Every finding on record at Carmel Hills Wellness & Rehabilitation

Based on interview and record review, the facility failed to provide supervision for one sampled resident (Resident #3), out of three sampled residents, when on 3/19/26 Floor Tech (FT) A did not secure the door to the secured unit resulting in the resident exiting the facility and later being found in the community and sent to the Emergency Room. The facility census was 154 residents.On 3/31/26 the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 3/19/26. All staff received education prior to working their next shift. The deficiency was corrected on 3/20/26. Review of the facility's Wandering and Elopement Policy, dated August 2020, showed:-The facility identified residents at risk for elopement and minimized any possible injury because of the elopement.-A licensed nurse assessed each resident for elopement risk and implemented preventative interventions were documented in the resident's medical record. 1. Review of Resident #3's face sheet, undated, showed the resident was admitted to the facility on [DATE].-His/Her diagnoses included: --Alzheimer's Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and eventually the ability to perform simple daily tasks).--Anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life).--Hearing loss. Review of the resident's initial Minimum Data Set (MDS- a health status screening and assessment tool used for all residents of long-term care nursing facilities) dated 1/29/26, showed the resident was severely cognitively impaired. Review of the resident's Elopement Risk Evaluation, dated 1/29/26, showed:-The resident was able to walk.-The resident wandered aimlessly.-The resident did not verbalize plans to elope.-The resident was at risk for elopement. Review of the resident's care plan, dated 1/30/26, showed:-The resident was at risk for elopement related to the Elopement Evaluation risk score.-The resident was on the secured unit. -The resident had impaired cognitive function (impaired thought processes). Review of Weather Underground dated 3/19/26 at 8 P.M. showed the outside temperature was 72 degrees. Review of the Police Report, dated 3/19/26, showed:-At 8:18 P.M., an unidentified caller reported a disoriented older person walking on the street wearing camo pants and blue or black sweater. The older person had tried to walk in the caller's home.-At 9:58 P.M. Emergency Medical Services (EMS) located the resident about 1.5 miles from the facility and transported him/her to the local hospital. Review of the resident's hospital discharge paper work, dated 3/19/26, showed:-The resident was found wandering and was only alert to self.-The resident had no injuries. Review of the facility's investigation, dated 3/20/26 showed:-Investigation determined that the entry door to the facility was not securely closed after staff exited the unit.-This condition was likely associated with staff use of the door and created a window of opportunity for unauthorized egress.-The facility provided education to all employees regarding elopement.-The facility had the door between the rehab unit and the secured unit serviced and adjusted it to have the alarm sound whenever the door was opened.-The timeline was complete and thorough, showing the times of the incident. During an interview on 3/30/26 at 12:11 P.M., Certified Medication Technician (CMT) A said:-He/She was working the night the resident eloped.-He/She saw the resident around 8:00 PM standing at the nurses station.-At approximately 8:30 P.M., he/she was passing meds and when he/she went to give the resident their meds the resident was not in his/her room.-He/She called a Code Pink (code to inform all staff there was a missing resident) over the intercom and searched every room and closet on the unit.-At that time each staff member swept their assigned area.-The resident was not found and the search started on the outside of the facility.-He/She notified the Administrator, and they contacted the police and corporate.-The resident was not exit-seeking.-The resident was not noted to be staring at the door or watching codes.-The resident did not usually wander, he/she went back and forth between his/her room, the dining room and the nurses station.-The Administrative Team did an investigation, and it was determined the resident went out through the door between the rehab and the secure unit.-He/She received training after the elopement regarding the door alarms and resident elopements.-At the time the doors were alarmed, the alarm went off if anyone pushed on the handle for 20 seconds. -The alarm did not go off when the resident exited.-Doors can be opened with a code and the alarm would not go off. During an interview on 3/30/26 at 12:11 P.M., the DON said:-Prior to the elopement the door would alarm after pushing on the release bar 20 seconds.-The administrative staff were notified, and contacted the police department and the hospitals.-He/She and the Regional Nurse Consultant (RNC) and did the sweep of the outside grounds and drove up and down the streets trying to find the resident. -The Administrator remained at the facility.-Staff continued to actively look for the resident. -The resident was found a local hospital without injury.-The hospital called the facility and Licensed Vocational Nurse (LVN) C took the call.-All staff were educated about the elopement and door alarms before coming back to the next shift. During an interview on 3/30/36 at 2:36 P.M., the Administrator said:-Prior to the elopement the doors were set up to push and hold for 15 seconds then it will open, and alarm would sound. -Staff did not hear the alarm.-When FT A used the code to get off the unit the door did not sound.-FT A received education and a corrective action plan. -FT A was newer to working on that unit. During an interview on 3/30/26 at 6:21 P.M., FT A said:-He/She was working on the secured unit.-He/She left the unit using the code and didn't check to see if anyone was following him/her.-He/She did not listen for the door to click shut once he/she passed through it. -Prior to the incident he/she had received training to watch the door for anyone trying to leave behind him/her.-Now, he/she made sure the door was closed correctly, and no one was following him/her.-He/She reported he/she was not paying attention and did not intentionally let the resident off the unit.-He/She was unsure of what time he/she came through the door, maybe around 8:15 and 8:30 P.M. During an interview on 3/30/26 at 6:26 P.M., LVN C said:-The door used to sound about 15-20 seconds after pushing on it. -It was enough time for the person to go through the door if no one was paying attention.-To his/her knowledge the door alarm was working correctly.-Staff were trained not to allow residents out to make sure the door closes behind you. During an interview on 3/30/26 at 6:59 P.M., Certified Nurses Aide (CNA) A said:-He/She was working the night of the elopement.-He/She remembered seeing the resident around 8:00 P.M. to 8:10 P.M -The resident was following him/her around and the last place the resident was seen was in the dining room.-The alarm did not go off the night the resident eloped.-If staff pushed on the door for a few seconds the door would open. During an interview on 3/31/26 at 9:14 A.M., the facility's Nurse Practitioner said:-The resident was fairly new to the facility.-He/She was aware the resident had eloped.-The facility physician was in the building the next day and saw the resident.-He/She adjusted one of the resident's medications that caused restlessness.-The resident had no recollection of eloping.-He/She expected the staff to check on the resident every hour to two hours.-The resident was not exit-seeking but liked to wander.-He/She expected the staff to know he was a wanderer as that was the reason the resident was on the secure unit. 2978949

Based on observation and interview, the facility failed to maintain the sprinkler heads above the food preparation and food serving areas, free from dust and grease; maintain the oven mittens in good repair; maintain the drainage pipes, metal fixtures and walls under the dishwasher area, free of a buildup of grime and discarded dishes; ensure items (lemon juice and beef base), were refrigerated; maintain the handwashing sink free of obstructions; maintain hot foods ( pureed French Toast and regular French Toast) at or close to 135 ºF ( degrees Fahrenheit) at the steam table; to ensure that fresh fruits ( grapes) were washed prior to mixing them with the fruit salad for breakfast and to ensure Dietary Aide (DA) B use tongs or gloves while he/she handled French Toast from the steam table. This practice potentially affected 143 residents who received food from the kitchen. The facility census was 143 residents. 1. Observations on 5/14/25 at 12:17 P.M., during the lunch meal, showed: - A buildup of grease and dust on the sprinkler heads and ceiling tiles over the food serving and food preparation areas. - The presence of grime on the metal fixtures under the dishwasher and the walls behind the dishwasher. - Two oven mittens with rips that were about two inches (in.) - One bottle of lemon juice that was on the counter next to the microwave with a label which stated to refrigerate after opening. 2. Observations on 5/16/25 from 6:19 A.M. through 8:20 A.M., during the breakfast meal preparation showed: - A buildup of dust and grease on the sprinkler heads and ceiling tiles over food preparation and food serving areas. - The presence of grime on the metal fixtures and pipes under the dishwasher and the walls behind the dishwasher. - The presence of a red tray, a gray cup, and a plastic glass that was under the dishwasher. - The presence of a black speaker which laid right across the handwashing sink. - Dietary Aide (DA) B slicing grapes to add to the fruit bowl mixture, without washing them. - One bottle of lemon juice that was on the table next to the microwave that was not refrigerated - Two containers of beef base on the same table as the soda dispenser that were not refrigerated. During an interview on 5/16/25 at 7:35 A.M., Dietary [NAME] (DC) A said the mittens have been like that for 2-3 days. Observation on 5/16/25 at 7:46 A.M., showed the pureed French Toast was 124.5 ºF on the steam table. Observation on 5/16/25 at 7:53 A.M., showed the slices of French Toast which were not under the metal cover in the pan at the steam table, were between 104 ºF -- 107 ºF. Observation on 5/16/25 at 8:22 A.M., showed DC B picked up a slice of French Toast with his/her bare hands after he/she was requested to taste the French Toast. Observation on 5/16/25 at 8:23 A.M., showed the Dietary Manager (DM) told DC B to place gloves on and take a different slice. During an interview on 5/16/25 at 8:42 A.M., DA C said he/she has worked at the facility for about 7 months and he/she remembered that the area under the dishwasher has only been cleaned twice. During an interview on 5/16/25 at 8:46 A.M. the Maintenance Director said he/she had a work order that was dated 5/14/25 for cleaning behind the dishwasher and the dishrack table. During an interview on 5/16/25 at 8:52 A.M., DA B said he/she was not trained to and did not know how to wash grapes before adding them to the fruit bowl. During an interview on 5/16/25 at 9:10 A.M., the DM said he/she told the Maintenance Director about cleaning the dust and grease from the sprinkler heads and ceiling tiles on 5/16/25. During an interview on 5/16/25 at 9:14 A.M., the DM said he/she expected the DAs to wash fruit before adding fruit to the fruit bowl. MO00253234.

Based on observation, interview and record review, the facility failed to ensure hot foods (vegetables on 5/14/25) and (French Toast on 5/16/25) were at or close to 120 ºF (degrees Fahrenheit) for two different meals. This practice potentially affected at least four residents (Residents #11, #3, #2 and #13) out of 19 sampled residents. The facility census was 143 residents. Review of the facility's policy entitled Food Temperatures and revised on 12/20, showed: - Purpose: To provide the nutrition services department with guidelines for food preparation and service temperatures. - Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. - Procedure: Measuring Food Temperature It is recommended to use a thermometer with a practical range of 0 ºF to 220 ºF. - Wash, rinse, and sanitize a dial face, metal probe type thermometer with an alcohol wipe. - Insert the thermometer into the center of the product. - Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots. -Take the temperature of each pan product before serving. - Resanitize the thermometer after each use. 1. Observation on 5/14/25 at 12:34 P.M., showed the vegetables on a test tray on the 100 Hall, had a temperature of 111.4 ºF, when the vegetables were checked for temperature. During an interview on 5/14/25 at 12:51 P.M., Resident #11 (a resident who was assessed by the annual Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 4/11/25, as cognitively intact, said his/her food is delivered cold sometimes. Observation on 5/16/25 at 8:07 A.M., showed the temperature of the French Toast on a test tray for the 100 Hall was 106.3 ºF. During an interview on 5/16/25 at 11:15 A.M., Resident #3 (a resident who was assessed as cognitively intact) by the annual MDS dated [DATE], said: - He/she received cold food on 5 of 5 days. - There was no difference amongst the meals ( breakfast, lunch or dinner) as to which ones were cold. - When he/she ate lunch, both the entrée and the side items were cold. During an interview on 5/16/25 at 11:21 A.M., Resident #2 (a resident who was assessed as cognitively intact) by the quarterly MDS dated [DATE], said: -The food including the entrees was cold almost daily. - Usually there was one staff member working to deliver trays on the halls where he/she resided on. During an interview on 5/16/25 at 11:50 A.M., Resident #13 (a resident who was assessed as cognitively intact) by the quarterly MDS dated [DATE], said: - Most of the time all the items were cold. Sometimes, he/she requested the alternative menu. -Many of the items on the alternative menus are delivered cold as well. During an interview on 5/16/25 at 11:24 A.M., Resident #11 said: - The food was delivered to his/her room cold at least 3 out of 5 days per week. - Lunch was cold more often than other meals. - There were not many staff who delivered room trays to the rooms. During a phone interview on 5/22/25 at 3:38 P.M., the Dietary Manager said: - Test trays are done by dietary staff 2-3 times per week. - It was the last tray on the hall they chose for that day that was tested. - If cold food food is found on a test tray, they keep the cooked food inside an oven until about 15 minutes before service. - The dietary staff is then encouraged to check temperatures of the food on the steam table, and - The dietary staff knows how to check temperatures, but he/she had to stay on them. MO00252740 & MO00252293

Based on observation, interview and record review, the facility failed to offer substitutes and honor preferences for one sampled resident (Resident #2) out of 19 sampled residents. The facility census was 143 residents. Review of the facility's policy, Resident Preference Interview, revised December 2020 showed: -Resident preferences will be reflected on the tray card and updated in a timely manner. --If a preferred item is not available, a suitable substitute should be provided. 1. Review of Resident #2's admission record showed he/she was admitted [DATE] with diagnoses to include: -Congestive heart failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body) - Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety) Review of the resident's Order Summary report for May 2025 showed he/she was on a regular diet with a fluid restriction of 2000 milliliters in a 24-hour period. Review of the resident's care plan showed: -He/She eats a heart healthy diet with regular consistency food and thin fluids. --Monitor tolerance and acceptance of diet. --Monitor, document, and report any signs and symptoms he/she appears concerned during meals. During an interview on 5/14/25 at 9:59 A.M. the resident said: -The facility has run out of food at times. -He/She should be on a cardiac diet. -The food was horrible. -He/She liked fresh fruit and salads. -He/She had to buy her own food. -The facility was not offering alternatives. -When he/she requested a chef salad she received a huge mound of mashed potatoes and gravy, approximately three helpings. Interview on 5/14/25 at 1:09 P.M. the resident said: -He/She was waiting his/her lunch tray. -He/She had requested a chef salad from Certified Nursing Assistant (CNA) C. -He/She was told there was no chef salad. -He/She made a salad from his/her refrigerator. Observation on 5/14/25 at 1:14 P.M. showed the resident received a lunch tray with chili and no salad. The resident refused the tray and asked staff to follow up on his/her requested salad. The meal ticket showed a chef salad but was marked out. Review the resident's progress note dated 5/14/25 at 4:33 P.M. the Director of Nutritional Services showed: -He/She spoke with resident after meal service to get an update on food preferences. -The resident stated he/she would request a chef salad when he/she wanted one. -The resident also said either lettuce or fresh cabbage as his/her base for salad was acceptable. During and interview on 5/16/25 at 7:10 A.M. the resident said he/she discussed food preference again with the Dietician on 5/14/25 and a new Food Profile was completed. During an interview on 5/16/25 at 9:53 A.M. the resident said: -He/She did not get the chef salad again last night. -He/She received enchiladas. He/She had a colon issue and could not eat the food they serve. During an interview on 5/16/25 at 10:00 A.M. the Dietary Manager said: -Yes, we have lettuce. -He/She went to the store to get some and some came on the truck. -He/She was not aware resident did not get chef salad on 5/15/25 as requested for the evening meal. -He/She would educate dietary staff. During an interview on 5/16/25 at 11:24 A.M. the Administrator said: -He/She expected residents to get diet requests within reason. -Staff should offer alternative food choices. -The always available food choice was too large and had food wasted so it was reduced. -The facility had not run out of food. -The facility had gone to the store to buy lettuce. -He/She was not aware the resident did not get a chef salad. MO00251558

Based on observation, interview and record review, the facility failed to ensure snacks were being offered on the long term care unit consistently between meal times during the day and evening for two sampled residents (Resident #11 and #13) out of 19 sampled residents. The facility census was 143 residents. Record review of the facility snack schedule showed facility snacks were supposed to be at 10:00 A.M., 2:00 P.M., and 7:00 P.M. daily. 1. Review of Resident #11's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, high cholesterol, high blood pressure and cancer. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/11/25, showed the resident: -Was alert and oriented with no confusion. -Ambulated with a walker and was able to eat with supervision only. Observation and interview on 5/14/25 at 1:15 P.M., showed the resident was ambulatory in his/her room but also used a wheelchair. On the resident's dresser were a variety of snacks. During an interview on 5/16/25 at 12:40 P.M., the resident said: -He/she had snacks in his/her room that were his/her personal snacks (self-purchased). -Dietary staff brought snacks to the nursing station up to three times daily but they don't always get the snacks on evenings. -When snacks are delivered, some residents take a lot of the snacks and other residents don't get anything, depending on when they get to the nursing station after snacks were delivered. -Snacks were not delivered this morning. 2. Review of Resident #13's Face Sheet showed the resident was admitted on [DATE], with diagnoses including heart failure, high cholesterol, diabetes and malnutrition. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no confusion. -Ambulated with a walker and wheelchair and was able to eat with supervision only. Observation on 5/14/25 at 10:41 A.M. showed the resident was laying in his/her bed watching television. There were beverages and graham crackers on his/her tray table that was next to his/her bed. The resident said he/she was able to ambulate independently but used a walker and wheelchair as needed. He/she was able to eat independently but usually ate all meals in his/her room. During an interview on 5/16/25 at 11:50 A.M. the resident said: -He/She received breakfast between 7:30-8:15 A.M., lunch between 12:30-1:30 A.M., dinner between 6-6:30 A.M. -He/She ate independently. -At 12:44 P.M., he/she kept his/her own snacks in his/her room. -The snacks the facility passed out were placed at the nursing station between meals. -Residents could go to the nursing station to get snacks, but staff did not pass snacks out. -The dietary staff did not bring snacks to the unit on the evening shift/at bedtime. Observation on 5/16/25 showed from 9:00 A.M. to 12:00 P.M., there were no snack trays brought to the long term care unit. During an interview on 5/16/25 at 12:34 P.M., Certified Medication Technician (CMT) C said: -Dietary staff usually brought snacks out to the nursing station between 10:00 A.M. and 11:00 A.M. after breakfast and before lunch. -Dietary staff usually brought a variety of chips, fudge bars, peanut butter and jelly sandwiches, bananas and apples on the trays and residents came up to the nursing station to get snacks if they wanted them. -He/She did not see dietary deliver any snacks this morning and he/she did not know why they were not brought out. -He/She usually left work at 3:00 P.M. before the evening snacks were delivered and did not know if evening snacks were delivered. During an interview on 5/16/25 at 12:35 P.M. Certified Nursing Assistant (CNA) D said: -He/She worked during the week and on the weekends and snacks were usually brought out between 10:00 A.M. and 11: 00 A.M., and then again between 2:30 P.M. and 4:00 P.M. before dinner. -Dietary staff brought out two snack trays and placed them at the nursing station. -Dietary staff does not bring enough snacks for all of the residents to have a snack. -They do not pass snacks out to the residents. The residents have to go to the nursing station to get a snack if they wanted one. -For residents who are primarily in their room or who cannot come to the nursing station, if they want a snack the nursing staff will bring one to them. -Some residents will take several snacks so they run out quickly. -The Dietary staff don't always bring snacks at night and did not bring any snacks last night when he/she worked. -Dietary staff did not bring snacks this morning before lunch today. -It was not uncommon for the dietary staff to miss bringing snacks out to the nursing station because they have had several staff changes in the kitchen and they may not know they were supposed to bring snacks between meals. During an interview on 5/16/25 at 12:37 P.M., CNA E said: -He/She worked from 7:00 A.M. to 3:00 P.M. during the week and sometimes worked the evening shift. -The dietary staff brought snacks between breakfast and lunch and again between lunch and dinner. -When dietary staff brought snacks, they put them at the nursing station. -The dietary staff did not bring snacks today. -He/She worked last night until 7:30 P.M. and they did not bring the evening snacks. -There are certain dietary staff who make sure they get the snacks when they are working but when those dietary staff are not working, they may not have the snacks delivered on evenings. -They did not deliver snacks to the resident rooms, the residents usually came to get their own snacks. -Residents who were unable to go to the nursing station could have staff bring their snack to them if they wanted a snack. During an interview on 5/16/25 at 12:47 P.M., Dietary Aide A said: -He/She was a newer employee and said he/she worked the evening shift. -They were supposed deliver snacks to each unit twice during his/her shift at 2:00 P.M. and at 7:00 P.M. -Each unit receives one tray of snacks and the long term care unit received two trays due to the number of residents on the unit. -Once the dietary staff deliver the trays, the nursing staff pass the snacks out. -He/She was not aware that the snacks were not brought to the long term care unit last night or this morning. -If the nursing staff let them know they did not have the snacks delivered, they would bring snacks to the unit. During an interview on 5/16/25 at 12:54 P.M., [NAME] A said: -The schedule for snacks to be delivered to the unit are at 10:00 A.M., 2:00 P.M., and 7:00 P.M. -He/She made sure snacks were passed out during the day shift at 10:00 A.M., and 2:00 P.M. -He/She was not at the facility during the evening shift and did not know if snacks were passed out then. -Each unit should get a tray of snacks (variety) and the long term care unit was supposed to receive to trays of snacks. -They deliver the snack trays to the nursing station. -He/She did not remember if snacks were passed out at 10:00 A.M. today because there was a lot going on in the kitchen. -He/She would ensure that snacks would be passed out at 2:00 P.M. During an interview on 5/16/25 at 1:00 P.M., the Dietary Manager said: -Kitchen staff is to make and provide snacks at 10:00 A.M., 2:00 P.M., and 7:00 P.M. -Snacks got missed today. -Staff knows to pass snacks daily. Aides who usually work on the food side make snacks. -Snack schedule times are posted in dining room. During an interview on 5/16/25 at 2:00 P.M., Registered Nurse (RN) A said: -Snacks are not provided daily per the schedule. -He/She had not seen snacks provided for weeks. During an interview on 5/16/25 at 2:13 P.M., the Assistant Director of Nursing (ADON) A said: -Snacks were supposed to be offered to the residents three times daily. -The Dietary staff brought the snack trays to each nursing station and residents could go to get their choice of snack and nursing staff also take snacks to those resident who are unable to obtain their own snack. -They have had some issues with residents taking several snacks and there not being enough (running out) and that they were not always being passed three times daily. -Dietary staff was getting better about bringing snacks out between meals. MO00251977

