of the facility CNA vital signs form, dated 7/2/19, completed by CNA E, showed the resident's BP was 99/54. During an interview on 7/10/19 at 7:31 A.M., CNA G said he/she took care of the resident on 7/3/19 and 7/4/19 on the day shift. He/she gets residents' vitals around 7:30 A.M. or 8:00 A.M. On 7/3/19, the resident looked kind of sick, but he/she was alert and speaking to him/her. He/she ate about 50% of breakfast and lunch. The resident did not say anything was wrong. The resident's BP was kind of low that day, but could not recall how low. He/she wrote the BP down and gave it to the nurse, but he/she did not recall which nurse for sure. He/she told the nurse the resident's BP was low when he/she handed the nurse the paper. The nurse said he/she would check it out. The nurse did not give him/her directives to monitor the resident more closely or repeat the BPs. He/she saw the resident about four or five more times that day. The resident was basically the same at the end of the shift as he/she was at the beginning. Review of the facility CNA vital signs form, dated 7/3/19, and completed by CNA G, showed the resident's BP was 99/64. During an interview on 7/11/19 at 6:54 A.M., CNA H said he/she was assigned to the resident on the evening shift of 7/3/19. The first time he/she went into the resident's room was around 3:00 P.M. or 3:30 P.M. The resident was talking and laughing. He/she had his/her oxygen on low. Speech therapy was working with the resident. His/her oxygen saturation level (normal 95-100) was in the 80's and he/she reported it to the nurse on duty. Later that nurse said he/she had worked with the resident and got the resident's oxygen level back up to 90. The other times he/she went into the resident's room that evening, the resident was smiling and laughing. Sometimes he/she was restless and it took him/her a bit of time to answer questions. He/she thought the resident's skin was pale. During an interview on 7/10/19 at 6:56 A.M., CNA [NAME] said on the 7/3/19 into 7/4/19 shift, the resident did not look as though he/she felt good. He/she asked the resident general questions like if he/she felt ok, but the resident did not respond, only making eye contact. He/she obtained the resident's BP twice, once in each arm because they were low. The first BP from the right arm was 61 or 65 over 41. The BP from the left arm was something like 75 over 40 something. He/she was concerned and that's why he/she obtained the BPs twice. He/she made a copy of the BPs and gave them to Nurse F and another nurse around 10:30 P.M. He/she told the nurses the resident's BP and said someone needed to recheck it. The nurses did not say anything to him/her and did not give him/her any directives. He/she did not see either nurse go into the resident's room to recheck the BP at that time. Around 12:30 A.M. or 1:00 A.M., he/she did see Nurse F go into the resident's room. The resident had a very large loose bowel movement, which was black and had a distinctive smell. Nurse F helped him/her change the resident's bed. Nurse F said he/she would document it. By the end of the shift the resident's skin had went from a peach color at the beginning of the shift to pale, but dry. He/she does not think he/she mentioned that to Nurse F. The resident's response to him/her at the end of the shift was the same as at the beginning of the shift. He/she did not say anything about being sick or hurting or anything like that. He/she told CNA G, the 7:00 A.M. to 3:00 P.M. CNA, to keep an eye on the resident. Review of the nurse's 24 hour report form (progress notes) and skilled progress notes, showed Nurse F did not document contacting the resident's physician, an assessment including a resident statement, and no further monitoring. There was no documentation regarding the large loose bowel movement. Further review of the nurse's 24 hour report form, showed no other documentation until 7/4/19 at 10:35 A.M. Review of the facility CNA vital signs form, dated 7/3/19 11:00 P.M.-7:00 A.M., showed CNA [NAME] obtained two BPs, one from the right arm and one from the left arm. The first BP recorded was 67/52 and the second BP recorded was 71/42. During an interview on 7/12/19 at 7:26 A.M., Nurse F said he/she had worked at the facility since the end of March. He/she worked on the night shift, 7/3/19 into 7/4/19. He/she had been told by the evening shift nurse that the resident's BPs were low. CNA [NAME] never reported the resident's vitals and he/she was not aware until around 1:00 A.M., after he/she reviewed the vital signs sheet. After noting the low BP, he/she checked the resident's BP five or six times and gave the resident fluids throughout the shift. By the end of the shift, the BPs were getting better. The resident was verbal and answering questions with yes no responses. He/she could not recall what the BPs were for sure but thinks the systolic was around 85. He/she usually writes the vitals down and records them later in the shift, but he/she could not find them. He/she did not document anything else about the resident that shift because the shift was getting hectic. The resident had no specific order of when the physician should be notified for low BPs. He/she was not aware the facility had a policy to call the physician when the BP was low. The facility may have made him/her aware and he/she had just forgot. Had he/she known about the policy he/she would have contacted the resident's physician. He/she did not complete the shift change report because Nurse I was in a hurry and wanted to get started. He/she verbally told Nurse I the resident's BPs were low, he/she had given the resident fluids and the BPs were coming up. The resident's loose stool was brown, not black and had an odor more like [MEDICAL CONDITION] (occurs due to the disruption of the healthy bacteria in the colon). There was an order to send in a stool specimen, but the stool was so thin he/she was unable to obtain a sample. Review of the 11:00 P.M. - 7:00 A.M. report sheet (used by the off-going shift to give report to the on-coming shift), dated 7/4/19, showed no information regarding the resident. During an interview on 7/10/19 at 7:31 A.M., CNA G said he/she took care of the resident on the day shift of 7/4/19. CNA [NAME] told him/her the resident did not look good throughout the night. In his/her opinion, the resident looked worse the second day. His/her skin was kind of moist and it felt funny. The resident did speak and say he/she was feeling ok. The resident's spouse was there as well. The spouse had concerns about the resident's BPs, as they were low in the hospital as well. The resident was on oxygen. He/she obtained the resident's vitals. He/she left the interview and returned with the vital sign sheet he/she recorded the resident's BPs on 7/4/19. Review of the vital sign sheet, showed the CNA took the resident's BP twice. The BPs were 75/49 and 80/52 and his/her temperature was 95.9. He/she went right to Nurse I to report the resident's BPs and temperature. The nurse said he/she would look at the resident. The nurse gave him/her no directives. He/she did not see the nurse assess or check the resident's BP. He/she checked on the resident about three times after taking the vitals. The resident did not appear any different during those checks. The last time he/she saw the resident alive was at 10:00 A.M., he/she knows it was 10:00 A.M. because Rachael Ray was coming on the television. The resident was sleeping. He/she pulled back the resident's covers to check for incontinence. The resident woke up and looked at him/her, but he/she did not say anything. His/her skin was still pale. Review of the nurse's 24 hour report form, dated 7/4/19 at 10:35 A.M., showed Nurse I documented: This nurse summoned to resident's room by Nursing Supervisor (Nurse J). Resident unresponsive in bed, no rise and fall of chest or pulse noted at this time. Resident's spouse present and aware. There was no documentation regarding contacting the resident's physician regarding the resident's BP or low temperature obtained by CNA G and no documentation regarding low oxygen levels. During an interview on 7/10/19 at 10:35 A.M., Nurse I said he/she had worked at the facility for two years. He/she came to work on 7/4/19 between 6:30 A.M. - 7:00 A.M. This was the first time he/she had worked with the resident. Nurse F gave him/her shift report but did not tell him/her anything but the resident was declining and the plans were to make the resident hospice. He/she was not made aware of the resident's BP or large loose stool. He/she did not recall CNA G giving him/her the resident's vitals or verbally reporting the vitals. Had he/she seen those vitals, he/she would have reported them to the physician. The first time he/she saw the resident was around 7:15 A.M. after receiving report from Nurse F. The resident's spouse was in the room. He/she asked the spouse if the resident was going to be admitted to hospice. The spouse did not want to discuss hospice in front of the resident because the resident did not want to be a hospice patient. The resident was lying in bed and breathing normally. He/she was responding verbally and his/her answers were appropriate to the questions. He/she did not do a physical assessment of the resident or take the resident's vitals. He/she was in the room again about an hour or hour and a half later. Speech therapy was doing therapy with the resident. At that time the resident had shortness of breath. The speech therapist checked the resident's O2 saturation and it was in the low 80's. He/she checked it and it was 84 or 85. They put him/her on oxygen and the saturation level went up to 92 or 93. He/she did not document that because he/she usually does not document until the end of the shift. During an interview on 7/10/19 at 6:23 A.M., the Assistant Administrator (AA), who is also a nurse, said in regards to the resident's BP of 71/42, Nurse F should have initiated interventions such as pushing fluids, elevating legs, then rechecked the BP within an hour. If the BP had not improved the nurse should have followed the facility policy and called the physician. The large loose black stool should have been documented as well. The resident's physician saw the resident on 7/3/19 at 9:12 P.M. This