Based on interview and record review, the facility failed to notify the legal guardian of one discharged resident (Resident #6), in a timely manner (usually within 24 hours) after the resident passed away. The facility also failed to notify the facility's Business Office Manager (BOM) in a timely manner, which caused the business office to cash a check sent by the legal guardian's office to the facility, 14 days after the resident passed away out of 19 sampled residents. The facility census was 143 residents. On 5/21/25 the Administrator were notified of the past noncompliance that occurred on 3/26/25. All staff were educated on the notification policy. The deficiency was corrected on 4/22/25. Review of the Facility's policy entitled Change of Condition Notification revised 6/20, showed: -Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the residents' condition in a timely manner. -Definition: An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains, Clinically important means a deviation that without intervention, may result in complications or death. -Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: -Family Notification: The licensed Nurse will notify the resident, he resident's responsible party or the family/surrogate decision makers of any changes in the resident's condition as soon as possible. --Documentation: A licensed Nurse will document the following: --Date, time and pertinent details of the incident and the subsequent assessment in the nursing notes. --The time the attending physician was contacted, the method by which he/she was contacted, the response time and whether orders were received. --The time the family/responsible person was contacted. 1. Review of Resident #6's admission record printed on 5/16/25, showed he/she admitted on [DATE] with the following diagnosis: -Unsteadiness on his/her feet. -Alzheimer's disease (a progressive neurological disorder that primarily affects the brain, causing memory loss, thinking problems, and behavioral changes) with late onset; need for assistance with personal care. -Hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood). -The resident's legal guardian was the Public Administrator's Office and was listed as the first contact. Review of the resident's Progress Notes dated 3/26/25, showed: -At 9:07 A.M. The resident was actively dying. Comfort medications only. There was no documentation of notification of the legal guardian. -At 10:15 A.M., The hospice (end of life care) Case Manager was at the facility with Comfort Medications. The resident's relative was at the bedside of the resident. There was no documentation of notification of the legal guardian. -At 11:02 A.M., The pulse and respirations quietly ceased at 10:57 A.M., with the resident's relative and the hospice nurse at the bedside of the resident. There was no documentation of notification of the legal guardian. -At 12:10 P.M., the Post Mortem provide by the hospice nurse. The body was released to the funeral home transportation at this time. Death report was faxed to the local County Medical Examiner. There was no documentation of notification of the legal guardian. Review of a check dated 4/3/25, showed a check from the legal guardian was made payable to the facility for $1,580.09. Review of the deposit sheet dated 4/9/25 and the batch report (a report which showed a batch of checks which were processed into the facility's account) dated 4/9/25, showed the check from the legal guardian was processed on 4/9/25, 14 days after the resident passed away. During an interview on 5/14/25 at 9:24 A.M., the Business Office Manager (BOM) said: -He/she was on vacation from 3/12/25 through 4/1/25. -Therefore, he/she did not find out the resident passed away until 21 days after he/she returned to duty at the facility. -He/she notified the corporate business office on 4/23/25 that the legal guardian needed a refund because the resident passed away. During a phone interview on 5/14/25 at 12:04 P.M., the legal guardian said the following: -The office of the legal guardian was not notified of the Resident's death. -He/she expected his/her office within 24 hours after a ward (a person, for whom a guardian has been appointed by a court or who has become directly subject to the authority of that court) of that office has passed away, because the Office of the legal guardian has to notify Medicaid, Social Security, and Medicare because the ward may have been recipient of some of that aide. -The resident was on hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). -The methods of contacting him/her were the main office phone number, the after-hours number, his/her e-mail, and his/her work phone. -The process of notifying the guardian's office, if the Deputy Legal Guardian, were not there, would be let the clerical person know there was a death of one of the wards and the phone call would be transferred to another deputy Legal Guardian. -It was not until 4/22/25, that his/her assistant was informed the resident had passed away when his/her assistant went to the facility to do a monthly visit of their wards at that facility. -The facility did not submit any paperwork During a phone interview on 5/14/25 at 3:04 P.M., the Deputy Legal Guardian's Assistant said the following: -He/she went to the facility on 4/22/25 for a monthly visit and stated he/she wanted to Resident #6. He/she was directed to the business office. -At the business office, he/she was told that Resident #6 passed away and the date that Resident #6, passed away. -He/she was very surprised to hear than one of the wards of the Legal Guardian's office had passed away. -He/she did not hear about the resident's death, until she got to the facility. and -No one in her office received a phone call from the facility regarding the death of the resident. During an interview on 5/16/25 at 10:38 A.M., Licensed Practical Nurse (LPN) A said: -He/she was the charge nurse for his/her unit the day the resident passed away. -He/she had not notified the business Office the resident passed away. -He/she did not notify the legal guardian's office because when Hospice was in the facility, Hospice was in charge of notify the family and legal guardians. During an interview on 5/16/25 at 10:48 A.M., the Director of Nursing (DON) said hospice mentioned they notified the Legal Guardian's office. During an interview on 5/16/25 at 11:38 A.M., Assistant Director of Nursing (ADON) A said: -If a hospice staff member was in the facility when a death occurs, hospice was supposed to notify the Legal Guardian. -He/she was told by a hospice staff member that a nurse from hospice notified the PA's office. During an interview on 5/16/25 at 1:36 P.M., the Administrator said: -The former Social Service Director (SSD) said he/she reached out by calling the Deputy Legal Guardian's mobile phone. -He/she found out later that the SSD did not reach out to anyone at the Legal Guardian's Office. -He/she found out in April 2025 that the Deputy Legal Guardian was not notified after the death of the resident. -Based on his/her understanding of the situation, the BOM posted the checks into the accounts, without looking at the dashboard he/she was supposed to normally look at. During a phone interview on 5/19/25 at 2:48 P.M., Hospice Licensed Practical Nurse (LPN) A said: -On 3/25/25, he/she called the legal guardian and left a message for the legal guardian that the Resident was in the process of dying. -The hospice Agency only does the notification to the legal guardian if there was no one at the bedside on the resident behalf and since the resident's relative was at the bedside, the hospice agency did not have to notify the legal guardian. -The Facility should have notified the legal guardian. MO00253155

2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, heart disease, stroke, high blood pressure and asthma. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert with significant confusion. -Needed substantial assistance with transfers, mobility, bathing and dressing. Review of the resident's Care Plan updated 2/13/25, showed the resident had impaired cognitive functioning, vision loss, was at risk for falls, was incontinent and had a self care deficit. Interventions showed the resident was dependent on staff for bathing and staff was to provide maximum assistance to the resident. Review of the resident's bathing sheets from 3/24/25 to 5/8/25, showed the resident received bathing on the following dates: -March-3/24/25 -April-4/2/25, 4/11/25, 4/18/25, 4/25/25 -May-5/1/25, 5/8/25 -Bathing for the resident was once per week. Review of the resident's Medical Record showed there was no documentation showing the resident declined bathing. During an interview on 5/16/25 at 11:01 A.M., showed Certified Medication Technician (CMT) A said: -He/She worked with the resident and the resident had some cognitive impairment and needed total assistance for transfers. -The resident needed total care, to include bathing and mobility assistance. -The resident was supposed to receive bathing twice daily. -They have bathing assistants but he/she was not sure if the resident received bathing twice every week while he/she was living there. 3. During an interview on 5/16/25 at 1:38 P.M., showed CMT B said: -They try to have two bath aides to give the baths to residents. -One of the bath aides worked consistently on Monday, Tuesday, Thursday and Friday and the other bath aide worked on the other days, but they do not have a bath aide on weekends. -Both bath aides try to get as many baths completed as possible when they are here but they are giving baths to 90 or more people. -Residents do not always get two baths weekly. During an interview on 5/16/25 at 1:42 A.M., CNA A said: -The bath aides were responsible for giving baths twice weekly. -The primary bath aide gave baths four days weekly and they try to get as many baths as they can, but the resident's get at least one bath weekly. -There were no bath aides working today. -When the bath aides call in, the CNA staff try to get baths done as they are able and they complete the shower/bathing sheet and turn it in. During an interview on 5/16/25 at 1:48 P.M. Registered Nurse (RN) A said: -The bath aides were supposed to give each resident a bath/shower twice weekly. -When the bath aide was not in the building, or was unable to give baths, the CNA staff was supposed to try to give the baths or make up the bath for the resident. -He/She had not been in the facility for a few weeks, but the CNAs were expected to assist with giving baths so the residents get baths twice weekly. -The bath aide had called in today and no baths had been given today. During an interview on 5/16/25 at 1:51 P.M., Assistant Director of Nursing (ADON) A said: -Residents were supposed to get baths/showers at least twice weekly. -There were two bath aides on the long term care unit and one on the rehabilitation unit. -There was no bath aide on the dementia unit and the CNA staff on the unit completed the baths weekly. -All of the nursing staff were educated that if the bath aide was not there they were supposed to give baths/showers. -He/She has also given baths/showers to residents -They were trying to find additional staff to fill a bath aide position. -Currently, residents were getting at least one bath per week, but not two. -He/She did not believe the CNA staff were meeting their expectation because baths should be given on every shift and not by only the bath aide. 3. During an interview on 5/16/24 at 2:00 P.M., the Director of Nursing (DON) said: - Assigned Restorative Aides (RA) and Bath Aides were over all responsible for offering and providing the resident a bath or shower two times a week. -He/she would expect the CNA's and bath aides to ensure the resident was offered and received showers/bathing at least two times a week. -He/she would expect the CNA's who were assigned to a specific hallway, to be responsible for ensuring the residents received scheduled baths/showers assigned for that day and the resident was kept well-groomed and clean. -He/she would expect the shower sheet be completed by the staff who had provided the resident's shower/bath. -He/she would expect the shower sheet to be reviewed by the charge nurse and signed as reviewed. MO00252740 & MO00253115 Based on observation, interview and record review, the facility failed to follow their policy to ensure bathing was completed two times a week for two sampled residents (Resident's #9 & #5) out of 19 sampled residents. The facility resident census of 143 residents. Review of the facility's undated Bathing/Shower Program policy showed: -The resident will initially be placed on the schedule of two baths/showers per week, which may be adjusted to more or less often according to the resident's preference. -Showers/baths will be available 24 hours per day as the resident request. 1. Review of resident #9's admission Record showed he/she had the following diagnosis: -Absence of a right leg below the knee. -Needs assistance with personal care. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/21/25 showed he/she: -Had a moderate cognitive impairment. -Was frequently incontinent of urine and frequently incontinent of bowel. -Had no documentation related to rejection of cares noted. Review of the resident's Activity of Daily Living (ADL'S) Care Plan revised on 2/13/25 showed: -He/she has self care deficit related to a right below the knee amputation. -He/she was dependent on facility staff for personal cares and bathing. Review of the resident's Certified Nursing Assistant (CNA) Care Kardex (summary of how to care for the resident) showed the resident required assistance with bathing and personal. Review of the resident's CNA Shower Sheet and Skin Condition reporting form from 4/1/25 to 4/29/25 showed: -On 4/1/25 and 4/4/25, he/she had received a bath. -On the week of 4/6/25 to 4/12/25, he/she received one bath on 4/11/25. -On 4/15/25 he/she received a bath and none the rest of the week. -No baths were recorded for the week of 4/20/25 to 4/26/25. -On 4/29/25 he/she received a bath. -The resident received five showers out of nine opportunities. Review of the resident's CNA Shower Sheet and Skin Condition reporting form showed: -On 5/2/25 documentation of a shower given and no skin issue noted. -On 5/5/25, the staff did not indicate type bath or shower was given. -On 5/8/25, the staff did not indicate type of bath or shower was given. Observation and interview 5/14/25 at 10:25 A.M., the resident said: -He/she was getting at least one bath a week. -He/she had no lingering odors at that time of interview. During an interview on 5/16/25 at 8:00 A.M., CNA B said: -The facility has one or two bath aides assigned during the week to provide the residents baths/showers. -If the facility does not have a bath aide assigned that day, then CNA staff assigned to each hall would be responsible for ensuring and completing their resident's scheduled shower that day. -CNA staff who provide the shower for their assigned resident would be responsible for completing the shower sheets and they were to be reviewed by nursing staff. During an interview on 5/16/25 at 10:55 A.M., CNA C said: -The resident was able to make his/her care needs known. -The residents were scheduled to have a bath or shower two times a week. -The resident would normally receive bath/shower from the bath aides at least weekly, if not two times a week when bath aides are scheduled. -The CNA's are also responsible for providing showers/baths to those residents assigned that day, if no bath aides were scheduled. -He/she does not always have time to provide a shower/bath for the resident when a bath aide not available. -The bath aide had called in sick today (5/16/25), so most likely those residents scheduled for baths today will not be completed. -The staff providing the shower would be responsible for completing the shower sheet to include type of bathing provided.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #17) was supervised during smoking times. On 5/15/25 the resident was outside on the smoking patio when the wind came up and the resident's hair caught fire. Hospitality Aide B failed to report the smoking incident which resulted in a delayed burn treatment for the resident. The facility further failed to ensure resident electronic smoking materials were stored safely and not used in the facility for one sampled resident (Resident #9) who had a Electronic-cigarettes (also known as e-cigarettes/vape pen are battery-operated devices that heat a liquid and produce an aerosol) found in the resident bed, and also observed on bedside table, out of 19 sampled residents. The facility census was 143 residents. Review of the Facility's Smoking by Resident Policy revised on 6/2020 showed: -This policy applies to the use of both cigarettes and e-cigarettes. -Smoking is not allowed anywhere inside the facility. -Resident who choose to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in designated smoke areas. -Resident will be allowed to smoke in designated smoking areas only. -All smoking materials will be stored in a secure area to ensure they are kept safe. -All smoking area session will be supervised by facility staff members. Review of copy of undated Resident's Smoking Violation policy/Agreement showed: -Smoking by resident will occur under the direct supervision of facility staff or delegated volunteer. The resident smoking care plan indicate type supervision needed. -The resident will be assessed and evaluated for safe smoking and if can smoke independently or with supervision. -Smoking supplies will be labeled with the resident name, room number and bed number, maintained by facility staff and stored in a suitable cabinet the kept lock at nursing station. -If resident cognitively and physically able to secure all smoking materials, the facility may allow him/her to maintain his/her own tobacco or electronic cigarette product in a locked compartment. -No resident will be allowed to maintain their own lighter fluid or matches. Review of the facility undated guidelines for Hospitality Aid and All staff, resident smoking showed: -Smoking materials locked up in the smoking cart. Resident should not have smoking material in possession. Review of the Facility's policy entitled Change of Condition Notification revised 6/2020, showed: -Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. -The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by an injury /accident, The Licensed Nurse will notify the residents Attending Physician when there is an: -Incident/accident involving the resident which results injury and has the potential for requiring physician intervention. Review of the Facility's Smoking by Resident Policy revised on 6/2020 showed: -Resident who choose to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in these smoke areas. -All smoking area session will be supervised by facility staff members. Review of copy of undated Resident's Smoking Violation policy/Agreement showed: -Smoking by resident will occur under the direct supervision of facility staff or delegated volunteer. The resident smoking care plan indicate type supervision needed. -The resident will be assessed and evaluated for safe smoking and if can smoke independently or with supervision. Review of the facility undated guidelines for Hospitality Aid and All staff related to monitoring residents who smoke showed burns should be reported immediately to the nurse on duty. Review of the Hospitality Aid job description revised 12/2023 showed: -Monitor residents during smoking hours (in the facility designated smoke area). Chart and keeps track of cigarette counts for each resident, updates and organizes smoking book, log and storage. -Identifies and correct safety hazards and reports safety concerns as required. 1. Record review of Resident #17's admission Record showed he/she had the following diagnoses: -Cerebrovascular Accident (CVA, stroke a blockage in the one or more of the arteries supplying blood to the brain) affecting left non-dominant side. -Nicotine Dependence-cigarettes. -Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation.) -Bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Lack of coordination. -He/she was own responsible party. Review of the resident's smoking care plan dated 11/19/24 showed: -He/she had been advised of the facility smoking policy. -The resident required supervision while smoking. -Reassess the resident's smoking ability quarterly and after reported unsafe smoking practices. Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 3/25/25 showed he/she: -Was cognitively intact. -He/she was able to understand others and make his/her needs known. -Required supervision from staff for most cares. -Used tobacco. Review of the resident's Burn and Blister Incident Report from 5/15/25 at 11:00 A.M., showed: -The report was documented and reported on 5/17/25. -Nurse description: The resident received burns to his/her left ear while outside smoking. The resident stated the wind was blowing and the ashes from the end his/her cigarette blew in his/her hair and caught his/her hair on fire and burned his/her ear. The resident said he/she had asked HA B not to report the incident to the nurse because he/she did not want to have to wear burn apron. HA B did not report this information to nursing, the Director of Nursing (DON) or to the Administrator. The resident did finally tell the nurse on 5/17/25 that he/she was burned three days ago, and his/her ear was hurting. -Intervention were put in place at that time. All staff was educated on all incidents must be reported regardless of what the resident requests. The resident care plan has been updated to wear a burn apron when smoking and to braid his/her hair or ensure his/her hair is secured while smoking. -On 5/18/25 root cause documented by DON showed: The incident was primarily due to environmental factors, specifically the wind conditions and an isolated failure by HA B to follow established oversight protocols. -Reinforce of the facility policy that all incidents must be reported immediately. -Regular training session for staff on safety protocols and incident reporting. -Environmental assessments to mitigate risk associated with outdoor smoking areas. Review of the resident's Weekly Skin Check dated 5/17/25 at 8:45 A.M. showed: -He/she had new skin impairment of burn to his/her left ear. -No detail description noted of the area burn. Review of resident's Wound Assessment Detail Report dated 5/17/25 at 1:47 P.M. showed: -The resident had a facility acquired burn injury to his/her left ear. -The left ear tissue was deep purple with scant amount of drainage noted. -The burn area measured length of 1.20 centimeters (cm) by width of 0.9 cm. -Apply Silvadene ointment every shift. Review of the resident's Physician Order Sheet (POS) dated 5/17/25 showed an physician order for Silvadene External Cream 1% (is a topical antibiotic used to prevent and treat infections in second- and third-degree burns) to apply cream to his/her left ear every shift for burn. Review of the facility's Summary of Events date reported on 5/17/25 showed: -Incidents happen on 5/15/25 at 11:00 A.M. in outside smoking area. -On 5/15/25, the resident was outside smoking when the wind cause ashes from the end of his/her cigarette to blow into his/her hair, igniting his/her hair and resulting in a burn to his/her left ear. -The resident chose not to report the incident immediately due to concerns about wearing a burn apron. -HA B who was with the resident had not reported the incident per the resident's request. -On 5/17/25, the resident informed the nurse about the burn, which had been causing him/her pain for three days. The DON, Administrator, and Primary Care physician (PCP) were notified immediately. -Conclusion documented: The incident was primarily due to environmental factors, specifically the wind conditions and an isolated failure by HA B to follow established oversight protocols. This incident underscores the importance of strict adherence to safety protocols and environmental consideration in preventing accidents. The failure to report the incident promptly was an isolated case involving a staff member who did not follow the rules. Measure have been taken to prevent recurrence and ensure the safety and well-being of all residents. Review of the resident's POS dated 5/19/25 showed a physician order for Doxycycline Hyalite (antibiotic It's used to treat a wide range of bacterial infections and also has anti-inflammatory properties) oral capsule 100 milligrams (mg) give one tab by mouth every 12 hours for the burn to his/her ear until 5/27/25. Review of the resident's Medical Nurse Practitioner (NP) Note dated 5/19/25 at 3:10 P.M. showed: -Reason for visit due to resident's burn to his/her left ear. -Evaluation for follow-up of burns to the resident's left ear cause by a smoking incident. -Exam showed the resident had a first-degree burn and second degree burn to his/her left ear. -Started treatment for the burns with Silvadene cream and will start Doxycycline antibiotic prophylactic and will continue to monitor the resident. -Wound care by nursing staff to monitor daily and call with adverse reaction. -Monitor resident during smoking as per facility protocols. Observation on 5/20/25 showed the resident's left ear had white cream on lower lobe and noted yellowish dried crusted drainage on the lower ear lobe. Review of the resident's handwritten witness statement dated 5/17/25, documented and witness signature by License Practical Nurses (LPN) B showed the resident said: -On 5/15/25, While out at the smoke area, he/she tried to light a cigarette. -It was windy, and his/her hair caught fire. -He/she and the roommate shouted for HA-B to bring the fire blanket. -HA-B did not act very quickly and his/her roommate rubbed out the fire. -He/she had pleaded with HA-B not to report the resident's fire, because he/she was afraid of consequences for the incident. -On 5/17/25 he/she started to scratch his/her ear and now was painful. -He/she was not aware he/she had a burn injury on his/her ear. During an interview on 5/20/25 at 8:25 A.M., the resident said: -On 5/15/25 in the afternoon (unsure time, after lunch) the resident was outside in smoke area. -He/she was sitting with his/her roommate in the uncovered smoke area. -He/she was not in visual site of HA-B, who inside the smoking covered carport area. -It was very windy that day, he/she did not have his/her hair in a braid or ponytail, that day. -He/she was trying to light his/her cigarette, when his/her hair had caught on fire. -He/she was not aware that his/her hair was on fire until his/her roommate notice and tried to put the fire out him/herself while yelling for HA -B to assist and to grab the smoke blanket. -HA-B came around the corner to assist his/her roommate put the fire out. -He/she had begged HA-B not to report the fire incident to nursing staff. -HA-B informed the resident he/she need to notify the nursing staff, but the resident did not want nursing staff to know because he/she did not want to have wear the safety smoke apron while smoking. -He/she did not realize he/she burnt his/her left ear until two days later on 5/17/25, after he/she scratched his/her ear and broken a blister. -On 5/17/25, LPN B found out about the smoking incident and did a skin assessment of the resident's left ear. LPN B had received orders for burn treatment, to apply burn ointment two times a day. -He/she was educated by the DON on safe smoking to included prevention safety measure to include he/she was to ensure to place hair in braid or ponytail while smoking and he/she was required to wear the smoke apron while outside smoking. Observation on 5/20/25 at 8:35 A.M., showed: -The resident was wheeled himself/herself outside to the smoking area. -He/she grabbed a smoke apron prior to exiting the facility. -While outside, HA A assisted the resident with placement of the smoke apron. -The resident had wheeled himself/herself over to place where the fire incident happened on 5/15/25. -He/she was located outside the smoke carport area to right and sat by the open smoke area by the covered ashtray. Record review of Resident's #11's (roommate) dated 4/11/25, showed he/she was cognitively Intact. Review of Resident #11's handwritten undated witness statement showed: -On 5/15/25, while out at the smoke area all of sudden Resident #17 was yelling for help that something was biting his/her ear. -As, he/she turned around to look at the resident the left and right side of his/her hair was on fire as well as his/her left ear. -He/she immediately started smacking Resident #17's head and yelling for help, specifically for the fire blanket. -HA B came around the corner to see what was going on. -HA B seemed to be confused as what to do. -HA B told Resident #17 needed to report the incident. -Resident #17 was afraid of the consequences. -The resident's left the smoke area went back into their room. During an interview on 5/20/25 at 10:04 A.M., Resident #11 said: -On 5/15/25 in afternoon he/she and Resident #17 were outside smoking. -The HA B was located inside the smoking carport area. HA B was not able to see them because they were out in courtyard area smoking. -He/she heard Resident #17 yelling for help that something had stung his/her ear. -He/she turned around and saw Resident #17's hair was inflamed with fire. -He/she went over started hitting Resident #17's head to get the flames out. -He/she was scared at that time. -Resident #17 thought he/she was stung by a wasp but Resident #17's hair was on fire. -He/she yelled for HA B to come to assist and bring the smoke blanket. -His/her fingers were tingling after he/she slapped the fire out on Resident #17's head but he/she had no burns . -No resident or staff were notified of what happened. -He/she encouraged Resident #17 to call his/her daughter and tell the nursing staff about the burn. -HA B flipped the resident's hair back but did not look at the resident's ear or skin. -On 5/16/25 he/she noticed Resident #17 had blisters on his/her left ear. -On 5/17/25 he/she told LPN B about the smoking incident and Resident #17 had a burn blister to his/her left ear. Review HA B employee file on 5/20/25 showed: -A Corrective Action Memo dated 5/17/25. -Type of violation was insubordination. -Employer stated the employee neglected to notify anyone of incident when a resident caught his/her hair on fire which resulted in a burn. -The employee was suspended pending investigation. Review of HA B handwritten witness statement dated 5/19/25 showed: -He/she was outside on Thursday 5/15/25 in the smoke area. -Resident #17 and Resident #11 were outside smoking with other unknown residents. -Resident had called for HA-B to help Resident #17. -He/she came around the corner of smoking carport, and sure enough Resident #17 hair was on fire. -HA-B and Resident #11 assisted getting the fire out. -Many times, he/she had told Resident #17 they needed to report the smoking incident to the nurse. -Resident #17 did not want HA B to report smoking incident to the nurse. -He/she should had reported the smoking incident but, he/she did not report the fire. He/she had written, was My fault, and he/she was sorry. -He/she was notified by the DON on 5/17/25 related to the incident on 5/15/25 and did not complete a witness statement until 5/19/25. During an interview on 5/20/25 at 8:10 A.M., HA A said: -He/she worked as a smoke aid from 7:00 A.M. to 3:00 P.M. -He/she was not working on 5/15/25 when smoke incident happened. -He/she had worked on Friday 5/16/25 as a smoke aid and Resident #17 had his/her hair down that day and did not see the resident's left ear. -He/she was not informed nor aware of any smoking incident that had happen on 5/15/25 until 5/17/25. -On Saturday 5/17/25 he/she was completing his/her resident safety smoking check which include checking resident clothing for burn holes and burn on the resident hands and fingers from smoking. -He/she would have notified the charge nurse immediately if noted any resident with clothes with burn holes or skin burns noted. -On 5/17/25 Resident #17 was going out to smoke with his/her hair in a braid and that's when he/she notice Resident #17 had blisters on his/her left ear. -He/she immediately asked Resident #17 what happen to his/her ear. -Resident #17 said on Thursday 5/15/25, he/she and peers were out smoking while being supervised by HA B when his/her hair caught on fire trying to ash his/her cigarette. -Resident #17 had asked HA B not to report his/her smoking/fire incident from 5/15/25 to nursing staff. -He/she would immediately report any smoking incident immediately to charge nurse or administrative staff. Review of Resident #18 Quarterly MDS dated [DATE] showed he/she was cognitively Intact. During an interview on 5/20/25 at 8:13 A.M., Resident #18 said: -He/she was outside smoking on 5/15/25 when the fire incident happened. -He/she and HA B were under the smoking carport area. -Resident #17 and Resident #11 were sitting outside to right of the carport out view by HA B. -Resident #17's hair caught on fire, as heard Resident #11 yelling for HA B to get the smoke blanket. -HA B went around to outside of the carport to see what had happened and the fire was already put out by Resident #11. -He/she heard Resident #17 asking HA B not to report the smoking incident to nursing staff. -He/she did not report the smoking incident from 5/15/25 to nursing staff. During an interview on 5/20/25 at 9:40 A.M., Administrator said: -He/she was not notified of the smoking incident occurred on Thursday 5/15/25 until Saturday 5/17/25. -The facility started their smoking incident report and investigation on 5/17/25 to include obtaining witness statements from resident and staff and assessment of the resident. -Resident #17 was assessed by LPN B and burn treatment order received on 5/17/25. -Resident #17 did not require emergency medical treatment or hospitalization for burn care. -HA B was suspended until further investigation for not reporting smoking incident immediately to nursing staff after it happen on 5/15/25. -He/she would expect all facility staff to report any resident incident immediately to nursing staff and administrative staff. During an interview on 5/20/25 at 11:56 A.M., LPN B said: -On 5/17/25 HA A reported Resident #17 had a burn blister to his/her left ear from a smoking incident that happen on 5/15/25. The resident had scratched his/her ear was painful and had opened up the blister. -Resident #17 said on 5/15/25 it was very windy and his/her hair had caught fire. Resident #17 and HA B did not report the smoking incident to nursing staff. During an interview on 5/20/25 at 12:08 P.M., NP A said: -On 5/17/25 he/she was notified by LPN B of the resident's smoking incident that happen on 5/15/25. -On 5/17/25 the resident was examined and had a second degree/third degree burn to his/her left ear, the skin was broken open. -He/she had ordered Silvadene cream 1% apply every shift. -On 5/19/25 he/she ordered an antibiotic to be given due to increased risk for infection with burns. -He/she would expect all facility staff to follow the policy of reporting any incident immediately to nursing staff or administrative staff member. -He/she would expect the resident to follow the smoking policy related safe smoking. During an interview on 5/20/25 at 1:30 P.M., DON said: -He/she was notified on the morning of 5/17/25, that Resident #17 had a smoking incident on 5/15/25 that resulted in a burn to his/her left ear. -Root cause analysis of the smoking incident showed it was a windy day causing ash to fly into the resident's hair cause the fire. HA B, Resident #17 and Resident #11 did not report the smoking incident on 5/15/25 to nursing staff which delayed medical care for Resident #17's burn to left ear for two days. 2. Review of resident #9's admission Record showed he/she had the following diagnosis: -Absence of right leg below the knee. -Needs assistance with personal care. -Uses tobacco. Review of the resident's Plan of Care revised on 11/24/25 showed: -The resident was dependent on tobacco. -All facility staff were to notify the social services or Administrator immediately if it is a suspected resident had violated the facility smoking policy. -NOTE: The resident's care plan did not show the resident vaped using a e-cigarette. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 2/21/25 showed he/she: -Had a moderate cognitive impairment. -Had no documentation related to rejection of cares noted. -Uses tobacco. Review of the resident's Safe Smoking Evaluation dated 2/28/25 showed: -The resident smokes. -He/she able to independently light smoking material safely. -He/she was safe to smoke with minimal supervision. -Had no documentation that smoking material was storage in the resident's room. -The facility did not have a specific Safe Smoking Assessment for residents that use e-cigarettes. Review of the resident's medical record on 5/20/25 showed no documentation that the resident used e-cigarettes or could store smoking material at bedside. Observation and interview on 5/14/25 at 10:25 A.M., showed: -The resident laid in his/her bed covered up with blankets. He/she was looking for his/her e-cigarette. -He/she had found the square vape pen, the size of his/her palm of his/her hand, located under the resident's blankets. -He/she does use the e-cigarettes while in his/her room most of the time. -He/she requires assistance with transfer and was easier to just use e-cigarettes while in room. Observation on 5/16/25 at 5:45 A.M. the resident showed: -He/she was in bed with eyes closed. -The e-cigarette was located on top of bedside table within the resident's reach. Observation on 5/16/25 at 11:02 A.M., showed: -The resident was sitting up in wheelchair. -He/she had e-cigarette on bedside table, he/she asks for assistance reaching for the e-cigarette off the bedside table. During an interview on 5/16/25 at 11:03 A.M., the resident said: -He/she will go out to smoke some days, but he/she uses his/her e-cigarette while in his/her room. -He/she did not have secure place to store vape pens. During an interview on 5/14/25 at 12:35 A.M., Hospitality Aid (HA) A said: -He/she has a list of residents that smoke, and the type of assistance needed. -The resident does go outside to smoke, but does not go out to smoke every day. -He/she noted the resident did use his/her e-cigarettes outside in smoke area. During an interview on 5/16/25 at 7:55 A.M., HA A said: -He/she not aware of any resident that uses e-cigarette while inside the facility. -E-cigarettes should be use in supervised designated smoke areas only. -All tobacco smoking material should be stored in the locked smoking cart. -The resident that use e-cigarettes atre normally kept in the resident's room or carried with the resident. -Most e-cigarette required to be charged. -He/she not aware of any e-cigarette stored in the secured smoke material cart. -He/she would notify the charge nurse of any resident not following safe smoking practices. During interview on 5/16/25 at 8:00 A.M., Certified Nursing Assistant (CNA) B said: -Residents were not to use e- cigarettes while inside the facility. -He/she aware of several residents in the facility that keep e-cigarettes in their room. -He/she aware of some the facility residents that have difficulty leaving their room will use a e-cigarette while inside the facility. -The resident does have more than one e-cigarette in his/her room and does use it while in bed or up in wheelchair. -He/she was not aware of the facility policy for the use of e-cigarettes. During interview on 5/16/25 at 10:55 A.M., CNA C said: -The resident does go outside to smoke but does have his/her own e-cigarette that he/she uses in his/her room. He/she keeps e-cigarette at bedside. -The resident will leave the facility with family and does propel himself/herself outside around the facility. -He/she was aware of other unknown residents on the hallway that do keep and use e-cigarettes at bedside. During an interview on 5/16/25 at 11:45 A.M., Certified Medication Technician CMT) B said: -He/she aware of the resident storing e-cigarettes on bedside table and do use e-cigarettes in the facility. -Resident are aware they should not being using any smoking devices while in the facility. During an interview on 5/16/25 at 11:55 A.M., Licensed Practical Nurse (LPN) B said: -E-cigarettes and any other smoking material should not to be stored or keep in resident's room. -He/she was not aware the resident had e-cigarettes at bedside and should not be using e-cigarette while inside the facility including resident's room. -The facility smoking policy says no smoking material shall be kept in resident's rooms and no use of smoking items while inside the facility. During an interview on 5/16/25 at 12:13 P.M., Administrator said: -The facility aware ongoing issue with resident having e-cigarettes with nicotine only used in the facility. -The facility staff and resident had been educated on use of e-cigarettes usage and other smoking material should not be kept in resident room. -He/she would expect facility staff complete safety checks during cares to ensure no smoking materials left in resident room including e-cigarettes. -He/she would expect facility staff to ask the resident to show the smoking material to staff and then request those smoking material be removed from resident room and place in secure smoking material cart. During an interview on 5/16/25 at 12:13 P.M., Director of Nursing (DON) said: -The resident smoking assessment were to be completed by social service upon admission, quarterly or if resident had smoking incident, includes the use of e-cigarettes. -He/she was not aware the resident had e-cigarette and been using them while inside the facility. -The residents were not allowed to use e-cigarettes while inside the facility. -Residents are not allowed to keep smoking materials including e-cigarettes, stored in residents' rooms. -He/she would expect facility staff to ensure that the resident smoking items are being turned into nursing staff for safe secure storage. -He/she would expect all staff to ensure the resident only smoke in designated smoke areas. MO00253115 & MO00254444

Refer to F550 Event ID ZSB9 Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents.

See F 804 Event ID ZSB9 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiency dated 11/25/24. Based on observation, interview and record review, the facility failed to ensure hot foods on room trays were served at or close to 120 F (degrees Fahrenheit), on 1/15/25 during lunch and on 1/16/25 during breakfast. This practice potentially affected at least 60 residents who resided on the 100, 200, 300 and 400 Halls. The facility census was 158 residents.

Based on observation, interview, and record review, the facility failed to properly screen new employees for Tuberculosis (TB a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled new employees (Employee F, G, H, I, and J,) out of ten sampled new employees. This practice had the potential to affect all residents, employees, and visitors to the facility; the facility failed to ensure appropriate hand hygiene, glove usage, and barrier placement was appropriately used during medication administration, blood glucose (sugar) test, and insulin (a hormone produces in the pancreas which regulates the amount of glucose in the blood) administration for one sampled resident (Resident #84) and for one supplemental resident (Resident #132) out of five supplemental residents; failed to ensure enhanced barrier precautions (EBP-an infection control method that uses personal protective equipment (PPE-clothing or equipment that protects the wearer from injury or the spread of infection or illness) to reduce the spread of multidrug-resistant organisms) were used and failed to use handwashing/sanitizing to prevent cross contamination when providing care for six sampled residents (Resident #95, #84, #72, #19, #40, and #116) out of 35 sampled residents; The facility census was 151 residents. Review of 19 Code of State Regulations (CSR) 20-20.100 TB testing for residents and workers in long-term care facilities, paragraph three, showed: -All new long-term care facility employees who work ten or more hours per week should have the first of two TB skin tests (TST) within one month prior to starting employment in the facility. -The results of the TSTs should be read within 48-72 hours from administration. -If the initial TST result is zero to nine millimeters (mm) induration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year. Review of the facility's Employee TB Screening and Interpretation of TST's policy revised 6/2020 showed: -After a TST test was administered, the TST test must be read within 48 to 72 hours by a qualified nurse or health practitioner in mm of induration. 1. Review of Employee F's employee file showed: -The employee was hired on 5/9/24 as a Certified Medication Technician (CMT). -The first step TB test was administered 5/9/24 and read as 0 millimeter (mm). There was no date showing when the TST was read. -The second step TB test was administered 5/20/24 and read as 0 mm. There was no date showing when the TST was read. Review of Employee G's employee file showed: -The employee was hired on 6/7/24 as a Registered Nurse (RN). -The first step TB test was administered 6/7/24 and read as 0 mm. There was no date showing when the TST was read. -The second step TB test was administered 6/20/24 and read as 0 mm. There was no date showing when the TST was read. Review of Employee H's employee file showed: -The employee was hired on 8/16/24 as a Licensed Vocational Nurse (LVN). -The first step TB test was administered 8/2/24 and read as 0 mm. There was no date showing when the TST was read. -The second step TB test was administered 8/12/24 and read as 0 mm. There was no date showing when the TST was read. Review of Employee I's employee file showed: -The employee was hired on 9/4/24 as a Certified Nursing Assistant (CNA). -The first step TB test was administered 9/4/24 and read as 0 mm. There was no date showing when the TST was read. -The second step TB test was administered 9/13/24 and read as 0 mm. There was no date showing when the TST was read. Review of Employee J's employee file showed: -The employee was hired on 10/23/24 as a Cook. -The first step TB test was administered 10/23/24 and read as 0 mm. There was no date showing when the TST was read. -The second step TB test was administered 11/1/24 and read as 0 mm. There was no date showing when the TST was read. During an interview on 11/22/24 at 2:14 P.M. the Human Resources Coordinator said: -When an employee was hired, he/she would let Assistant Director of Nursing (ADON) A know the new employee needed TB testing. -ADON A would complete the TB testing for the new employee. -The TB testing should show a date when the TB test was read in mm of induration. During an interview on 11/22/24 at 2:27 P.M. ADON A said: -He/she was responsible for completing the TB testing for the new employees. -He/she would administer the TST then read the TST within 48-72 hours. -The TB form did not have a space for the date read so it did not prompt him/her to write a date down. -He/she had not been documenting the date the TB test was read. -When a TB test was read, a date should be listed along with the mm of induration. During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said: -Nursing staff were responsible for ensuring new employee TB testing was completed. -TST's should be read within 48-72 hours after administration. -He/she expected the date the TB test was read to be documented on the TB testing form. -The ADON's should be monitoring for completion and accuracy. 46519 2. Review of the facility's policy titled Personal Protective Equipment dated June 2020 showed hands were to be washed before and after glove usage. Review of the facility's policy titled Blood Glucose Monitoring dated June 2020 showed: -Staff were to wash their hands and put on gloves before performing the test. -Staff were to remove their gloves and wash their hands after completing the procedure. -The policy did not include the use of a barrier for placing supplies during the test. Review of the facility's undated policy titled Hand Hygiene showed: -Facility staff were to wash hands with soap and water in between glove changes. -Facility staff were to use alcohol-based hand hygiene products: --Immediately upon entering a resident occupied area regardless of glove use. --Immediately upon exiting a resident occupied area regardless of glove use. --Before moving from one resident to another in a multi-bedroom or procedure area regardless of glove use. --After removing PPE and before moving to another resident in the same room or exiting the room. -The use of gloves did not replace hand hygiene procedures. Review of the facility's undated policy titled Medication Administration showed staff were to wash hands before and after medication administration. Review of Resident #84's face sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Trimalleolar (ankle) Fracture of Left Lower Leg. -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Physician Order Sheet (POS) dated November 2024 showed: -An order for blood glucose monitoring. -An order for Hydrocodone-Acetaminophen Oral Tablet (pain medication) 5-325 milligrams (mg), give one tablet by mouth every four hours as needed for pain. -An order for Novolog Injection Solution (Insulin Aspart- a short acting insulin) 100 unit/milliliters (ml), inject 20 units subcutaneously (situated or applied under the skin) before meals for DMII. Observation on 11/19/24 at 8:39 A.M. of the resident's medication administration, blood glucose test, and insulin administration completed by Licensed Practical Nurse (LPN) A showed: -LPN A did not sanitize his/her hands prior to the medication pass. -He/She put on gloves and then got his/her keys out of his/her pocket and unlocked the medication cart. -He/She then removed his/her gloves and walked away from the cart without sanitizing his/her hands. -He/She returned to the medication cart and put on new gloves without sanitizing his/her hands. -He/She sanitized the glucometer (glucose meter- a medical device used to determine the approximate concentration of glucose in the blood), set the glucometer down on a barrier, then removed his/her gloves. -He/She then entered the resident's room to give the resident his/her pain medication and washed his/her hands before exiting the room. -He/She walked out of the room and applied new gloves. -He/She unlocked the medication cart and removed the other supplies needed for the blood glucose test. -He/She then entered the resident's room with the same pair of gloves on and performed the blood glucose test. -During the test LPN A placed the glucometer on the resident's bedside table without using a barrier. -He/She removed his/her gloves and exited the resident's room. -He/She returned to the medication cart and put on new gloves without sanitizing his/her hands. -He/She then unlocked the medication cart and touched multiple different bags that held insulin pens in order to find the resident's insulin. -He/She needed to get the resident a new insulin pen and removed his/her gloves without sanitizing his/her hands after the removal. -He/She left the medication cart and walked to the medication room to get the resident a new insulin pen. -Once LPN A was back at the medication cart, he/she did not sanitize his/her hands prior to getting a needle for the insulin pen out of the medication cart. -He/She sanitized the insulin pen hub and placed the needle on the insulin pen without using gloves. -He/She then put on new gloves without sanitizing his/her hands and walked into the resident's room to administer the insulin. -He/She administered the insulin, removed his/her gloves, and walked out of the resident's room. 3. Review of Resident #132's face sheet showed he/she admitted to the facility with a diagnosis of DM II. Review of the resident's POS dated November 2024 showed: -An order for blood glucose monitoring before meals and at bedtime. -An order for Humalog Injection Solution (Insulin Lispro- a short acting insulin), inject 15 units subcutaneously with meals for DM II. Observation on 11/19/24 at 9:05 A.M. of the resident's blood glucose test and insulin administration completed by LPN A showed: -LPN A transported the resident via his/her wheelchair to the medication cart. -He/She put on gloves without sanitizing his/her hands. -He/She performed the blood glucose test on the resident. -The glucometer read an error and LPN A needed to re-perform the test. -He/She grabbed new supplies from the cart with the same gloves and performed the test again. -He/She then removed his/her gloves, sanitized his/her hands, removed the resident's insulin from the cart and put on new gloves. -He/She removed insulin from the resident's insulin vial and administered the resident's insulin. -He/She removed his/her gloves and did not sanitize his/her hands before continuing the resident's medication pass. During an interview on 11/19/24 at 9:14 A.M. LPN A said: -He/She would not have done anything differently during the medication administration, blood glucose tests, and insulin administrations for either resident. -He/Should would normally perform hand hygiene after each glove removal. -There was not a specific reason as to why he/she had not done that during the observation. -He/She would normally sanitize his/her hands before and after any type of resident care including medication administration, when going from task to task during resident care, and after glove removal. 4. During an interview on 11/20/24 at 10:55 A.M. RN A said: -Hand hygiene was to be performed before and after each resident during medication pass. -The nurse should not have worn gloves when gathering supplies at the cart and going into the cart and should not have worn them into Resident #84's room. -The nurse had not performed hand hygiene correctly throughout Resident #84's care. -The nurse should have sanitized his/her hands before gloves were put on and taken off. -The nurse should have placed a clean barrier between the resident's bedside table and the glucometer during the blood glucose test. -The nurse should have removed his/her gloves before going into the resident's room. -Upon entering the resident's room, the nurse should have sanitized his/her hands and put on new gloves before performing the blood glucose test. -The nurse had not performed appropriate hand hygiene during Resident #132's care. -The nurse should have sanitized his/her hands after touching the resident's wheelchair. -The nurse should have removed his/her gloves, sanitized/washed his/her hands, and put on new gloves before redoing the resident's blood glucose test. -Gloves were not a substitute for hand hygiene. During an interview on 11/20/24 at 11:36 A.M. ADON A said: -He/She expected staff to perform hand hygiene before and after each medication pass. -He/She expected staff to perform hand hygiene before entering and after exiting resident rooms. -Gloves were not a replacement for hand hygiene. -LPN A did not perform appropriate hand hygiene during Resident 84's and Resident #132's care. -LPN A should have washed/sanitized his/her hands after each glove removal and before putting on gloves. -LPN A should not have worn gloves into Resident #84's room. -LPN A should not have kept the same pair of gloves on to redo Resident #132's blood glucose test. -LPN A should have removed his/her gloves, washed his/her hands, and put on new gloves before re-performing Resident #132's blood glucose test. -LPN A should have placed a barrier on Resident #84's bedside table during Resident #84's blood glucose test. During an interview on 11/20/24 at 12:07 P.M. the DON said: -He/She expected staff to sanitize their hands between each resident during medication pass. -Gloves were not a substitution for hand hygiene. -Staff were expected to wash/sanitize their hands before and after glove use. -Staff were expected wash/sanitize their hands before and after any resident care. -Staff were expected to wash/sanitize their hands when entering and exiting resident rooms. -LPN A had not performed appropriate hand hygiene during Resident #84's and Resident #132's care. -LPN A should not have worn gloves into Resident #84's room. -LPN A should have placed a barrier down between Resident #84's bedside table and the glucometer. -Gloves were not to be worn when accessing non-medical supplies. -LPN A should not have worn the same gloves after Resident #132's first blood glucose test. -LPN A should have removed his/her gloves, washed his/her hands, and put on new gloves when he/she performed Resident #132's blood glucose test again. 21003 5. Review of the undated policy Understanding Enhanced Barrier Precautions showed: -When using PPE staff members wear a clean gown and gloves while performing high contact resident care activities with residents who are at increased risk of carrying a resistant organism. This includes all residents with any of the following: --Known infection or colonization with a resistant organism when Contact Precautions do not otherwise apply. --Wounds or indwelling medical devices like central line, urinary catheters, feeding tube, tracheostomy, or ventilator. -High contact resident care activities were typically bundled care activities that were provided either during the morning or evening care to include: --Dressing. --Bathing/showering. --Changing linens. --Changing briefs or assisting with toileting. --Caring for or using an indwelling medical device like central venous catheter, urinary catheter, feeding tube care, tracheostomy, or ventilator care. --Performing wound care. -Unlike Contact Precaution which are used by some types of facilities while treating a resident with a resistant organism, EBP: --Was intended to be used for the duration of the resident's stay in the facility. --Did not require isolation in the room or exclusion from participation in group activities. --Provided long term protection for residents and staff even after the infection is resolved. --These residents could still serve as a source of transmission even after the infection had resolved. Review of Resident #95's Face Sheet showed the resident was admitted on [DATE], with diagnoses including respiratory failure, high blood pressure, anxiety, severe obesity, sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep), heart failure, and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/27/24, showed the resident: -Was alert and oriented without confusion. -Was dependent or needed substantial assistance with transferring, bed mobility, ambulation, toileting, bathing and dressing. -Had coughing or choking during meals. -Received oxygen therapy, suctioning and tracheostomy care. Review of the resident's POS dated [DATE], showed physician's orders for: -Tracheostomy care every shift and as needed on every shift (9/24/24). -High Humidity Tracheostomy Collar: FIO2 28 percent, every shift for shortness of air, change in condition (9/24/24). -Clean the non-disposable inner cannula every day shift for shortness of air, change in condition and as needed (9/24/24). -Tracheostomy change as needed for shortness of air, change in condition (9/24/24). -Change oxygen tubing and set, including drainage bag every night shift every 7 day(s) for shortness of air, change in condition (9/24/24). -Suction Tracheostomy as needed for shortness of air, change in condition (9/24/24). -Complete Tracheostomy care every shift and as needed for shortness of air (9/24/24). -Change disposable inner cannula size 5 every day shift for shortness of air, change in condition and as needed (9/24/24). -Keep at bedside for emergency use: a disposable ambu bag (a device used to provide respiratory support to patients in emergency and non-emergency situations), a back up complete tracheostomy set and suction machine (9/24/24). Observation on 11/18/24 at 11:22 A.M., showed: -There was no sign outside of the resident's door identifying the room as needing EBP and there was no PPE outside of the residents door but there was a PPE cart containing gowns and gloves down the hallway. -The resident was laying on his/her back in bed with the head of his/her bed up. -He/She was alert and oriented with his/her call light within reach. -The resident's tracheostomy was clean and the surrounding skin was clean and intact. -There was a breathing treatment machine on a dresser against the wall. Next to it was the resident's humidifier machine and beside the humidifier machine was the resident's suction machine. During an interview on 11/18/24 at 11:22 A.M. the resident said: -The nurse came in cleaned around and checked his/her tracheostomy this morning and it was okay. -Nursing staff had changed his/her tracheostomy last night. -The nurse said he/she would come back later today to see if he/she needed to be suctioned, but he/she had a breathing treatment this morning and was not congested. -He/She only received oxygen as needed, not continuously. Observation on 11/21/24 at 10:26 A.M. showed: -There was no EBP signage on or by the resident's door and no PPE cart by the resident's door but there was a PPE cart containing gowns and gloves in the hallway. -CMT C went into resident room and placed a blood pressure cuff on the resident's wrist. He/She removed it and then gave the resident a cup with medication inside. The resident took his/her medication. CMT C left the room to put the blood pressure cuff away, then grabbed a pair of gloves, re-entered the residents room, applied the gloves and applied the residents pain patch. CMT C then left the resident's room, discarded the gloves at the med cart then re-entered the resident's room and washed his/her hands. During an interview on 11/21/24 at 10:26 A.M. CMT C said: -They were supposed to wash their hands prior to entering the resident's room and before leaving. -Usually if there was a need for EBP the resident had a sign on the door and there was a cart with PPE gowns, gloves, and red bags if needed. -If the resident had an infection, they were to gown, glove and if needed use the face mask and eye protection they would wash or sanitize their hands prior to putting gloves on. -When they had completed care, they were to discard the PPE and sanitize or wash their hands upon leaving the room. -They would use EBP on residents with any infections. -He/She was not sure they needed to use PPE with residents with catheters, tracheotomies, tube feedings or wounds. -He/She did not know that he/she should use PPE or that the resident should be on EBP. -He/She usually did sanitize his/her hands prior to entering the resident's room, but he/she hadn't sanitized his/her hands prior to entering the resident's room. -He/She usually had gloves on his/her cart, but someone took them and he/she had to go get gloves off of the linen cart and did not sanitize his/her hands upon re-entering the resident's room. Observation on 11/21/24 at 11:00 A.M., showed: -CNA C sanitized his/her hands then entered the resident's room without gowning or gloving. -He/She began assisting the resident and informed him/her they would be getting him/her up after they completed his/her bed bath. -CNA C sanitized his/her hands before he/she left the resident's room to get a brief from the linen cart then re-entered the resident's room without washing/sanitizing his/her hands, gowning or gloving. -CNA D sanitized his/her hands and entered the resident's room to assist with care without putting on a gown or gloves. -At 11:15 A.M., both CNA's exited the resident's room and sanitized their hands. They said they were going to transfer the resident but they went to get the resident's sling and would be back. During an interview on 11/22/24 at 9:35 A.M., CNA C said: -Usually he/she knew who was on EBP and who was not. -They learn who was on EBP from the nurses during their morning meeting and the CNA staff from the prior shift would also inform them during rounds. -There was usually a sign on the resident's door and a PPE cart outside the door for those residents on EBP. -When they saw the sign on the door they had to sanitize their hands, gown and glove prior to entering the resident's room, and then remove their PPE and sanitize or wash their hands before leaving the room. -He/She did not think the resident was on EBP because the nurses did not tell them that EBP was needed and there was no sign on the resident's door or PPE cart indicating EBP was needed. 6. Review of Resident #84's Face Sheet showed the resident was admitted to the facility on [DATE], with fracture, high cholesterol, depression, and diabetes. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented without confusion, -Needed moderate to maximum assistance with bathing, dressing and mobilized with a wheelchair. -Had no history of or current pressure sores, no other wounds or skin issues, no unhealed pressure sores during lookback period. Review of the resident's POS dated [DATE], showed physician's orders for treatment to apply skin prep (a waterproof skin barrier which protects the skin from irritation and trauma resulting from tape or dressing applications) to the resident's left heel and leave it open to air, every day shift for wound care and as needed if dressing becomes soiled or comes off (11/18/24). Review of the resident's Wound Care Consult notes dated 11/20/24 showed: -The resident was being seen for follow up to a left heel wound. -The resident's assessment showed the resident's wound was doing better. -There was a scab still present. The plan of care was to continue cleaning with wound cleanser, apply skin prep and leave open to air, wear soft booties, change daily and as needed if dislodged, saturated or soiled. -Educated nursing team and/or patient to assess and communicate any significant changes in wound status, noting evidence of wound infection, or acute changes and notify wound provider or primary care provider accordingly. -If no evidence of healing within 2 to 4 weeks, re-evaluate plan of care and patient adherence. Observation and interview on 11/19/24 at 10:36 A.M., showed the resident was laying down in bed watching tv and resting. The resident said: -He/She had a wound on his/her left heel that resulted from being in an immobilizer boot while in the hospital for a fracture. -He/She did not have any other wounds. -The wound was almost healed and there was only a scab there. Observation on 11/20/24 at 9:45 A.M., showed: -There was no signage showing the resident was on EBP precautions and there was no PPE cart outside of the resident's door. -LPN C sanitized his/her hands and LPN D sanitized their hands and went into the resident's room without putting on a gown. -Both gloved and LPN C informed the resident they were going to complete his/her wound treatment. -LPN C removed the resident's sock on his/her left foot and cleaned the resident's wound then LPN D opened a skin prep packet, raised the resident's left foot and wiped the heel with the skin prep. -LPN C discarded his/her gloves, washed his/her hands, re-gloved, then placed the resident's sock back on. -LPN D discarded the skin prep packet and wipe and his/her gloves then washed his/her hands. -LPN C then discarded her gloves and washed his/her hands. 7. During an interview on 11/25/24 at 9:42 A.M., RN A said: -They just started training on EBP and they were not using the protocols regarding EBP until last Thursday. -They did not have an Infection Control Nurse until just recently and the prior Infection Control Nurse did not provide the training on EBP so they were unaware of the new protocols. -Anyone with a tracheostomy, tube feeding, catheter, ostomy of any kind, or opening in the body, they were considered to be on EBP and staff was to use a gown, gloves and masks before entering the room. -They were only using gowns, and face masks with residents who had infections. -They learned they would need to place a sign on the resident's door and PPE cart available. During an interview on 11/25/24 at 11:10 A.M., the DON said: -Training with staff regarding EBP was just started with the nursing staff and had not been completed with the nursing staff prior to now. -Residents with tracheotomies, extensive wounds, and catheters should be on EBP. -He/She did not know if they have had an EBP training with the staff yet. -They have not been using EBP with residents. 51303 8. Review of Resident #72's Admission Record showed he/she initially admitted to the facility 12/24/19 with the following diagnoses: -Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). -Need for assistance with personal care. Review of the resident's care plan with a start date of 12/24/19 showed: -The problem of required tube feeding for nutritional needs related to history of cerebrovascular accident (CVA/stroke), Cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke). -He/She was to have Nothing By Mouth (NPO). -Activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) care plan showed a problem the resident was dependent to complete ADLs. The resident was dependent with dressing, bathing, incontinence, and transfers. -The care plan did not show EBP precautions with cares. Review of the resident's Significant Change MDS dated [DATE] showed: -He/She was severely cognitively impaired and required total support from staff. -He/She had a gastrostomy tube (G Tube). -He/She was dependent for incontinent care, hygiene, shower/bathing, transferring, and dressing. Review of the resident's POS dated November 2024 showed: -Enteral Feed order as needed. (1/13/20). -Enteral Feed Order every 24 hours as need for tube feeding (enteral) Complete tube site care with warm water and soap. (12/24/19). -Enteral Feed Order every day and night shift check and record residuals every shift. Hold feeding for 1 hour if greater than 100 Milliliters (mls). Contact physician if residual exceeded 100 mls for three consecutive checks. (1/13/20). -Enteral Feed order every day and night shift check tube placement before initiation of formula and medication administration. (1/13/20). -Enteral Feed Order every day and night shift for tube feeding complete tube site care with warm water and soap. (12/24/19). -Enteral Feed order every night shift change syringe tube feeding administration set up and graduate. (1/13/20). -Enteral Feed Order NPO, administer Osmolite (nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 at 40 mls per hour nocturnally (at night) for 12 hours as tolerated (from 7:00 P.M. to 7:00 A.M.) to provide 480 mls of formula. Routine water flush 30 mls an hour during duration of enteral feeding (12 hours) and routine flush 150 mls at start and completion of enteral feed. (9/62/24). -Elevate head of bed (HOB) at 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feed had stopped. (1/13/20). -Flush G Tube with 45 to 60 mls before and after administration of medications. (1/25/23). -There was not an order for Enhanced Barrier Precautions with cares. Observation on 11/18/24 at 11:04 A.M. showed there was no sign on the resident's door for EBP. Observation on 11/20/24 at 12:53 P.M. showed LPN B: -Had the bedside table set up with supplies for G Tube site care and flush. -Spoke to resident and explained the procedure. -Performed hand hygiene at sink and donned gloves. -ADON B entered room and asked resident if it would be ok to observe care. -The head of bed was up at a 30-degree angle. -He/She left the room and reentered and performed hand hygiene and donned new gloves. -He/She obtained the syringe and pulled back 20 mls air. LPN B then cleaned the G Tube hub and placed syringe into hub and expelled the air with stethoscope close to G Tube site to check for placement. -He/She then pulled back on the syringe plunger to assess residual. No residual noted. -He/She pulled water into the syringe and pushed the water into the G Tube hub. -He/She thanked resident. Rinsed syringe and graduate and set them out to dry upside down. -He/She gathered trash, removed gloves, and performed hand hygiene. -He/She put on gloves and removed trash from the room then returned, removed gloves and performed hand hygiene again. -LPN B did not put on a gown for EBP. -No sign for EBP noted on the door. During an interview on 11/20/24 at 1:02 P.M. LPN B said this was how he/she completed a G Tube flush and care daily. Observation on 11/25/24 10:12 A.M. of the resident's door showed no EBP signage and no PPE cart observed on the hall. 9. Review of Resident #40's Admission Record showed he/she initially admitted to the facility 11/21/18 with the following diagnoses: -Quadriplegia (paralysis of all four extremities and usually the trunk) -Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bact

Based on observation, interview and record review, the facility failed to ensure the appropriate storage and labeling of medications throughout the facility's medication carts and medication storage rooms. This deficient practice had the potential to affect all residents within the facility. The facility census was 151 residents. Review of the facility's policy titled Storage of Medications dated August 2020 showed: -Nurses were not to transfer medications from one container to another or return partially used medication to the original container. -All medications dispensed by the pharmacy were to be stored in the pharmacy container with the pharmacy label. -Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were to be immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed. -Expirations dates (beyond-use dates) of dispensed medications should be determined by the pharmacist at the time of dispensing. -The nurse would check the expirations date of each medications before administering it. -All expired medications would be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 1. Observation on 11/18/24 at 1:59 P.M. of the Certified Medication Technician (CMT) cart for 300 hall showed a Fluticasone Propionate Nasal Spray (Flonase- used to treat allergies and non-allergic nasal symptoms) and a Fluticasone Propionate and Salmeterol (Advair- used to treat asthma (a condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe) or Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation) stored in the same box. 2. Observation on 11/18/24 at 2:07 P.M. of the nurse cart for 100/200 hall showed: -A vial of Lidocaine 1% (typically used to cause numbness or loss of feeling for patients having certain medical procedures) half-used, outside of its original container, with a label that appeared to have been ripped off. -A bottle of Dakin's solution (used to prevent and treat skin and tissue infections) that expired October 2024. 3. Observation of on 11/18/24 at 2:17 P.M. the medication storage rooms on the Long-Term Care (LTC) side of the facility showed: -A box of liquid skin preparation (prepares damaged or intact skin for attachment sites, tapes, films, and adhesive dressings) that expired 5/17/24. -12 Dermaview II transparent film wound dressings with label (a moisture-vapor permeable transparent dressing that aids in the prevention of bacterial contamination) that expired 5/6/23. -Two boxes of Curad oil emulsion dressings (a dressing that is ideal for lightly draining wounds including minor burns, lacerations, and abrasions) that expired on 7/7/2024. -A carton of thickened water that had been opened on 6/21/24 and had expired on 10/22/24. -A carton of thickened cranberry cocktail that had been opened on 7/4/24 and had expired on 11/14/24. -A Tuberculin purified protein derivative (PPD) (Aplisol- used in a skin test to help diagnose tuberculosis (TB- a serious infectious bacterial disease that mainly affects the lungs) stored in the fridge outside of its original container and unreadable open date. -An intravenous (IV) administration set that expired on 10/27/24. -Two needleless connectors that expired on 9/13/23. -A foley catheter (a device that drains urine from the bladder into a collection bag) insertion tray that expired on 9/29/24. 4. Observation on 11/18/24 at 3:15 P.M. of the CMT cart for 100 hall showed a bottle of liquid iron supplement that expired in September 2024. 5. During an interview on 11/19/24 at 2:54 P.M. CMT B said: -The CMT and nurse carts were checked about three times a week. -He/She thought the facility policy was for the CMT and nurse carts to be checked once a week. -CMTs were responsible for checking the CMT carts for expired medications and the appropriate storage and labeling of medications. -Nurses were responsible for checking the nurse carts for expired medications and the appropriate storage and labeling of medications. -The Assistant Directors of Nursing (ADONs) were responsible for ensuring completion of the CMT carts and nurse carts checks for expired medications and the appropriate storage and labeling of medications. -All medications including inhalers and nasal sprays needed to be stored in their own container. -He/She was aware that the Flonase and Advair had been stored in the same container. -The Flonase and Advair had been sent to the facility that way and he/she never asked for a new container for the Flonase. -Expired medications should not be in any cart that holds medications. -If expired medications were found in any medication cart, then the medication should be removed and thrown away/destroyed. - The CMTs and nurses were responsible for going through the medication storage rooms to check for expired medications and the appropriate storage and labeling of medications. -The ADONs were responsible for ensuring completion of the medication storage room checks. -The ADONs were responsible for checking the medication storage rooms for expired medical supplies. -Expired medical supplies should not be stored in the medication storage rooms and should be removed and disposed of appropriately. During an interview on 11/20/24 at 10:47 A.M. Registered Nurse (RN) A said: -The staff who get into the medication carts should be checking expiration dates of medications every time they are in the cart and pulling medications out of the cart. -The nursing supervisors were responsible for checking the CMT and nurse carts for expired medications and the proper storage and labeling of medication. -All medications including nasal sprays and inhalers should be stored in their own container. -The Lidocaine 1% vial should not be used if the label was illegible or ripped off. -The Lidocaine 1% vials were not multi-use vials and were supposed to be labeled for a specific resident. -The Lidocaine 1% vial needed to be removed from the cart and appropriately disposed of. -Expired medications should not be in any medication carts and should be removed from the carts and appropriately disposed of. -Nurses and nursing supervisors were responsible for checking the medication storage rooms for expired medications/supplies and the appropriate storage and labeling of medications. -Nursing supervisors were responsible for ensuring the checks were getting completed. -Expired medical supplies should not be stored in medication storage rooms and should be removed and appropriately despised of. -Any staff who use the thickened liquid cartons should be checking for expiration anytime the carton is used. -The staff should have noticed that the thickened liquid cartons had expired and should have thrown them away after they had expired. -The Tuberculin PPD solution should have been stored in its original container. -If the open date of the Tuberculin PPD solution was illegible, the staff should have appropriately disposed of the vial. During an interview on 11/20/24 at 11:19 A.M. ADON A said: -Anyone who were able to access medication carts were responsible for checking them for expired medications and the appropriate storage and labeling of medications. -This included CMTs, nurses, and nurse managers. -The nurse managers were responsible for ensuring the completion of the checks and it was normally completed once a week. -The medication storage rooms were also checked once a week for expired medications/medical supplies and was completed by the nursing managers. -Expired medications should never be stored in medication carts and if found they should be removed and appropriately disposed of. -All medications including nasal sprays and inhalers needed to be stored in their own container. -Lidocaine 1% vials were not multi-use vial and usually labeled with the designated resident's name. -The Lidocaine 1% vial should have been labeled and stored in its original container. -The staff should have removed the Lidocaine 1% vial and appropriately disposed of it. -Expired medical supplies should not be stored in medication storage rooms. -Any expired medical supplies found should be removed and be appropriately disposed of. -The dietary staff were the staff who usually opened the cartons of thickened liquids and would be responsible for the appropriate labeling of the cartons. -The nurses and dietary staff were able to check expiration dates of the thickened liquid cartons. -The expired thickened liquid cartons should have removed and thrown away. -The Tuberculin PPD solution should not have been outside of its original container. -If the Tuberculin PPD solution open date could not be read and the original container could not be found then the vial should be removed and appropriately disposed of. During an interview on 11/20/24 at 11:57 A.M. the Director of Nursing (DON) said: -The medication carts should be checked daily for expired medications and the appropriate storage and labeling of medications. -The ADONs were responsible for completing a weekly audit of the medication carts and ensuring all expired medications were removed from the cart and all medications in the cart were appropriately stored and labeled. -All medications should be stored in their own container including nasal sprays and inhalers. -The Lidocaine 1% vial should have been labeled with the resident's name and stored in its own container. -The Lidocaine 1% should have been removed form the nurse cart and appropriately disposed of since the label had been ripped off. -Anyone who enters the medication storage rooms can check for expired medications/supplies and the appropriate storage and labeling of medications. -The ADONs were responsible for ensuring the completion of medication storage rooms checks. -Expired medical supplies should not be stored in medication storage rooms and any expired medical supplies should be removed and appropriately disposed of. -If the thickened liquid carton comes from the kitchen, then the dietary staff would be responsible for checking the expirations dates. -Once the thickened liquid cartons were opened and stored in nursing areas, then nursing staff would be responsible for checking the expiration dates. -The night nurses were responsible for checking the medication room refrigerators and they would be the ones responsible for ensuring that everything stored in the fridge was not expired and stored/labeled appropriately. -The Tuberculin PPD solution should not have been stored outside of its original container. 50579 6. Observation on 11/18/24 at 1:58 P.M., a medication cart for the 500 hall showed: Expired medication on the cart included: -Docusate (a stool softener) liquid, expired 8/2024. -Pro-stat (a liquid protein supplement), with an opened date of 5/15/24 and manufacturer instructions printed on the bottle to discard three months after opening. - Iron supplement liquid, expired 8/2024. -Pro-stat, expired 2/2024. -Meclizine (a nausea medication), expired 3/2024. Other medications noted to be stored or labeled incorrectly included: -Insulin Lispro multi dose vial with no resident identifier. -Albuterol inhaler with no date or resident identifier. -A medication cup with several partially dissolved pills and a pink gel sitting in a medication drawer of the cart. 7. During an interview on 11/18/24 at 2:18 P.M., Registered Nurse (RN) A said: -He/She would expect expired medications to be removed from the cart. -He/She would expect all medications to be labeled appropriately with a resident name. -He/She did not know what medications were partially dissolved in the medication cup or when they were placed on the medication cart. During an interview on 11/19/24 at 1:27 P.M., the Director of Nursing (DON) said: -He/She would not expect expired medications to be kept on the medication cart. -He/She would expect medications to be labeled appropriately. -He/She would expect proper storage of all medications. During an interview on 11/19/24 at 2:54 P.M. CMT B said: -The CMT and nurse carts were checked about three times a week. -He/She thought the facility policy was for the CMT and nurse carts to be checked once a week. -CMTs were responsible for checking the CMT carts for expired medications and the appropriate storage and labeling of medications. -Nurses were responsible for checking the nurse carts for expired medications and the appropriate storage and labeling of medications. -The Assistant Directors of Nursing (ADONs) were responsible for ensuring completion of the CMT carts and nurse carts checks for expired medications and the appropriate storage and labeling of medications. -All medications including inhalers and nasal sprays needed to be stored in their own container. -He/She was aware that the Flonase and Advair had been stored in the same container. -The Flonase and Advair had been sent to the facility that way and he/she never asked for a new container for the Flonase. -Expired medications should not be in any cart that holds medications. -If expired medications were found in any medication cart, then the medication should be removed and thrown away/destroyed. - The CMTs and nurses were responsible for going through the medication storage rooms to check for expired medications and the appropriate storage and labeling of medications. -The ADONs were responsible for ensuring completion of the medication storage room checks. -The ADONs were responsible for checking the medication storage rooms for expired medical supplies. -Expired medical supplies should not be stored in the medication storage rooms and should be removed and disposed of appropriately. During an interview on 11/20/24 at 10:47 A.M. Registered Nurse (RN) A said: -The staff who get into the medication carts should be checking expiration dates of medications every time they are in the cart and pulling medications out of the cart. -The nursing supervisors were responsible for checking the CMT and nurse carts for expired medications and the proper storage and labeling of medication. -All medications including nasal sprays and inhalers should be stored in their own container. -The Lidocaine 1% vial should not be used if the label was illegible or ripped off. -The Lidocaine 1% vials were not multi-use vials and were supposed to be labeled for a specific resident. -The Lidocaine 1% vial needed to be removed from the cart and appropriately disposed of. -Expired medications should not be in any medication carts and should be removed from the carts and appropriately disposed of. -Nurses and nursing supervisors were responsible for checking the medication storage rooms for expired medications/supplies and the appropriate storage and labeling of medications. -Nursing supervisors were responsible for ensuring the checks were getting completed. -Expired medical supplies should not be stored in medication storage rooms and should be removed and appropriately despised of. -Any staff who use the thickened liquid cartons should be checking for expiration anytime the carton is used. -The staff should have noticed that the thickened liquid cartons had expired and should have thrown them away after they had expired. -The Tuberculin PPD solution should have been stored in its original container. -If the open date of the Tuberculin PPD solution was illegible, the staff should have appropriately disposed of the vial. During an interview on 11/20/24 at 11:19 A.M. ADON A said: -Anyone who were able to access medication carts were responsible for checking them for expired medications and the appropriate storage and labeling of medications. -This included CMTs, nurses, and nurse managers. -The nurse managers were responsible for ensuring the completion of the checks and it was normally completed once a week. -The medication storage rooms were also checked once a week for expired medications/medical supplies and was completed by the nursing managers. -Expired medications should never be stored in medication carts and if found they should be removed and appropriately disposed of. -All medications including nasal sprays and inhalers needed to be stored in their own container. -Lidocaine 1% vials were not multi-use vial and usually labeled with the designated resident's name. -The Lidocaine 1% vial should have been labeled and stored in its original container. -The staff should have removed the Lidocaine 1% vial and appropriately disposed of it. -Expired medical supplies should not be stored in medication storage rooms. -Any expired medical supplies found should be removed and be appropriately disposed of. -The dietary staff were the staff who usually opened the cartons of thickened liquids and would be responsible for the appropriate labeling of the cartons. -The nurses and dietary staff were able to check expiration dates of the thickened liquid cartons. -The expired thickened liquid cartons should have removed and thrown away. -The Tuberculin PPD solution should not have been outside of its original container. -If the Tuberculin PPD solution open date could not be read and the original container could not be found then the vial should be removed and appropriately disposed of. During an interview on 11/20/24 at 11:57 A.M. the Director of Nursing (DON) said: -The medication carts should be checked daily for expired medications and the appropriate storage and labeling of medications. -The ADONs were responsible for completing a weekly audit of the medication carts and ensuring all expired medications were removed from the cart and all medications in the cart were appropriately stored and labeled. -All medications should be stored in their own container including nasal sprays and inhalers. -The Lidocaine 1% vial should have been labeled with the resident's name and stored in its own container. -The Lidocaine 1% should have been removed form the nurse cart and appropriately disposed of since the label had been ripped off. -Anyone who enters the medication storage rooms can check for expired medications/supplies and the appropriate storage and labeling of medications. -The ADONs were responsible for ensuring the completion of medication storage rooms checks. -Expired medical supplies should not be stored in medication storage rooms and any expired medical supplies should be removed and appropriately disposed of. -If the thickened liquid carton comes from the kitchen, then the dietary staff would be responsible for checking the expirations dates. -Once the thickened liquid cartons were opened and stored in nursing areas, then nursing staff would be responsible for checking the expiration dates. -The night nurses were responsible for checking the medication room refrigerators and they would be the ones responsible for ensuring that everything stored in the fridge was not expired and stored/labeled appropriately. -The Tuberculin PPD solution should not have been stored outside of its original container.

Based on observation, interview and record review, the facility failed to ensure suction and oxygen equipment were kept covered to prevent cross contamination for one sampled resident (Resident #95) who had a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea. This hole allows air to pass into your windpipe); failed to ensure oxygen face masks and nasal cannulas (a medical device that provides supplemental oxygen to patients through two prongs that sit inside the nostrils) were covered for two sampled resident (Resident #126 and Resident #19) who had respiratory concerns; failed to ensure necessary respiratory care related to oxygen tubing and/or a bilevel positive airway pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) tubing, and mask bagged when not in use and the concentrators external filters to be free of buildup of dust for two residents (Resident #14 and #98); and failed to follow physician orders for tracheostomy care on one sampled resident (Resident #116) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's Physician Order policy dated 06/2020, showed: -The purpose of the policy was to ensure that all physicians orders were complete and accurate. -Documentation pertaining to the physician's order would be maintained in the resident's medical record. Review of the facility's policy Tracheostomy-Care of dated 06/2020, showed: -The purpose of the policy was to ensure airway patency by keeping the tube free from mucous buildup and to maintain mucous membrane and skin integrity. -Tracheotomy care would be performed as ordered by the attending physician. -No information regarding storage of equipment. Review of the facility's Oxygen Administration policy revised 06/2020 showed the oxygen items would be stored in a plastic bag when not in use at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #95's Face Sheet showed the resident was admitted on [DATE], with diagnoses including respiratory failure, sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep), heart failure, and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/27/24, showed the resident: -Was alert and oriented without confusion. -Had coughing or choking during meals. -Received oxygen therapy, suctioning and tracheostomy care. Review of the resident's Physician's Order Sheet (POS) dated [DATE], showed physician's orders for: -High Humidity Tracheostomy Collar: at 28 percent, every shift for shortness of air, change in condition (9/24/24). -Change oxygen tubing and set, including drainage bag every night shift every 7 days for shortness of air, change in condition (9/24/24). -Change disposable inner cannula size 5 every day shift for shortness of air, change in condition and as needed (9/24/24). -Keep at bedside for emergency use: a disposable ambu bag (a device used to provide respiratory support to patients in emergency and non-emergency situations), a back up complete tracheostomy set and suction machine (9/24/24). Review of the resident's Care Plan dated 9/24/24, showed the resident had a tracheostomy due to impaired breathing. Interventions showed staff should: -Give humidified oxygen as prescribed. -Keep extra tracheostomy tube and obturator (a thin, rigid, and curved rod that helps guide the outer cannula into the trachea) at bedside. If tube is coughed out, open stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea) with hemostat (a tool used to control bleeding). Observation on 11/18/24 at 11:22 A.M., showed there was a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) on a dresser against the wall. The face mask was uncovered, sitting beside the machine. Next to it was the resident's humidifier machine that showed an undated/unlabeled humidifier bottle containing a clear fluid. The mask and tubing that were connected to it was laying on the surface uncovered. Beside the humidifier machine was the resident's suction machine and the tubing was coiled around the machine and was uncovered. Observation on 11/19/24 at 9:40 A.M., showed the resident's suctioning machine was sitting on a dresser beside the resident's bed and the tubing and mask was uncovered. There was a humidifier machine that was across from his/her bed on a dresser. The humidifier bottle was unlabeled/undated and the tubing and mask were uncovered. There was a nebulizer on the dresser and the face mask was sitting next to the humidifier machine uncovered. Observation and interview on 11/19/24 at 1:40 P.M., showed the resident's nebulizer was across from the resident's bed and the face mask was uncovered, the resident's humidifier machine was on a dresser across from the resident's bed and the tubing and mask was still uncovered and the suction machine tubing was coiled up and around the machine and was also uncovered. During an interview on 11/22/24 at 10:37 A.M., the Infection Control Preventionist said: -The resident's humidifier mask and tubing and the resident's suction tubing should both be in a plastic bag. -He/She would have to discard the current masks and tubing and replace them since they were exposed. -Whenever they use any oxygen equipment they should store it in a bag after use and the suction tubing should be replaced. 2. Review of Resident #126's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, sleep apnea and Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that damage the airways and air sacs, making it difficult to move air in and out of the lungs). Review of the resident's POS dated [DATE] showed the following physician's orders: -Oxygen at 3 liters per minute via nasal cannula continuously every shift and as needed (10/3/23). -Bilevel positive airway pressure (BIPAP-a machine that helps people breathe by delivering pressurized air into their airways)in BIPAP mode at bedtime and as needed for COPD and shortness of air (4/22/24). -Change nebulizer tubing, mask and holding bag and date new tubing per protocol and as needed (every week) every evening shift on Wednesday (7/3/23). -Change oxygen tubing weekly, label each component with date and initials every evening shift every Wednesday (7/3/23). Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was alert and oriented without confusion. -Used oxygen therapy. It did not show the resident used BiPAP therapy. Review of the resident's Care Plan dated 11/14/24, showed the resident had altered respiratory status/difficulty breathing related to respiratory failure, COPD, obstructive sleep apnea, and hypoventilation (a condition where breathing is too slow or shallow, which prevents the body from getting enough oxygen and getting rid of enough carbon dioxide). Observation on 11/18/24 at 10:56 A.M., showed in the resident's room, on the resident's nightstand was a nebulizer machine with a mask on top of it that was uncovered, the re was a BIPAP machine sitting beside it with a face mask that was laying on top of it that was uncovered, and there was an oxygen concentrator sitting beside his bed on the floor. The nasal cannula and tubing was draped around the concentrator, also uncovered. The humidifier bottle was not labeled or dated and there was no bag or covering for any of the oxygen equipment observed. On the vanity was a portable oxygen container that had a nasal cannula and tubing that was wrapped around it uncovered. Observation on 11/19/24 at 9:35 A.M., showed on his/her nightstand was his/her nebulizer machine. The face mask was laying on top of the machine uncovered. The portable oxygen machine was sitting on the vanity with the oxygen tubing and nasal cannula coiled around the machine uncovered. Observation and interview on 11/21/24 at 9:47 A.M. showed: -On the vanity was a portable oxygen machine without any tubing attached. On the nightstand beside his/her bed was his/her nebulizer and his/her BIPAP machine. The face masks for both machines were sitting on top of the machines uncovered. The oxygen concentrator was on the floor next to his/her bed and it was on and running. The nasal cannula and tubing were laying on his bed linen, uncovered. The resident said that he/she had just removed his/her nasal cannula. He/She said: -He/She wore his/her BIPAP every night and the nursing staff have never provided any covering for his/her BIPAP face mask. -He/She usually took the BIPAP mask off and placed it on the nightstand beside his bed. -Nursing staff replaced the mask and tubing when he/she requested it. -He/She used his/her portable oxygen when he/she goes out of the building or during showers. Staff have never given him/her a covering/bag for the oxygen tubing or nasal cannula. -He/She had breathing treatments as needed and there was no covering for the face mask for his/her breathing treatment machine, so he/she usually laid it on top of the machine or on the dresser. -He/She had a lot of respiratory issues and was unaware that nursing staff was supposed to provide him/her with any bag or covering for any of his oxygen equipment to prevent cross contamination. 3. During an interview on 11/21/24 at 10:26 A.M., Certified Medication Technician (CMT) C said: -They have plastic bags they use to store oxygen nasal cannulas, face masks and other respiratory in and they usually put them on the oxygen concentrator or beside the breathing treatment machine. -The bags should be labeled and dated and the nasal cannulas, face masks and any oxygen equipment should be stored in the bags when the equipment is not being used. -Usually the oxygen tubing, humidifier bottles and face masks are changed out on Tuesdays and Thursdays on the night shift by the night shift CMTs and they also label and date the equipment and bags. -Nursing staff round every two hours and if they know a resident is on oxygen, they should be checking to ensure the resident's oxygen equipment is stored in the bags if it is not in use. During an interview on 11/25/24 at 9:42 A.M., Registered Nurse (RN) A said: -All oxygen supplies to include face masks, oxygen tubing, nasal cannulas should be stored in a bag when not in use. -Central supply provides the bag and the night shift change out the supplies and they are to provide the bags in each resident room. -The nursing staff who go in and out of the rooms daily are supposed to check to ensure the bag is in the room and the oxygen supplies are stored in the bag. -With residents who are more independent and able to remove their oxygen masks they should check to see if the masks are in the bag when not in use and remind the resident to put it in the bag when they remove it. 33409 4. Review of Resident #19's Admission Face Sheet showed had diagnosis of COPD. Review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact. -Was able to understand others and make his/her needs known. -Required assistant for staff for all cares and transfer. -Did not have documentation related to the use of oxygen (O2). Review of the resident's care plan revised on 10/24/24 showed; -The resident had chronic lung disease related to COPD. -The nursing staff were to monitor the resident for sign and symptoms of shortness of breath. -Note: He/she did not have a care plan for use of oxygen. Review of the resident's POS dated 11/1/24 to 11/21/24 showed: -Oxygen flow rate of 2 Liter per minute (LPM) per Nasal Cannula. Titrate oxygen to keep oxygen saturation (O2 SATs, which is a measure of how much oxygen is in your blood) above 90%, as needed for Shortness of Breath (SOB). -Albuterol Sulfate Nebulization Solution 3 ml inhaled orally via a nebulizer machine every four hours as needed for shortness of breath, ordered on 11/23/24. Observation on 11/18/24 at 12:02 P.M., the resident's room showed: -An O2 concentrator with an uncovered nasal cannula tubing coiled on top of the O2 concentrator machine. -The nebulizer mask was on the dresser not stored in a plastic bag. Observation on 11/19/24 at 9:13 A.M., of the resident room showed he/she had O2 and nebulizer tubing not covered at that time. During interview 11/19/24 at 9:18 A.M., the resident said: -He/she had used O2 and nebulizer treatment when had respiratory infection. -He/she was not currently using O2 or the nebulizer. Observation on 11/20/24 at 10:15 A.M., of the resident room showed: -He/she had the O2 tubing left uncovered on top his/her O2 concentrator. -The nebulizer mask was uncovered on his/her bedside table. Observation on 11/21/24 at 10:40 A.M. of the resident room showed: -He/she had uncovered O2 tubing coiled on top the oxygen concentrator machine. -His/her nebulizer mask was uncovered on the bedside table. -There were no dates on the oxygen tubing or nebulizer mask and tubing. -No bags were in the areas to place the mask or tubing in when not in use. 51303 5. Review of Resident #14's Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Acute and chronic respiratory failure with hypoxia (Respiratory failure occurs when the lungs have difficulty exchanging oxygen and carbon dioxide with the blood, resulting in hypoxia (low oxygen) or hypercapnia (high carbon dioxide) . -Chronic respiratory failure. -Chronic Obstructive Pulmonary Disease. Review of the resident's OSR orders dated 05/05/24 showed the following physician's orders: -Oxygen at 3 liters via nasal cannula continuously or to keep O2 sat greater than 90%. -Oxygen tubing to be changed weekly, label each component with date and initials every Sunday. Review of the resident's annual MDS dated [DATE] showed the resident: -Was moderately cognitively impaired. -Was on oxygen. Review of the resident's care plan on 11/19/24 showed: -Administer oxygen therapy as ordered. -Change tubing per protocol. Observation on 11/19/24 at 10:35 A.M. showed: -The concentrator was noted with dirt and debris on it and the external filter had a buildup of dust. -No bag was observed for the resident to take off the nasal cannula and place in a bag when he/she left the room. Observation on 11/20/24 at 9:07 A.M. showed: -The oxygen concentrator had dirt and debris on it and the filter had a buildup of dust. -There was no oxygen bag for when resident went outside to smoke or left the room. Observation on 11/21/24 at 8:48 A.M. showed the oxygen concentrator was on and the nasal cannula was draped across the top drawer of nightstand. Observation on 11/21/24 at 12:38 P.M. showed the oxygen concentrator remained on and noted with dirt and debris on it and the external filter had a buildup of dust. The nasal cannula was draped across top drawer of nightstand not bagged. Observation on 11/25/24 at 10:34 A.M. showed: -The oxygen concentrator was noted with dirt and debris on it and the external filter had a buildup of dust. -The resident returned to his/her room and retrieved the nasal cannula from the top drawer of nightstand. 6. Review of Resident #98's Admission Record showed he/she was initially admitted on [DATE] with the following diagnoses: - Chronic Obstructive Pulmonary Disease -Chronic respiratory failure -Dependence on supplemental oxygen. Review of the resident's Annual MDS dated [DATE] showed: -He/She was cognitively intact. -Did not show the usage of oxygen or the BiPAP. Review of the resident's OSR dated 6/23/24 showed the following physician's orders: -Oxygen and nebulizer tubing change weekly, label each component with date and initials weekly on Sunday. -Did not show an order for the BiPAP machine, how and when to use, clean, and for the storage. Review of the resident's nursing Admission MDS dated [DATE] showed: -He/She was cognitively intact -He/She was on oxygen. -Did not show the usage of the BiPAP. Observation on 11/21/24 at 9:39 A.M. showed he/she was lying on her bed and had the BiPAP mask over his/her mouth. Observation on 11/21/24 at 12:44 P.M. showed: -The resident with oxygen on via nasal cannula attached to the concentrator. -An oxygen tank in an cylinder cart by dresser with the oxygen tubing wrapped around the top by the handle and not dated or bagged. -The BiPAP was set on the dresser with tubing and mask laid over the machine and not bagged. -The concentrator was noted with dirt and debris and external filter had a buildup of dust. Interview on 11/22/24 at 12:10 P.M. with Certified Nursing Assistant (CNA) A said: -The nurses change the oxygen tubing. -The nurses clean the filters. -Oxygen tubing was to be put in a bag when not in use. -He/She was aware Resident #98 used a BiPAP machine. -He/She did not but store the mask when not in use. 7. During an interview on 11/21/24 at 10:26 A.M., Certified Medication Technician (CMT) C said: -They have plastic bags they use to store oxygen nasal cannulas, face masks and other respiratory in and they usually put them on the oxygen concentrator or beside the breathing treatment machine. -The bags should be labeled and dated and the nasal cannulas, face masks and any oxygen equipment should be stored in the bags when the equipment is not being used. -Usually the oxygen tubing, humidifier bottles and face masks are changed out on Tuesdays and Thursdays on the night shift by the night shift CMTs and they also label and date the equipment and bags. -Nursing staff round every two hours and if they know a resident is on oxygen, they should be checking to ensure the resident's oxygen equipment is stored in the bags if it was not in use. -The bag should be labeled with resident name and with date when tubing was change. During an interview on 11/22/24 at 2:12 P.M. CMT D said: -The nurse or resident would take off the nasal cannula. -Oxygen tubing was supposed to be stored in a bag when not in use. -The night shift nurses changed the tubing once a week and as needed. -Central Supply staff or the oxygen provider would clean the concentrators and filters. During an interview on 11/25/24 at 9:08 A.M. with Licensed Practical Nurse (LPN) B said: -Oxygen tubing was to be changed weekly on night shift. -There would be an order for oxygen. -There would be an order for changing the tubing. -Central Supply staff would clean the concentrators and filters. -There may not be an order for cleaning concentrators and filters since central supply did it himself/herself. -The respiratory specialist would enter the order for when to use, clean, store the BiPAP. -The oxygen tubing and BiPAP mask should be in bag when not in use. During an interview on 11/25/24 at 9:33 A.M. the Central Supply Manager said: -The night nurses were to change and date oxygen tubing weekly and as needed. -The oxygen tubing/BIPAP mask was to be stored in a bag when not in use. -The CNA, the nurse, or any staff could place tubing or mask in the bag. -The nurse would clean filters when oxygen tubing was changed. -The CNA would clean the concentrators. -The Infection Control Preventionist was responsible for monitoring the process of oxygen tubing and storage. During an interview on 11/25/24 at 9:44 A.M. Assistant Director of Nursing (ADON) B said: -The night nurses were responsible to change and date oxygen tubing. -That the ADONs monitored that oxygen tubing was changed and dated. -The oxygen tubing was to be placed in plastic bag when not in use. -The central supply staff cleaned the concentrators and filters. -The ADONs would audit the process. -He/She expected there would be an order to change tubing and clean filters weekly. During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said: -Oxygen tubing, nasal cannulas, masks, tracheostomy tubing, BIPAP machines and supplies should be in a bag labeled and dated. -He/She expected a physician's order for the concentrators, BIPAPs, and filters to be cleaned. -He/She expected oxygen tubing to be dated and bagged when not in use. -The Infection Preventionist (IP) was responsible to change oxygen tubing, but nurses could also change. -The Infection Control Preventionist was responsible for making rounds and following up with the nurses for education on when equipment should be changed. -The nurses should check for dates when they provided a breathing treatment. -He/She expected the CNA to wipe down concentrator before giving to a resident. -He/She expected filters to be cleaned by nurses. -Oxygen equipment and supplies were usually changed at night. -The nursing staff should be checking to ensure the oxygen equipment is stored in bags as they are in an out of the resident's rooms, and during cares. 51150 8. Review of Resident #116's POS dated 9/10/24, showed: -Tracheostomy care every shift, two times per day and as needed. Review of the resident's admission form dated 9/12/24, showed: -The resident was admitted to the facility on [DATE]. -The resident was cognitively intact. -The resident had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can't get enough oxygen into the blood). -The resident received tracheostomy care daily. Review of the resident's care plan dated 9/13/24, showed: -The resident had potential for impairment to skin integrity. -The resident had altered respiratory status and difficulty breathing related to chronic respiratory failure, tracheostomy, and oxygen dependent. Review of the resident's Treatment Administration Record (TAR) dated 9/1/24-9/30/24, showed: -A physician's order for tracheostomy care every shift, two times per day and as needed. -Two of the 43 ordered tracheostomy care opportunities were left blank. Review of the resident's TAR dated 10/1/24-10/31/24, showed: -A physician's order for tracheostomy care every shift. -Eight of the 62 ordered tracheostomy care opportunities were left blank. Review of the resident's TAR dated 11/1/24-11/18/24, showed: -A physician's order for tracheostomy care every shift, two times per day and as needed. -Three of the 36 ordered tracheostomy care opportunities were left blank. During an interview on 11/22/24 at 2:17 P.M. RN B said: -The resident had a physician's order to get tracheostomy care twice daily. -When a nurse performed tracheostomy care, the nurse documented implementation of the order in the resident's medical record. -If tracheostomy care was completed, the TAR would reflect the nurse's initials. -If a box on the TAR was blank, that would indicate that the tracheostomy care was not performed. During an interview on 11/22/24 at 3:00 P.M., ADON A said: -The resident had a physician's order to get tracheostomy care daily. -He/she performed the tracheostomy care on the resident when he/she worked the floor. -When tracheostomy care was done, the nurse that performed the care should have documented it being done. -When tracheostomy care was completed, the box on the TAR would have the nurse's initials. -A blank box on a resident's TAR would indicate that a physician's order was not completed. During an interview with the DON on 11/25/24 at 11:10 A.M., said: -The charge nurses provided tracheostomy care. -The nurse managers and the ADON monitor to ensure physician's orders are completed. -He/she would expect nurses to document in the TAR when tracheostomy care was completed. -If there were blank areas in a resident's TAR, the tracheostomy cares were not done. -He/she would expect the nurse to document in the resident's medical record a rationale as to why a tracheostomy care was not completed.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the residents' functional and health status, strengths and needs as related to dental services for two sampled residents, (Resident #14 and #98), failed to assess and care plan the usage of a Bilevel Positive Airway Pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) for one sampled resident, (Resident #98), and failed to assess and care plan two falls for one sampled resident (Resident #109) out of 35 sampled residents. The facility census was 151 residents. Review of the facility policy Care Planning revised June 2020 showed: -The purpose was to ensure the comprehensive person-centered care plan was developed for each resident based on individual assessed needs. -The Facility's Interdisciplinary Team (IDT) would develop a comprehensive care plan for each resident in accordance with Omnibus Budget Reconciliation Act (OBRA) a United States federal law that was passed in 1987 and 1990 to improve the quality of care in long-term care facilities and nursing homes and Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) guidelines. -The care plan serves as a course of action where the resident, resident's family and/or guardian or other legally authorized representative), resident's attending physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. -A licensed nurse would initiate the care plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #14's undated Admission Record Face Sheet showed he/she was initially admitted on [DATE] with the following diagnosis, Need for Assistance with Personal Care. Review of the resident's nursing Admission/Readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious teeth. Review of the resident's Nutrition Assessment -Registered Dietician Evaluation dated 1/20/24 showed: -He/She was on a regular diet and regular consistency -He/She had his/her own teeth in fair condition. Review of the resident's Order Summary Report (OSR) showed a physician's order dated 4/30/24 may be seen and treated by a dentist. Review of the resident's Annual MDS dated [DATE] showed: -He/She had moderate cognitive deficits and required support of facility staff. -Oral/Dental Status showed no problem with missing teeth or cavities. -He/She required supervision and touching assistance for oral hygiene. During an interview on 11/19/24 at 10:25 A.M. the resident said: -He/She didn't have many teeth. -His/Her teeth sometimes hurt. Observation on 11/19/24 at 10:25 A.M. of the resident's mouth showed: -Multiple teeth missing in the upper and lower jaw. -One tooth on lower right side loose and pointed towards the tongue. -Buildup of a yellow substance on the remaining teeth. Review of the resident's current care plan on 11/22/24 at 10:39 A.M. showed no dental care needs were identified. Review of the resident's Quarterly MDS dated [DATE] showed no issues with teeth. 2. Review of Resident #98's Admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation.) -Chronic Respiratory Failure with hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, resulting in a persistently low levels of oxygen in the blood (Hypoxemia), which is a hallmark symptom of chronic respiratory failure; essentially, the body is not getting enough oxygen due to impaired lung function). -Dependence on supplemental oxygen. Review of the resident's nursing Admission/Readmission Evaluation dated 7/25/23 showed: -He/She had her own teeth. -The assessment question that stated broken or carious teeth was left blank. Review of the resident's Admission MDS dated [DATE] showed: -He/She was cognitively intact. -Oral/Dental Status showed no problem with missing teeth or cavities. -No order for the utilization of the BiPAP. Review of the resident's Annual MDS dated [DATE] showed: -He/She was cognitively intact. -Oral/Dental Status showed no problem with missing teeth or cavities. -No order for the utilization of the BiPAP. Review of the resident's OSR dated November 2024 showed: -No order for dental to consult and evaluate. -No order for the utilization of the BiPAP. During an interview on 11/19/24 at 8:51 A.M. the resident said: -His/Her teeth hurt sometimes. -He/She had quite a few broken teeth or with cavities. -He/She was supposed to get all teeth pulled. -He/She had been on the BiPAP for approximately 7 years. Observation of the resident's mouth on 11/19/24 at 8:51 A.M. showed: -He/She had multiple teeth missing. -He/She had teeth with sharp edges and blackened areas on multiple teeth. Observation on 11/21/24 at 9:39 A. M showed he/she was currently utilizing the BiPAP. During an interview on 11/25/24 at 9:14 A.M. MDS Coordinator A said: -He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting. -He/She was aware of Resident #14's cavities. -He/She was not aware Resident #98 had broken and missing teeth. -Dental issues should be captured on the MDS. -A resident with dental issues should be care planned. During an interview on 11/25/24 at 9:14 A.M. MDS Coordinator B said: -He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting. -He/She was not aware Resident #98 had broken and missing teeth. -Resident #98 had never complained about dental concerns. -The facility offered dental services. -Dental issues should be captured on the MDS. -A resident with dental issues should be care planned. During an interview on 11/25/24 9:44 A.M. Assistant Director of Nursing (ADON) B said: -He/She was not aware of Resident #98's missed BiPAP order. -He/She expected the MDS to be correct. -He/She expected dental issues to be captured on the MDS. -He/She expected a BiPAP to be on the MDS. -He/She expected dental issues and BiPAP to be care planned. During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said: -He/She expected the MDS nurse to capture the documentation from the clinical chart. -He/She expected the MDS nurse to conduct his/her own assessments. -He/She was not aware Residents #14 and #98 had missing and/or broken teeth or cavities. -He/She expected dental concerns to be care planned. -He/She expected a BiPAP to be on the MDS and care planned. -He/She was aware Resident #98 had a BiPAP. 51150 3. Review of the facility policy Fall Evaluation and Prevention dated 08/2020, showed: -The purpose of the policy was to ensure the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. -The facility will evaluate residents for their fall risk and develop interventions for prevention. -A resident should be evaluated for their fall risk; on admission/re admission to the home, following any changes of status, following a fall, and quarterly. Review of the facility policy Care Planning, with no date, showed: -The purpose of the policy was to ensure that a comprehensive person-centered care plan was developed for each resident based their individual needs. -A licenses nurse will initiate the care plan, and the plan will be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed basis. Review of Resident #109's face sheet, showed: -The resident was admitted to the facility on [DATE]. -The resident had a diagnosis of difficulty in walking. Review of the resident's fall investigation dated 7/3/24 at 5:30 A.M., showed: -The resident verbalized to the nurse that he/she fell while outside of the building smoking. -The resident landed on his right elbow and arm when he/she fell . -The resident was complaining of right shoulder and elbow pain at a 7 on a 0-10 pain scale. -The resident had an egg sized abrasion on his/her right elbow. -The nurse on duty received an order for a 2-view x-ray of the right shoulder and elbow. Review of the resident's fall investigation dated 7/17/24 at 2:33 P.M., showed: -The resident fell outside in the smoking area. -The resident hit his/her outer left foot on the concrete curb. Review of the resident's psychiatric note dated 7/18/24, showed the resident's chief complaint was I am doing alright, I have foot pain from falling outside. Review of the resident's quarterly MDS dated [DATE], showed: -The resident was cognitively intact. -The resident had not had any falls in the facility since admission or the prior assessment. Review of the resident's care plan, revised 7/26/24, showed: -No previous falls noted. -No interventions for fall prevention noted. Review of the resident's annual MDS dated [DATE], showed: -The resident was cognitively intact. -The resident had not had any falls in the facility since admission or the prior assessment. During an interview on 11/20/24 at 9:38 A.M., the resident said: -He/she fell twice outside a few months back. -He/she continued to have pain in his/her right shoulder since the fall. During an interview on 11/22/24 at 2:00 P.M., Certified Nurse Assistant (CNA) E said: -The certified nurse assistants were made aware of when resident's fall from their charge nurse. -He/she was familiar with the resident. -He/she was not aware of the resident having any falls since admission. During an interview on 11/22/24 at 2:17 P.M., Registered Nurse (RN) B said: -The nurses were made aware when a resident fell from the electronic medical record. -The charge nurse on duty at the time of a resident's fall was the one responsible for completing a fall investigation. -He/she was familiar with the resident. -He/she was not aware that the resident had any falls since admission. -The MDS coordinator was responsible for updating the care plans when a resident fell . During an interview on 11/22/24 at 2:40 P.M., MDS coordinator A and MDS coordinator B said: -He/she was responsible for updating the MDS assessments after a resident fall. -The clinical team had morning meetings each morning and this was when falls with residents were discussed. -Both were aware of the resident. -Both denied having knowledge of the resident having any falls since admission. -The two falls should have been reflected in the updated MDS and care plan. -Both were unaware of how the resident's two falls were overlooked. During an interview on 11/22/24 at 3:00 P.M., ADON A said: -When a resident fell , a risk management should be documented in the resident's medical record by the charge nurse. -When a resident fell , the DON should be notified. -He/she was familiar with the resident. -He/she did recall one fall outside since the resident was admitted to the facility. -He/she was unaware of who was responsible for completing the fall investigations. -When a resident fell , the MDS and the care plan should be updated to reflect the fall to help prevent future falls. -The MDS Coordinators were responsible for updating the MDS and care plans after a resident had a fall. During an interview on 11/25/24 at 11:10 A.M., the DON said: -The MDS coordinator was responsible for updating the MDS assessments and care plans after a resident fall. -The MDS assessments were done quarterly and significant changes and care plans should be updated to reflect the MDS assessments. -He/she would expect the MDS and care plan to reflect a resident who had two previous falls.

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for two sampled residents (Residents #14, #98) out of 35 sampled residents. The facility census was 151 residents. A policy was requested and not received from the facility. 1. Review of Resident #14's Admission Record showed he/she was admitted to the facility on [DATE] with the diagnosis of Need for Assistance with Personal Care. Review of the resident's nursing Admission/Readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious teeth. Review of the resident's Nutrition Assessment-Registered Dietician Evaluation dated 1/20/23 showed the resident has his/her own teeth in fair condition. Review of the resident's Order Summary Report (OSR) showed a physician's order dated 4/30/24 may be seen and treated by a dentist. Review of the resident's Annual MDS dated [DATE] showed: -He/She had moderate cognitive deficits and required support of facility staff. -He/she had no missing teeth or cavities. Review of the resident's care plan on 11/22/24 10:39 A.M. failed to show the need for dental care. During an interview on 11/19/24 at 10:25 A.M. the resident said he/she didn't have many teeth. Observation on 11/19/24 at 10:25 A.M. of the resident's mouth showed: -Multiple teeth missing on both upper and lower jaw. -One tooth on the lower right side was loose and pointed towards the tongue. -A buildup of a yellow substance was on the remaining teeth. 2. Review of Resident #98's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation.) -Chronic Respiratory Failure with hypoxia a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, resulting in a persistently low levels of oxygen in the blood (Hypoxemia), which is a hallmark symptom of chronic respiratory failure; essentially, the body is not getting enough oxygen due to impaired lung function. -Dependence on supplemental oxygen. Review of the resident's nursing Admission MDS completed by facility staff dated 7/31/23 showed: -He/She was cognitively intact. -He/she had no missing teeth or cavities. -Did not use a BiPAP machine. Review of the resident's Annual MDS completed by facility staff dated 6/4/24 showed: -He/She was cognitively intact. -Oral/Dental Status showed no problem with missing teeth or cavities. -Failed to show usage of the BiPAP. During an interview on 11/19/24 at 8:51 A.M. the resident said he/she had quite a few broken teeth or with cavities. Observation of the resident's mouth on 11/19/24 at 8:51 A.M. showed: -He/She had multiple teeth missing. -He/She had teeth with sharp edges and blackened areas on multiple teeth. During an interview on 11/21/24 at 9:39 A.M. the resident said he/she had the Bilevel Positive Airway Pressure (BiPAP-a type of noninvasive ventilation that helps you breathe) machine for approximately seven years. Observation on 11/21/24 at 9:39 A. M showed he/she was currently utilizing the BiPAP machine. During an interview on 11/25/24 9:14 A.M. MDS Coordinator A said: -He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting. -He/She was aware of #14's cavities. -He/She was not aware Resident #98's broken and missing teeth. -Dental issues should be coded on the MDS. -The BiPAP machine should be coded on the MDS. - During an interview on 11/25/24 9:14 A.M. the MDS Coordinator B said: -He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting. -He/She was not aware if Resident #14 had teeth issues. -He/She was not aware Resident #98's broken and missing teeth. -He/She stated #98 had never complained about dental concerns. -He/She said the BiPAP machine should be coded on the MDS. During an interview on 11/25/24 9:44 A.M. Assist Director of Nursing (ADON) B said: -He/She was not aware of missed BiPAP order. -He/She expected the MDS to be accurate. -He/She expected dental issues to be coded on the MDS. -He/She expected a BiPAP machine to be coded on the MDS. During an interview on 9/11/24 at 11:47 A.M. the Director of Nursing (DON) said: -He/She would expect the MDS nurse to capture the documentation from the clinical chart. -He/She would expect the MDS nurse to conduct his/her own assessments. -He/She was not aware Residents #14 and #98 had missing and/or broken teeth or cavities. -He/She expected a BiPAP machine to be coded on the MDS. -He/She was aware Resident #98 had a BiPAP. 3. Review of Resident #109's Admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident had a diagnosis of difficulty in walking. Review of the resident's fall investigation dated 7/3/24 at 5:30 A.M., showed: -The resident verbalized to the nurse that he/she fell while outside of the building smoking. -The resident landed on his right elbow and arm when he/she fell . -The resident was complaining of right shoulder and elbow pain at a 7 on a 0-10 pain scale. -The resident had an egg sized abrasion on his/her right elbow. -The nurse on duty ordered a 2-view x ray of the right shoulder and elbow. Review of the resident's fall investigation dated 7/17/24 at 2:33 P.M., showed: -The resident fell outside in the smoking area. -The resident hit his/her outer left foot on the concrete curb. Review of the resident's annual MDS dated [DATE] showed: -The resident was cognitively intact. -The resident had not had any falls in the facility since admission or the prior assessment. During an interview on 11/22/24 at 2:17 P.M., Registered Nurse (RN) B said the MDS coordinator was responsible for updating the MDS assessments when a resident falls. During an interview on 11/22/24 at 2:40 P.M., MDS coordinator A and MDS coordinator B said: -They were responsible for updating the MDS assessments after a resident fall. -The clinical team has morning meetings each morning and this is when falls with residents are discussed. -They were both aware of the resident. -They both denied having knowledge of the resident having any falls since admission. -The two falls should have been coded on the MDS. During an interview on 11/22/24 at 3:00 P.M., ADON A said: -When a resident falls, the MDS should be updated to reflect the fall to help prevent future falls. -The MDS coordinators were responsible for updating the MDS after a resident had a fall. During an interview on 11/25/24 at 11:10 A.M., the DON said: -The MDS coordinator was responsible for updating the MDS assessments after a resident fall. -The MDS assessment should capture a resident's fall when the next assessment was completed.

Based on interview and record review, the facility failed to provide a bed hold notification to a resident and/or the resident's representative upon transfer or discharge for two sampled residents (Resident #137 and #109) out of 30 sampled residents. The facility census was 151 residents. Review of the facility's Bed Hold Policy dated 6/2020 showed: -The purpose of the policy was to ensure that the resident and/or their representative was aware of the facility's bed hold policy, and that such policy complies with state and federal law and regulations. -When a resident was admitted to the facility, the facility informed the resident or his/her personal representative in writing that the facility had a bed hold policy. -The facility notified the resident or his/her representative, in writing, of the bed hold policy any time the resident was transferred to general acute care hospital even if the facility has not met the occupancy requirements. -Upon notice to the resident or his/her personal representative, the licensed nurse (or designee) will document how the resident, or his/her personal representative was notified. 1. Review of Resident #137's Admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident was re admitted to the facility on [DATE]. Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/1/24, showed the resident was discharged to the hospital with his/her return anticipated. Review of the resident's electronic medical record on 11/21/24 at 9:31 A.M., showed no bed hold notice dated 6/1/24. 2. Review of Resident #109's Admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident was re admitted to the facility on [DATE]. Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/17/24, showed the resident was discharged to the hospital with his/her return anticipated. Review of the resident's electronic medical record on 11/21/24 at 11:14 A.M., showed no bed hold notice dated 1/17/24. During an interview on 11/21/24 at 1:53 P.M., Medical Records Staff said he/she could not locate a bed hold notice for resident #137 or resident #109 in the resident's medical records. During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) B said: -If a resident was transferred/discharged from the facility, the charge nurse was responsible for completing the bed hold notice. -If a bed hold notice was completed on a resident, it would be uploaded and documented in the resident's electronic medical record. -He/she was unaware of the process that the facility used to ensure that bed hold notices were being completed. During an interview with the Director Of Nursing (DON) on 11/25/24 at 11:10 A.M., said: -The charge nurses were responsible for completing the notice of discharges. -Once a bed hold notice was completed, it would be documented in the resident's electronic medical record. -If there was no documentation in the electronic medical record of a bed hold notice for a resident, then he/she would say that it was not completed.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing for two sampled residents (Residents #137 and #109) out of 35 sampled residents. The facility census was 151 residents. Review of the Facility's Transfer and Discharge Policy revised 06/2020 showed: -The purpose of the policy was to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. -The facility may use Notice of Transfer/Discharge or another comparable form to provide the resident or his/her personal representative with advanced notice of transfer or discharge. -When a resident is transferred/discharged , Social Services Staff include a copy of the written notice of transfer/discharge provided to the resident or his/her personal representative in the resident's medical record. 1. Review of Resident #137's Admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident was readmitted to the facility on [DATE]. Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/1/24, showed the resident was discharged to the hospital with his/her return anticipated. Review of the resident's Electronic Medical Record (EMR) on 11/21/24 at 9:31 A.M., showed no transfer/discharge notice dated 6/1/24. 2. Review of Resident #109's Admission Record showed: -The resident was initially admitted to the facility on [DATE]. -The resident was re admitted to the facility on [DATE]. Review of the resident's discharge MDS dated [DATE], showed the resident was discharged to the hospital with his/her return anticipated. Review of the resident's EMR on 11/21/24 at 11:14 A.M., showed no transfer/discharge notice dated 1/17/24. 3. During an interview on 11/21/24 at 1:53 P.M., Medical Records Staff said he/she could not locate a notice of transfer/discharge for Resident #137 or Resident #109 in the resident's medical records. During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) B said: -If a resident was transferred/discharged from the facility, the charge nurse was responsible for completing the notice of transfer/discharge. -If a notice of transfer/discharge was completed on a resident, it would be uploaded and documented in the resident's electronic medical record by the charge nurse or the nurse manager. -He/she was unaware of the process the facility used to ensure transfer notices were being completed. During an interview with the Director Of Nursing (DON) on 11/25/24 at 11:10 A.M., said: -The charge nurses or social services were responsible for completing the notice of transfer/ discharges. - There should be documentation including details for reason of transfer, where, safe, and who was notified (physician, family) in the resident's medical record. -If there was no documentation in the EMR of a notice of transfer for a resident, then he/she would say it was not completed.

Based on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sampled (Resident #96) out of 35 sampled residents. The facility census was 151 residents. Review of the facility's policy titled Self-Administration of Medication dated August 2020 showed: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. -The results of the interdisciplinary team assessment of the resident skills and of the determination regarding bedside storage were recorded in the resident's medical record on the care plan. -If the resident demonstrated the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage was conducted. 1. Review of Resident #96's Admission Record showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation). -Pulmonary Fibrosis (a diseases in which the lungs become scarred over time). Review of the resident's admission Minimum Data Set (MDS- federally mandated assessment instrument completed by facility staff for care planning) dated 10/16/24 showed the resident was cognitively intact. Review of the resident's care plan dated 10/21/24 showed: -The resident had altered respiratory status/difficulty breathing related to COPD but did not indicate the use of an inhaler. -There was not focus or intervention related to the self-administration of medication. Review of the resident's Physician Order Sheet (POS) dated November 2024 showed: -A physician's order for ProAir HFA Inhalation Aerosol Solution (Albuterol Sulfate- used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as COPD) 108 (90 Base) micrograms (mcg)/ actuation (ACT), one puff inhale orally every six hours as needed for wheezing. -No physician's order for the ability to self-administer any medication. Observation on 11/19/24 at 2:09 P.M. of the resident's room showed an albuterol sulfate inhaler sitting by the resident's sink. During an interview on 11/19/24 at 2:45 P.M. the resident said: -He/She had been given the inhaler from an unknown staff member to keep in his/her room because he/she told staff that he/she only needed the inhaler whenever he/she was walking around the facility. -He/She was unsure of when the staff had given him/her the inhaler to keep in his/her room. -The staff did not assess him/her to be able to self-administer the inhaler himself/herself. During an interview on 11/19/24 at 2:51 P.M. Certified Medication Technician (CMT) B said: -He/She was unsure if a self-administration assessment had been completed for the resident to use his/her inhaler. -The Assistant Directors of Nursing (ADONs) were responsible for completing the self-administration assessments for residents to be able to self-administer medications. -He/She was unaware that the resident had the albuterol inhaler in his/her room. During an interview on 11/20/24 at 10:43 A.M. Registered Nurse (RN) A said: -Residents were able to self-administer medications if they had an assessment for self-administration completed and a physician's order to do so. -The resident did not have an order to be able to self-administer any medication. -The inhaler should not have been kept in the resident's room due to the lack of the physician's order. -Nurses were able to perform the self-administration of medication assessment and obtain a physician's order. During an interview on 11/20/24 at 11:13 A.M. ADON A said: -Residents were able to self-administer their own medication if an assessment for self-administration of medication was completed and a physician's order was in place to do so. -If there was not an assessment in place, residents were not allowed to self-administer any medication and the staff were required to administer the medication. -The resident did not have an order for self-administration for the inhaler. -He/She would have expected the staff to notice the inhaler in the resident's room especially if it was on the resident's sink. -He/She would have expected the staff to have taken the inhaler out of the resident's room if they had seen it in the resident's room or get a nurse to take the inhaler out of the room. During an interview on 11/20/24 at 11:51 A.M. the Director of Nursing (DON) said: -The resident did not have a self-administration assessment for his/her albuterol sulfate inhaler. -The staff were unaware the resident did not have an assessment for self-administration of his/her inhaler and there was not a physician's order in place for the resident to keep the inhaler at bedside. -He/She would have expected staff to notify the ADONs an assessment needed to be completed for the resident to be able to self-administer medication. -The staff should have noticed the inhaler in the resident's room, especially if it was on the resident's sink and have taken it out of the resident's room.

Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The facility promoted resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. -The staff assisted with the residents in maintaining self-esteem and self-worth. -Staff were to treat residents with respect including respecting their social status, speaking respectfully, and listening carefully. -Staff were to focus on residents as individuals when they speak to them and address residents as individuals when providing care and services. 1. Review of Resident #104's Admission Record showed he/she admitted to the facility with a diagnosis of legal blindness. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/16/24 showed the resident was cognitively intact. Review of the resident's care plan dated 12/20/24 showed the resident was dependent on tobacco with the interventions to supervision while smoking. Review of an Allegation of Staff to Resident Abuse Investigation completed by the facility on 1/11/25 showed: -The incident involved the resident and Hospitality Aide (HA) B. -The resident smoked cigarettes and due to his/her visual impairment, he/she was to wear a smoking apron (a fire retardant garment that protects the wearer from cigarette ash and debris) based of the recommendation of the smoking assessment completed 1/2/25. -On 1/11/25 HA B observed the resident in the smoking area without his/her apron on. -HA B knew that the resident needed to wear a smoking apron to ensure his/her safety. -HA B then approached the resident and touched the back of the resident's head to get his/her attention and reminded him/her of the necessity to wear the apron while smoking. -The resident had initially expressed that HA B had struck him/her. -The facility removed HA B from all resident interactions. -The nurse assessed the resident and found no signs of trauma or injury. -The resident later clarified that the contact had not caused any injury or any mental anguish. -The resident had not believed that HA B had touched him/her to willfully inflict injury. -He/She stated that HA B should have just called his/her name. -HA B had only intended to remind the resident to wear his/her apron and had no intent to harm the resident. Review of the resident's written verbal statement collected from the resident by staff dated 1/11/25 showed: -He/She had been out smoking and HA B hit him/her a couple of times in the back of the head. -HA B had wanted him/her to come inside but he/she was not ready to go inside yet. -HA B had not hurt him/her, HA B should not have hit him/her. Review of an undated statement completed by HA B showed: -He/She had touched the resident to let the resident know he/she had needed his/her smoking apron on while outside. -The resident came in with him/her to get the resident's smoking apron and the resident went back outside. -Everything seemed okay. Review of a statement dated 1/11/25 completed by Registered Nurse (RN) A showed: -The resident stated that HA B had walked up behind him/her and tapped him/her hard on the back of the head. -The resident stated that it had not hurt him/her and felt that what HA B did was uncalled for and made him/her uncomfortable. During an interview on 1/15/25 at 12:22 P.M. the resident said: -HA B had hit him/her softly to the back of his/her head and neck area. -HA B had told him/her that it was too cold and that he/she needed to go inside. -He/She had told HA B that it was not too cold to be outside and then HA B became aggravated after that. During an interview on 1/15/25 at 3:25 P.M. the resident said: -He/She felt safe at the facility. -The whole incident just made him feel embarrassed and HA B had made him/her feel like a kid. During a phone interview on 1/17/25 at 11:18 A.M. HA B said: -The resident had needed his/her smoking apron. -He/She had gone to the bathroom and when he/she came back outside, the resident was already outside and was not wearing his/her smoking apron. -The resident had told HA B that he/she was not smoking, so he/she did not need a smoking apron. -The resident then proceeded to move closer to the other residents that were smoking. -He/She then tapped the resident on the back of his/her head to get his/her attention. -He/She had not hit the resident. -He/She knew that he/she should not have tapped the resident in the back of the head and should have tapped the resident's shoulder instead. -He/She was just not thinking at the time and would never intentionally hurt a resident. During a phone interview on 1/17/25 at 2:28 P.M. Certified Nurses Aide (CNA) K said: -He/She had been walking down the hall when he/she overheard a resident say that Resident #104 had been hit in the back of the head. -He/She had not seen anything expect for HA B assisting the resident's in his/her wheelchair to get the resident to come inside. -The resident had said you don't have to hit me in the back of the head like I am a kid. -HA B should not have approached the resident how he/she had. -The interaction between the resident and HA B made the resident feel embarrassed which indicated to him/her that HA B had showed the resident a lack of dignity. During a phone interview on 1/21/25 at 8:06 A.M. Assistant Director of Nursing (ADON) A said: -He/She was not sure what happened between HA B and the resident. -HA B should not have touched the resident's back of head/neck area. -He/She would have expected staff to have tapped the resident's shoulder to get his/her attention or to have brought over the smoking apron to the resident. -The interaction was disrespectful towards the resident. During a phone interview on 1/21/25 at 10:11 A.M. the Administrator said: -The investigation determined the resident felt like his/her dignity was compromised. -The incident between the resident and HA B was inappropriate because the resident did not want his/her back of head/neck area to be touched. -He/She would have expected HA B to have gone in front of the resident to get his/her attention or to have touched him/her on the shoulder or hand.

Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The facility promoted resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. -The staff assisted with the residents in maintaining self-esteem and self-worth. -Staff were to treat residents with respect including respecting their social status, speaking respectfully, and listening carefully. -Staff were to focus on residents as individuals when they speak to them and address residents as individuals when providing care and services. 1. Review of Resident #104's admission Record showed he/she admitted to the facility with a diagnosis of legal blindness. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/16/24 showed the resident was cognitively intact. Review of the resident's care plan dated 12/20/24 showed the resident was dependent on tobacco with the interventions to supervision while smoking. Review of an Allegation of Staff to Resident Abuse Investigation completed by the facility on 1/11/25 showed: -The incident involved the resident and Hospitality Aide (HA) B. -The resident smoked cigarettes and due to his/her visual impairment, he/she was to wear a smoking apron (a fire retardant garment that protects the wearer from cigarette ash and debris) based of the recommendation of the smoking assessment completed 1/2/25. -On 1/11/25 HA B observed the resident in the smoking area without his/her apron on. -HA B knew that the resident needed to wear a smoking apron to ensure his/her safety. -HA B then approached the resident and touched the back of the resident's head to get his/her attention and reminded him/her of the necessity to wear the apron while smoking. -The resident had initially expressed that HA B had struck him/her. -The facility removed HA B from all resident interactions. -The nurse assessed the resident and found no signs of trauma or injury. -The resident later clarified that the contact had not caused any injury or any mental anguish. -The resident had not believed that HA B had touched him/her to willfully inflict injury. -He/She stated that HA B should have just called his/her name. -HA B had only intended to remind the resident to wear his/her apron and had no intent to harm the resident. Review of the resident's written verbal statement collected from the resident by staff dated 1/11/25 showed: -He/She had been out smoking and HA B hit him/her a couple of times in the back of the head. -HA B had wanted him/her to come inside but he/she was not ready to go inside yet. -HA B had not hurt him/her, HA B should not have hit him/her. Review of an undated statement completed by HA B showed: -He/She had touched the resident to let the resident know he/she had needed his/her smoking apron on while outside. -The resident came in with him/her to get the resident's smoking apron and the resident went back outside. -Everything seemed okay. Review of a statement dated 1/11/25 completed by Registered Nurse (RN) A showed: -The resident stated that HA B had walked up behind him/her and tapped him/her hard on the back of the head. -The resident stated that it had not hurt him/her and felt that what HA B did was uncalled for and made him/her uncomfortable. During an interview on 1/15/25 at 12:22 P.M. the resident said: -HA B had hit him/her softly to the back of his/her head and neck area. -HA B had told him/her that it was too cold and that he/she needed to go inside. -He/She had told HA B that it was not too cold to be outside and then HA B became aggravated after that. During an interview on 1/15/25 at 3:25 P.M. the resident said: -He/She felt safe at the facility. -The whole incident just made him feel embarrassed and HA B had made him/her feel like a kid. During a phone interview on 1/17/25 at 11:18 A.M. HA B said: -The resident had needed his/her smoking apron. -He/She had gone to the bathroom and when he/she came back outside, the resident was already outside and was not wearing his/her smoking apron. -The resident had told HA B that he/she was not smoking, so he/she did not need a smoking apron. -The resident then proceeded to move closer to the other residents that were smoking. -He/She then tapped the resident on the back of his/her head to get his/her attention. -He/She had not hit the resident. -He/She knew that he/she should not have tapped the resident in the back of the head and should have tapped the resident's shoulder instead. -He/She was just not thinking at the time and would never intentionally hurt a resident. During a phone interview on 1/17/25 at 2:28 P.M. Certified Nurses Aide (CNA) K said: -He/She had been walking down the hall when he/she overheard a resident say that Resident #104 had been hit in the back of the head. -He/She had not seen anything expect for HA B assisting the resident's in his/her wheelchair to get the resident to come inside. -The resident had said you don't have to hit me in the back of the head like I am a kid. -HA B should not have approached the resident how he/she had. -The interaction between the resident and HA B made the resident feel embarrassed which indicated to him/her that HA B had showed the resident a lack of dignity. During a phone interview on 1/21/25 at 8:06 A.M. Assistant Director of Nursing (ADON) A said: -He/She was not sure what happened between HA B and the resident. -HA B should not have touched the resident's back of head/neck area. -He/She would have expected staff to have tapped the resident's shoulder to get his/her attention or to have brought over the smoking apron to the resident. -The interaction was disrespectful towards the resident. During a phone interview on 1/21/25 at 10:11 A.M. the Administrator said: -The investigation determined the resident felt like his/her dignity was compromised. -The incident between the resident and HA B was inappropriate because the resident did not want his/her back of head/neck area to be touched. -He/She would have expected HA B to have gone in front of the resident to get his/her attention or to have touched him/her on the shoulder or hand.

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for two sampled residents (Resident #1 and #3) out of six sampled residents. On 1/5/24 about 10:15 P.M., Certified Nurse Assistant (CNA) A transferred Resident #1 without using the Hoyer lift (a mechanical means to transfer a resident) from the wheelchair to the bed. During the transfer CNA A realized it was not safe to continue and lowered the resident to the floor. CNA A and CNA B then transferred the resident from the floor to bed by placing their arms under the resident's arms, one on each side and lifting the resident up. They did not use a gait belt or mechanical lift to transfer the resident back to his/her bed. Facility staff did not report the fall or assess the resident after the fall. The resident had an increase in yelling behavior throughout the night and was noted as not very responsive to questions being asked, pale in color, and yelling out in pain when turned from side to side during changing the next morning. The resident was also found to have bruising on their left upper arm and chest. The resident was sent to the hospital for further assessment. It was found the resident had extensive swelling in the left knee, left ankle, left posterior thigh and right hamstring, and multiple fractures in the left knee/femur. The hamstring bruising was a source of blood loss. The resident had a hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissue) of 6 and required 5 units packed red blood cells and surgical intervention. The facility also failed to ensure they knew the location and status of one resident (Resident #3) and to coordinate safe transportation when on 1/9/24 the resident was left sitting in the hospital lobby all night after a dialysis appointment. The facility census was 154 residents. The Administrator was notified on 1/31/24 at 1:50 P.M., of an Immediate Jeopardy (IJ) which began on 1/5/24. The IJ was removed on 1/7/24, as confirmed by surveyor onsite verification. Review of the facility's Transfer Policy, dated 6/1/2020, showed: -To provide the form of transfer best suited to the residents' needs and to maintain resident safety during the transfer. -A licensed nurse and/or Director of Rehabilitation Services assess and determine lifting and transfer requirements and the procedure used for each resident. -The procedure is recorded in the resident's Care Plan. -Residents must be lifted or transferred according to the determined procedure. -Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift. -Nursing staff are trained to use good body mechanics, knowing the proper procedure, and properly operating assistive devices. -Mechanical lift procedures are used on any resident unable to independently pivot or transfer. Review of the facility's Fall Policy, dated 8/1/2020, showed: -To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. -A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground. -Upon a fall, stay with the resident and send another staff member to notify a licensed nurse. -The resident should not be moved until the licensed nurse has assessed the resident's condition. -The assessment should include level of consciousness, position, possible injuries, pain, vital signs, swelling, bruising, alignment, and range of motion. -The resident's physician and responsible party will be notified. -After each fall a licensed nurse will complete a Post-Fall Assessment & Investigation and document in a detailed progress note. -Document all falls on the 24-hour report, notification of physician and responsible party. 1. Review of Resident #1's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Cognitive Communication Deficit (having trouble reasoning and making decisions while communicating, remembering their conversations and experiences and trouble responding in an appropriate or socially acceptable manner). -Parkinson's disease (a chronic disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). -Contractures (an abnormal usually permanent condition of a joint, characterized by flexion and fixation) of left & right ankles and left & right knees. -Osteoarthritis (a degenerative disease of the bone and Joint) of knee, unspecified. Review of the resident's Care Plan, revised on 3/24/23, showed: -Focus: --Had self-care performance deficit related to post-polio syndrome, Parkinson's disease, and stroke. -Interventions: --He/she was dependent assist by two staff for bed mobility, transfers, dressing and bathing. -Focus: --He/she uses opioid pain medication related to chronic pain. -Goal: --Will be free of any discomfort or adverse side effects from pain medication. -Interventions: --Administer pain medications as ordered by physician. --Monitor/document side effects and effectiveness every shift. --Monitor for increased falls. -Focus: --He/she was at risk for alterations in comfort related to chronic pain and decreased mobility. -Interventions: --Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. --Monitor/document for side effects of pain medications. --Monitor/record/report to nurse any signs or symptoms of non-verbal pain, changes in breathing, vocalization (grunting, moaning, yelling out or silence), mood/behavior changes (more irritable, restless, aggressive,squirmy, or constant motion), eyes (wide open/narrow, slits/shut, glazed, tearing, or no focus), Face (sad, crying, worried, scared, clenched teeth or grimacing), and body (tense, rigid, rocking, curled up, or thrashing). --Provide the resident with reassurance that pain is time limited. --Encourage to try different pain relieving methods (positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound). -The care plan did not identify the resident need or use of a Hoyer lift. Review of the resident's undated Card-X (a resource for care staff that gives a brief overview of each resident and updated as needed) that was generated by the care plan showed: -He/she was dependent for transfer via Hoyer lift by two staff. -Bed mobility was extensive assist by two staff. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 12/6/23, showed: -He/she was cognitively intact. -Was able to make self understood and understand others. -His/her lower extremities were impaired on both sides. -He/she used a mechanical lift for transfers. -Dependent on staff for sit to lying, lying to sitting, chair/bed to chair and cannot sit to stand. -No pain frequency assessed. -Had as needed pain medication. -No non-medical interventions for pain received. -No opiods given for pain. Review of the resident's Order Summary Report dated 1/1/24 to 1/31/24, showed: -No physician order for the use of a Hoyer lift for transfers. -Pain monitoring every shift for pain. -Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg), give one tablet by mouth every 4 hours as needed for moderate to severe pain, started 5/9/23. -Tylenol (Acetaminophen) Tablet, give 650 mg by mouth every 4 hours as needed for pain related to pain in left knee, not to exceed three grams (gms) of Acetaminophen in 24 hours, started 9/26/22. -Voltaren External Gel 1% (Diciofenac Sodium) Topical, apply to both knees topically two times a day for pain, Apply 4 gms, not to exceed 16 gms per knee or 32 gms in 24 hours. Review of the resident's Skilled Evaluation Note, dated 1/4/24 at 9:50 A.M., showed: -He/she was alert and oriented to person and place. -He/she had impaired balance. -He/she had paralysis. Review of the resident's Behavior Note, dated 1/7/24 at 00:07 A.M., showed: -On 1/5/24 the resident sat by the nurse's station in his/her wheelchair and requested pain medication for his/her chronic right knee pain. -No new issues with the resident's knee noted at 9:30 P.M. on 1/5/24. -At 10:15 P.M. on 1/5/24 the resident verbalized pain medication was effective. -Resident was transferred to bed by CNA A at 10:30 P.M. on 1/5/24. -Resident had increased yelling after getting into bed which is a behavior that is related to the resident's dementia. -Upon entering his/her room to check on him/her, he/she would just stare at Licensed Practical Nurse (LPN) A and stopped yelling. -When asked what the problem was, he/she would not respond. -No signs or symptoms of pain or discomfort noted when checking on him/her, reminded him/her to use the call light if he/she needed LPN A. -LPN A checked on the resident throughout the night, when entering the room, he/she would stop yelling. -This occurred multiple times throughout the night. -LPN A would inquire if he/she was in pain or discomfort and he/she would smile and not answer the question. -He/she had documented history of yelling out at night for no reason for doing so when assessed by LPN A. -He/she had dementia and history of exhibiting this type of behavior during late evening and night. -LPN A offered emotional support and encouraged him/her to use his/her call light which was kept within reach. -LPN A also offered drinks and snacks for comfort and was assessed for pain and discomfort every time which he/she did not have when LPN A went into room. Review of written statements by CNA C and CNA D, dated 1/6/24, showed: -Around 8:30 A.M., CNA C heard the resident yelling out, so he/she and CNA D went to see what the resident needed. -They proceeded to get the resident up, when they noticed he/she was not very responsive to questions being asked. -The resident was pale in color and was yelling out in pain when turned from side to side during changing. - They asked the resident several times if he/she was having pain, but the resident could not tell them if he/she was in pain. -The resident was Hoyer lifted into his/her wheelchair and was still moaning. -The resident was asked again about pain with no response. -CNA C went and got the Assistant Director of Nursing (ADON) while CNA D stayed with the resident. -CNA D changed the resident's shirt and that is when the bruising on the resident left upper arm and chest were noticed. -The ADON took over the care of the resident at that time. Review of the resident's Behavior Note, dated 1/6/24 at 7:24 A.M., showed: -Resident screamed for 10 hours of the shift, increased when he/she was put to bed by CNA A. -Resident had no pain or discomfort noted. -LPN A checked on him/her several times throughout the night. -He/she was just sitting in bed with eyes closed screaming and yelling. Review of the resident's Nurse's Note, dated 1/6/24 at 10:14 A.M., showed: -ADON was alerted by CNA C and CNA D the resident was not baseline and had bruising to the left arm that was spreading across his/her chest. -Physician was called and received an order for STAT chest X-ray. -Resident was put on oxygen via nasal cannula for low oxygen level and low blood pressure. -Communicated with Nurse Practitioner (NP) and received an order to send resident to the hospital for evaluation and treatment. -Resident left the facility at 9:58 A.M. via Emergency Medical Services (EMS) in route to the hospital. Review of the resident's Treatment Administration Record (TAR), dated 1/1/24 to 1/31/24, showed: - No pain medications was given to the resident on the night of 1/5/24 or on 1/6/24. Review of the resident's emergency room and Hospital notes, dated 1/6/24, showed: -Resident arrived by EMS on 1/6/24 at 10:45 A.M., from the facility. -The resident's injuries were described as traumatic injuries of unknown source. -He/she was non-ambulatory. -He/she arrived having altered mental status, moaning, writhing and crying out in pain. -He/she had significant bruising to the left upper chest and shoulder and center of his/her chest, and noted to have bruising to right anterior (front) chest which was tender and painful. -He/she had swelling in his/her left knee, left ankle hematoma (a collection of blood outside of the blood vessel), left posterior (back) thigh and had a large right proximal (center) hamstring (a group of three muscles that run along the back of the thigh from hip to below the knee) hematoma 9 centimeter (cm) x 8 cm. -Hemoglobin was 6.0., (normal range is 12 to 16). -Radiology showed no chest fractures. -He/she had multiple comminuted supracondylar fractures (a break to the lower part of this bone) left knee/femur. -The hamstring hematoma was an avulsion injury (bone attached to tendon/ligament gets pulled away from the main part of the bone) which was the source of the blood loss. -He/she required 5 units PRBC (Packed Red Blood Cells) and surgical intervention. Review of the facility investigation, dated 1/6/24, showed: -On 1/6/24 at 10:14 A.M., ADON was alerted by CNA C the resident was exhibiting a deviation from his/her baseline cognitive state. -He/she needed repeated stimuli to awaken, had low blood pressure and oxygen levels. -ADON immediately applied oxygen on the resident. -Further assessment revealed the resident had dark purple bruising on his/her left upper arm extending to his/her left breast area accompanied by trace swelling. -ADON notified the physician and received an order to send the resident to the hospital for evaluation and treatment. -CNA A had attempted to transfer the resident by him/herself and had lowered the resident to the floor on 1/5/24. -LPN A noted no new issues with the resident's knee at 9:30 P.M. on 1/5/24. -At 10:15 P.M. on 1/5/24 the resident verbalized pain medication was effective that was given for resident chronic pain in both knees. -Resident was transferred to bed by CNA A at 10:30 P.M. on 1/5/24. CNA A placed his/her arm under the resident's left arm and lifted the resident up. CNA A said that was how he/she transferred the resident 6 to 7 months ago when he/she worked at the facility. He/she said the resident had gained some weight and he/she could not hold the resident up and lowered him/her to the floor. -During the transfer CNA A realized it was not a safe to continue and lowered the resident to the floor. No gait belt, Hoyer, or Sit to Stand was used in the transfer. -CNA A was able to get assistance from CNA B and together they placed their arms under the resident's arms, one on each side and lifted the resident up off the floor and into bed. No gait belt, Hoyer, or Sit to Stand was used to transfer the resident from the floor back to the bed. -Neither of the CNAs informed LPN A about lowering the resident to the floor, because they did not believe it was a fall since he/she was lowered to the floor. -The resident sustained a fracture to his/her left knee from being lowered to the floor by CNA A, as the resident had a contracted left knee and was lowered to the floor with pressure on his/her left knee. -It was ascertained the resident suffered a left knee fracture during the descent to the floor, exerting undue pressure on his/her already contracted left leg, compounded by preexisting comorbidities and the bruising under his/her left arm area was a result from being transferred off the floor into bed by the CNAs. During an interview on 1/23/24 at 2:30 P.M., CNA A said: -He/she had worked at the facility before and had only been back at the facility for three days. -He/she used to transfer the resident by holding onto the resident's arm to help steady the resident. -He/she figured he/she could transfer the resident just like he/she had in the past. -The care plan had not identified any new way to transfer the resident. He/she transferred the resident the same way he/she transferred the resident six to seven months ago when last working with the resident. -Staff are supposed to look at the resident's card-x as well to know how to transfer residents. -The resident had gained some weight and he/she could not hold the resident up, so he/she lowered the resident to the floor. -He/she then left the resident's room to get CNA B to help lift the resident up off the floor and into bed. -The resident did not have a Hoyer pad under him/her, so CNA A figured the resident still transferred the same way he/she did six months ago. -He/she did not think it was necessary to notify the nurse of lowering the resident to the floor. -He/she did not think if was a reportable incident since he/she lowered the resident. He/she did not know it was considered fall. Review of a written statement by CNA B, dated 1/6/24, showed: -He/she worked on the 1/5/24 evening shift on the 400 hall. -CNA A asked him/her for help. -He/she went to help CNA A with the resident. -The resident was on the floor next to the bed, feet in front of him/her. -CNA A stated that he/she had alerted LPN A and needed help putting the resident in bed. -He/she assisted CNA A with putting the resident in bed. -He/she used the resident's pants and lifted with one hand in the front and one hand in the back on the right side of the resident. -Once the resident was back in the bed, he/she left the room, because CNA A said he/she was able to finish cares on the resident. During an interview on 1/23/24 at 2:13 P.M., CNA B said: -He/she was working a different hall when CNA A came and asked him/her for help transferring the resident. -He/she went to the resident's room and saw the resident on the floor. -He/she asked CNA A if LPN A said it was okay to get the resident up off the floor. -CNA A said LPN A said it was alright to get the resident up, so they both lifted the resident off the floor by each one taking a side and arm without using a lift or gait belt. -The resident was a Hoyer lift to transfer, but there was no sling under the resident or in the resident's wheelchair to lift the resident up. -CNA A said the Care Plan card-x did not indicate the need for a lift or gait belt. He/she did not look at the care plan themselves. -He/she asked CNA A if she had notified LPN A about lowering the resident to the floor and CNA A said yes, LPN A said it was ok to lift the resident up off the floor. Review of written statement by LPN A, dated 1/6/24, showed: -He/she worked on 1/5/24 from 7:00 P.M. to 7:00 A.M., as the charge nurse for the 300/400 halls. -The resident was at the nurse's station in his/her wheelchair and asked for pain medication for chronic right knee pain. -The resident was transferred to bed by staff. -The resident noted to increase yelling and when asked what the problem was, he/she would not respond, no signs/symptoms of pain or discomfort noted when checking on the resident . -He/she checked on the resident throughout the night, when entering the room the resident would stop yelling. This occurred multiple times during the night. -He/she would ask the resident if he/she was in pain or discomfort, the resident would just smile and not answer any of the questions. -At no time during his/her shift was he/she notified of the resident being lowered to the floor or having a fall. During an interview on 1/24/24 at 8:20 A.M., LPN A said: -He/she had given the resident pain medication for his/her chronic pain before he/she was put to bed. -He/she was not notified by CNA A or CNA B the resident was lowered to the floor, he/she would have expected the staff to notify him/her if that occurred. -To his/her knowledge the resident was put to bed without any problems. -When the resident would yell out, he/she would help the resident and he/she would quit yelling. -He/she checked on the resident for chronic pain several times during the night when he/she was yelling out and it was not normal. -The resident never said he/she was in pain when checking on him/her. -He/she only assessed the resident for pain before the resident was put to bed. -He/she did not turn on the resident's room light when he/she would got to the resident' room, because the resident had a big television that was always on. -He/she did not see any color change in the resident's skin and did not see any signs or symptoms of pain when he/she went into the room. -He/she did not do a skin assessment, because the resident was not due for a skin assessment. -CNA A was the staff member who checked the resident to see if he/she needed his/her brief changed during the night. -CNA A never said anything about the resident having a change in condition. -The resident's right leg was contracted straight and would not bend and the left leg moved around and was not contracted. -The resident was not able to stand and pivot due to weakness in the left leg. -The resident was a Hoyer lift transfer and it should have been on the care plan card-x. -He/she did not know the resident was lowered to the floor until the administrator called him/her during the investigation. During an interview on 1/30/24 at 2:55 P.M., CNA D said: -CNA C and CNA D were covering the 300 Hall the day shift when he/she heard the resident moaning. -He/she asked the resident if he/she was ready to get up for breakfast. -The resident did not respond, just moaned. -CNA D and CNA C changed the resident's brief and the resident did not say anything about pain or even moan during rolling from side to side. -The resident was pale in color in his/her face and was not at his/her normal baseline. -CNA C went to notify the nurse of the resident's change in condition. -CNA D went to change the resident out of his/her gown and that was when CNA D noticed all the bruising to the resident's left upper arm, left side, and chest. -CNA D asked the resident if the bruising hurt and the resident did not respond. -The resident would yell out when in pain or he/she would tell staff when in pain. -It was not normal behavior for the resident to yell out. -He/she can find how a resident was to transfer on the care plan and card-x for all residents. -Max assist means Hoyer lift with two staff. -Hoyer pad stays with the resident after a transfer. During an interview on 1/30/24 at 3:11 P.M., CNA C said: -The resident was not his/her normal self on the morning of 1/6/24. -The resident was very picky on how he/she got ready for the day and would tell staff it they were not doing something to his/her liking. -He/she did not say anything to CNA C or CNA D that morning, he/she would just moan. -CNA C had worked with the resident for several years and the resident was able to tell staff when he/she needed assistance or was in pain. -He/she notified the nurse the resident was pale in color in his/her face and was not answering questions when asked. -When CNA C returned with the nurse is when he/she saw the bruising on the resident's left arm, side and chest. During an interview on 1/30/24 at 3:26 P.M., the ADON said: -He/she was working the floor when CNA C notified the nurse of the resident's change in condition. -The resident was already sitting in his/her wheelchair when he/she arrived to the resident's room. -He/she did not notice any signs or symptoms of pain. -He/she was more worried about the bruising on the resident's left arm, side, and chest. -He/she did not assess the resident's lower half of the body. -The resident had very low blood pressure and his/her oxygen level low. During an interview on 1/16/24 at 4:46 P.M., the Administrator said: -The resident should have been transferred by the Hoyer lift as ordered by the physician and care plan card-x. -LPN A should have been notified of the resident being lowered to the floor. -The resident should have never been moved until LPN A assessed him/her for injuries. -A gait belt or the Hoyer lift should be used to assist a resident up off the floor if no injuries are found. During an interview on 1/17/24 at 12:53 P.M., the resident's Nurse Practitioner (NP) said: -CNA A and/or CNA B should have notified LPN A the resident was lowered to the floor so LPN A could assess the resident for injuries. -The resident yelling out for 10 hour was not the resident's baseline. -LPN A should have notified him/her about the change in the resident's behavior. -He/she was not notified of the resident being lowered to the floor, until the next morning. -He/she gave an order to send the resident to the hospital for evaluation and treatment. -He/she would expect the facility staff to notify him/her or the physician of any changes in the residents. During an interview on 1/30/24 at 2:20 P.M., CNA E said: -The resident was a two person Hoyer transfer at all times. -The resident would yell instead of using his/her call light. Once the resident's needs were met the resident would not yell out until he/she needed help again. During an interview on 1/30/24 at 2:25 P.M., CNA F said: -The resident was a Hoyer lift when transferring. -Resident could use the call light when he/she needed assistance. -He/she could notify staff if he/she was in pain. -The resident would yell instead of using his/her call light. Once the resident's needs were met the resident would not yell out until he/she needed help again. During an interview on 1/30/24 at 2:32 P.M., the MDS Director said: -The resident had been a Hoyer lift for sometime. -The care plan and card-x would list how the resident was to transfer and how many staff were required for the transfer. -How a resident transfers was not in the clinical orders, but is on the care plan from the MDS. -As a resident's condition changes items will be added or deleted from the care plan. 2. Review found no transportation policy. Review of Resident #3's Admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -End stage renal disease with dialysis (is when the kidneys have a decline in function to the point that the kidneys can no longer function on their own). -Chronic Obstructive Pulmonary disease (COPD) (is a chronic inflammatory lung disease the causes obstructed airflow from the lungs). -Diabetes Mellitus (a disease in which the body's ability to produce or respond to the insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). -Major Depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). -High blood pressure. -Heart failure (the heart does not pump blood as well as it should). Review of the resident's Order Summary Report, MAR & TAR dated 1/1/24, showed: -Resident to receive hemodialysis on Tuesday, Thursday, and Saturday. -Chair time is 11:00 A.M. -Transportation to pick up resident every day shift on Tuesday, Thursday, and Saturday. -PM medications were Baclofen 5 mg tablet for muscle spasms, Carvedilol 25 mg tablet for high blood pressure, Insulin Glargine 10 units for diabetes, Insulin Aspart 8 units for diabetes. Review showed these medications were not given on 1/9/24. -AM medications were Allopurinol 100 mg tablet for end stage renal disease, Aspirin 81 mg for prophylaxis (action taken to prevent disease), Gabapentin 300 mg capsule for pain, Sertraline 25 mg for depression, Carvedilol 25 mg for high blood pressure, and Insulin Aspart 8 units for diabetes. Review showed these medications were not given as on 1/10/24. Review of the resident's Nurse's Note, dated 1/9/24 at 12:20 P.M., showed: -The resident went to dialysis as scheduled. -Call received from dialysis center after he/she arrived and start of dialysis, nurse stated that he/she coded and was sent to the ER. Review of the resident's hospital visit summary dated 1/9/24, showed the resident went to theER on [DATE] at 11:11 A.M. and discharged back to dialysis on 1/9/24 at 12:40 P.M. He/she received IV Normal Saline 500 ml for hypotension or fluid hydration. Review of the resident's Nurse's Note, dated 1/10/24 at 8:30 A.M., showed: -The resident came back to the facility at 8:00 A.M. -He/she was alert, no complaints of pain or discomfort, skin was dry and intact no concerns currently. -NP notified of his/her return to the facility. During an interview on 1/17/24 at 2:15 P.M., the resident said: -He/she went to dialysis via transportation on 1/9/24 chair time 11:00 A.M. -He/she was taken to what he/she thought was the ER and given fluids for dehydration. -He/she then went back to the chair for dialysis. -After dialysis was over, the clinic nurse took the resident to wait for his/her ride back to the facility. -The ride never came, and he tried to call the facility several times with no one answering the phone. -He/she fell a sleep in the hospital lobby and woke up about 3:30 A.M. -He/she decided if he/she wanted to get back to the facility he/she needed to call UBER for a ride. -He/she arrived back to the facility around 8:00 A.M. on 1/10/24. -He/she did not receive his/her evening medications or any supper on 1/9/24. During an interview on 1/16/24 at 4:30 P.M., LPN B said: -He/she received a call from an unknown staff person at dialysis the resident had a rapid response, but was never told when the resident would be returning to the facility. -He/she assumed rapid response meant the resident had coded at dialysis and was sent to the ER. -He/she never called dialysis or the hospital afterward to check on the resident or if the resident was ready to return. -He/she told LPN A the resident had coded and was at the ER. During an interview on 1/24/24 at 8:20 A.M., LPN A said: -The facility takes the resident to dialysis and picks up the resident from dialysis. -If the resident goes to the ER from dialysis, then the ER at the hospital is responsible for the resident's return to the facility. -The facility transportation driver leaves around 3:00 P.M. daily. -An outside transportation company will bring the resident back to the facility or the ambulance might bring a resident back to the facility. -ER nurse is to set up the resident's transportation back to the facility. During an interview on 1/24/24 at 1:14 P.M., Dialysis Social Worker said: -The resident usually arrives at dialysis around 10:30 A.M. for chair time at 11:00 A.M. -He/she was done with dialysis at 2:30 P.M. -Pick up time is 2:45 P.M. to 3:00 P.M. for ride back to the facility. -A dialysis nurse called the facility for the resident to be transported back to the facility, he/she could remember the facility was specifically called when the resident was finished with dialysis. -Facility informed the nurse that UBER Health would be picking up the resident. -The nurse stayed with Resident #3 while waiting for transportation to pick up the resident. -After awhile the nurse called the facility again to see when transportation was going to show up. -Around 2:30 or 3:00 P.M., facility said transportation should be at dialysis anytime to pick up the resident. -The nurse had to go and help other clients and left the resident in the main lobby. -The resident did not feel good at dialysis and a rapid response was called and the resident was given fluids for dehydration. -The resident never coded or went

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #4) were free from verbal and physical abuse. Resident #4 hit Resident #3 multiple times with a cane on 8/29/22. Resident #4 had to be physically separated from Resident #3 by facility staff members. Resident #4 was sent to the hospital for psychological evaluation and returned back to the facility with no new orders and placed back in the same room with Resident #3. Resident #3 realized Resident #4 was back in the room, notified Family Member A. Family Member A contacted Family Member B. Family Member B arrived to the facility and went to the residents' room. Family Member B stood over Resident #4 and verbally abused and hit the resident with a cane. Three residents were sampled for abuse out of ten residents. The facility census was 166 residents. The Administrator was notified on 8/31/22 at 4:00 P.M. of an Immediate Jeopardy (IJ) which began on 8/29/22. The IJ was removed on 9/1/22 as confirmed by surveyor onsite verification. Record review of the facility's Abuse Prevention and Prohibition Program revised 12/2017 showed: -Each resident had the right to be free from physical and verbal abuse. -The facility was committed to protecting residents from abuse by anyone including residents, family members and visitors. -Staff training should include appropriate interventions to deal with aggressive reactions of residents. -If an allegation was regarding resident to resident altercation, the residents would be separated immediately pending the investigation. 1. Record review of Resident #3's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Traumatic subdural hemorrhage: (significant bleeding inside the skull, and pressure against the brain). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -[CONDITION(S)] (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). Record review of Resident #3's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning), dated 5/23/22, showed the resident: -Was cognitively intact. -Needed the assistance of staff with transfers. -Used a wheelchair for mobility. -Did not have any behaviors. Record review of Resident #3's revised care plan, dated 8/29/22, showed the resident did not have any behaviors. Record review of Resident #4's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Difficulty walking. -Muscle weakness. Record review of Resident #4's quarterly MDS, dated [DATE], showed the resident: -Was moderately cognitively impaired. -Did not have behaviors. -Was able to self-transfer and used a wheelchair for mobility. Record review of Resident #4's care plan showed no plan for behaviors. Record review of Resident #4's Behavioral Note, dated 5/27/22 at 4:32 A.M., showed: -Resident #4 just attacked the Certified Nurse Assistant (CNA), who was trying to change this resident's roommate. -Attempted to calm the resident and explain that the CNA has to perform care on his/her roommate. -This resident feels he/she shouldn't have a roommate. -The resident was informed that he/she can voice concerns to management. Record review of Resident #4's Behavioral Note, dated 7/7/22 at 3:45 A.M., showed: -The resident was harassing his/her roommate (Resident #10) and was threatening to kill him/her. -His/her roommate had a sinus headache and Resident #4 was screaming threats in Resident #10's face. -The aggressive behavior had been reported on numerous occasions, he/she accuses staff of abuse, directly after abusing staff. Record review of Resident #4's Behavioral Note, dated 7/9/22 at 12:36 A.M., showed: -Resident #4 had become very irate with staff when complaining Resident #10 was using the bathroom when he/she needed to use the restroom. -Resident #4 threatened to kill Resident #10 and urinate on Resident #10 the next time Resident #4 had to wait for Resident #10 to get out of the bathroom. -Resident #4 would not calm down and listen to any reasoning on the matter. -Resident #4 was told to not harm Resident #10 and Resident #4 stated watch me. Record review of Resident #4's Behavioral Note, dated 7/21/22 at 1:10 A.M., showed: -Resident #4 was heard screaming in his/her room, Resident #10 was sleeping. Resident #4 woke up Resident #10 and began screaming and accusing Resident #10 of trying to kill him/her. -Resident #4 was asked by staff to leave Resident #10 alone and go back to his/her own side and go to bed. -Resident #4 refused, threatened to kill staff, saying he/she would fight staff to the death. -Resident #4 had harassed and attacked staff and Resident #10 several times, each time management was notified, no intervention had occurred but roommate swapping, and every roommate was attacked by Resident #4 and the CNA staff cannot perform cares on other residents. -This resident cannot be redirected, his/her behaviors had escalated and were unprovoked, on each occasion of similar behavior. During an interview on 8/31/22 at 9:48 A.M., Resident #10 said: -He/she had been roommates with Resident #4. -Resident #4 was mean to me and had his/her own agenda. -Resident #4 had yelled at him/her quite a bit. -It was terrible and he/she started to get tears in his/her eyes. -Resident #4 would get in my face and yell at me all the time. -I am scared of Resident #4. -Resident #10 became visibly anxious and upset during the interview. Record review of Resident #4's Behavioral Note, dated 8/29/22 at 2:50 A.M., showed: -Nursing staff called to room. -Resident #4 had a cane and was hitting/jabbing at Resident #3. -Nurse brought Resident #4 immediately to TV main area. -He/she transferred to hospital via ambulance for evaluation and treatment. -Resident's family, DON, Administrator, and Nurse Practitioner notified. Record review of Resident #3's Nurses Notes, dated 8/29/22 at 3:23 A.M., showed: -This writer was notified of a resident altercation by staff, upon arrival resident was noted to be bleeding from bottom left lip, left thigh, and left calf. -When asked what happened resident stated his/her roommate had been saying things like you don't know what it's like to have air conditioning and you never had anything growing up before coming around the privacy curtain with his/her walking cane and striking/jabbing resident. -The resident was able to disarm Resident #4. -The resident assessed by this writer and charge nurse, dressing applied to thigh injury. -Resident #4 was removed from the residents' shared room to ensure resident safety. Record review of Resident #3's untitled incident report, dated 8/29/22, showed: -Nursing staff were called to the room. -Resident #4 was hitting/jabbing Resident #3 with a cane while he/she was in bed. -Resident #4 had become upset and attacked Resident #3 with a cane. -Resident #3 had an injury to his/her face. -The administrator, the Director of Nursing (DON) and the physician were notified. During a telephone interview on 8/30/22 at 11:30 A.M., LPN A said: -He/she was the charge nurse on another unit when the altercation occurred between Resident #3 and Resident #4. -A staff member had yelled out onto his/her unit there was a fight, so he/she went over. -He/she went to the room and at that time both Resident #3 and Resident #4 were heavily breathing. -He/she assessed Resident #3 as he/she was sitting on the side of his/her bed and the resident had a small amount of blood on his/her lip and had scrapes on the outer thigh of the left leg. -The DON, administrator, and nurse practitioner were notified. -Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #3 did not have a history of aggression. -Resident #3 stated Resident #4 said he/she had been making noise while sleeping. -Resident #4 had come to the side of his/her bed and started hitting him/her with a cane. -Resident #4 was sent to the hospital for a psychiatric evaluation. -Whenever aggressive behaviors happen monitoring should be completed. Observation on 8/30/22 10:12 A.M., showed Resident #3 had abrasions approximately four inches long on his/her left hip. During an interview on 8/30/22 at 11:49 A.M., Resident #3 said: -During the night when the altercation occurred, Resident #4 kept calling me a scum bucket. -He/she fell asleep in bed and Resident #4 said he/she was making noises. Resident #4 had came up to Resident #3's bed with a cane hitting his/her bed. -Then he/she started swinging and hitting me with the cane and was yelling you don't have nothing and don't mess with the air conditioning. -He/she was hit over and over with the cane by Resident #4. -He/she tried to defend himself/herself. -The nurses came in and separated Resident #3 from Resident #4. During a phone interview on 8/31/22 at 9:04 A.M., LPN D said: -Resident #4 had aggressive behaviors and staff were always getting hurt by him/her. -Resident #4 had Resident #10 cornered in their room screaming at him/her. -Resident #4 had been moved to be with a different roommate. -Resident #4 had extreme aggressive behaviors and could not be handled by the staff. -He/she had been hit in the jaw, kicked and had been slammed into the wall by the resident's wheelchair. -Resident #4 could not be re-directed when escalated and would use his/her wheelchair as a weapon. During an interview on 8/31/22 at 9:35 A.M., the DON said: -He/she had been notified of Resident #4's behaviors towards other residents by the nursing staff. -Resident #10 resided with Resident #4 until 7/22/22 when he/she had behaviors towards Resident #10. -Resident #4 was in a room alone until 8/8/22 then was placed in a room with Resident #3. -He/she thought Resident #4 mainly had issues with staff caring for more dependent residents so he/she placed Resident #3 in the room. -The nursing staff should put monitoring in place after every incident for safety. During an interview on 8/31/22 at 2:55 P.M., Physician A and Nurse Practitioner A said: -When a resident exhibited aggressive behaviors monitoring should be put into place and the residents should be separated. -Resident #4 had been sent to the hospital twice now for psychiatric evaluations for aggressive behaviors and nothing had been done by the hospital. -The hospital sent the resident back to the facility with no new orders. -[MEDICATION(S)] had been started after this incident. 2. Record review of the Resident #4's Nurses Note, dated 8/29/22 at 8:33 A.M., showed: -Resident #4 returned from hospital at 8:15 A.M. following an altercation with Resident #3. -Resident #4 returned with no new orders and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -In-house Nurse Practitioner ordered the resident to have labs drawn and start resident on [MEDICATION(S)] (antipsycotic) 25 milligrams (mg) hour of sleep daily a antipsychotic medication (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat [CONDITION(S)]). -Resident stated he/she did not remember the episode the night prior and stated he/she was sorry if he/she had hurt anyone. -Staff would continue to monitor resident for continuation of care. During an interview on 8/30/22 at 10:49 A.M., LPN E said: -He/she was told Resident #4 and Resident #3 had an altercation on the night shift and Resident #4 had been sent to the hospital for a psychiatric evaluation. -He/she was the day shift nurse and the hospital called around 7:00 A.M. on 8/29/22 to give report on Resident #4. -Resident #4 arrived back to the facility at 8:15 A.M. and he/she put Resident #4 back in the same room with Resident #3. -He/she pulled the curtain between Resident #3 and Resident #4. -Resident #4 was not put on any monitoring. -He/she notified management Resident #4 was back. -He/she was waiting on instructions and where to move Resident #3 and Resident #4. -He/she was not sure when Resident #3 noticed Resident #4 was back in the room. -Resident #3 and Resident #4 were in the original room together from 8:15 A.M. until 1:15-1:30 P.M. -Around 1:30 P.M. Resident #3 was talking on the phone to Family Member A. -Resident #3 was very upset and yelling because Resident #4 was back in his/her room after the altercation. -Family Member A was yelling and telling Resident #3 to not talk to staff, he/she was going to handle the situation. -He/she tried to talk to Family Member A on the phone, but could not de-escalate Family Member A or Resident #3. -Not long after Family Member B came into the building while he/she was trying to calm Family Member A and Resident #3. -Family Member B spoke with Resident #3 and Family Member A on the phone. -Family Member B went straight to Resident #3 and