was not documented in the resident's medical record. She said she expects staff to document when a physician is in the facility to see a resident. Nurses can make a decision to send a resident to the hospital independently, although they would prefer for them to contact the physician first. She would have expected Nurse I to have done the same as well as documented the low oxygen levels. During an interview on 7/10/19 at 9:12 A.M., Nurse J said he/she came to the facility on [DATE] around 8:00 A.M. He/she knew the resident and his/her spouse personally. During the daily meeting, social service worker (SSW) K said they were planning a meeting that day at 11:00 A.M. with the resident's spouse about hospice and discuss the resident going home. He/she spoke to the resident's spouse outside the resident's room after the daily meeting. The spouse said the resident did not want hospice care. By the time their conversation had ended and they went back into the room, the resident had passed away. No one had told him/her about the low BPs. Had he/she had known, he/she would have checked the BPs himself/herself and if accurate, he/she would have called the physician. During an interview on 7/10/19 at 9:37 A.M., SSW K said a CNA told him/her the resident's spouse was upset because the physician was encouraging him/her to make the resident hospice. The spouse was confused as to why the physician wanted to make the resident hospice if the hospital had sent the resident for rehab. Typically the first care plan meeting is five to seven days after admission, but because the resident was so sick, they wanted to hold it sooner. During an interview on 7/12/19 at 9:02 A.M., the resident's physician said the resident was not her patient prior to the resident's admission on 7/2/19. Regarding the resident's BP of 71/42, she would have expected the nurse on duty to have called her or the on-call physician. The nurse should not have made a decision to give more fluids without consulting her or her designee. The nurse is not the physician and that is not the nurse's place. Had the nurse contacted her, she would have told the nurse to contact the family and allow them to decide if they wanted the resident to be sent to the hospital or stay at the facility. If the choice was for the resident to stay, she would have expected the nurse to have completed routine follow-up vitals and assessments and document that information. The nurse should have informed the on-coming shift as well. During a telephone interview on 7/19/19 at 10:15 A.M., the facility Administrator and the AA both said the orders on the After Visit Summary contain the orders they expect staff to process as the resident's orders. The AA said the admitting nurse is responsible to process the admission orders [REDACTED] During a telephone interview on 7/19/19 at 12:45 P.M., the resident's physician said the orders on the After Visit Summary were not the resident's orders. The resident receiving the [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 60 mg BID had nothing to do with the resident being very weak, very sleepy and less responsive as reported to her by the staff on 7/3/19. During telephone interview on 7/19/19 at 1:15 P.M., Nurse M said he/she was the admitting nurse on the evening of 7/2/19 when the resident was admitted from the hospital. The ambulance crew gave her the admitting paperwork and he/she sat it down on the desk. When he/she returned to review the admission paperwork, it had already been opened by the resident's physician who was in the facility for a few minutes. He/she asked the physician for the admitting orders and was given the orders from the hospital records, contained in the hospital records pages 1-46. The physician said these are the orders and handed them to him/her. He/she asked the physician if he/she was sure those were the orders and the physician said yes. He/she asked the physician if she was sure those were the orders because they did not look like the order sheet he/she normally receives from the hospital. He/she did not tell the physician that because she was the physician and he/she thought the physician must know. He/she processed the orders the physician gave him/her. During a telephone interview on 7/19/19 at 3:30 P.M., the facility medical director said he was familiar with that particular hospital's discharge orders. They are listed on the After Visit Summary. Those should have been the orders the resident received. He would speak to the resident's physician. 2. Review of Resident #167's MAR, dated 6/1/19 through 6/30/19, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (anti-hypertensive) 200 mg every A.M.; -Carvedilol (anti-hypertensive) 6.25 mg at 8:00 A.M. and 10:00 P.M. Review of the resident's blood pressure recording, located in the resident's medical record, showed staff obtained a BP of 73/47 on 6/5/19 at 2:22 A.M. Review of the resident's medical record, showed no assessment, repeat BPs or physician notification regarding the resident's BP of 73/47. 3. Review of Resident #126's admission MDS, dated [DATE], showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED].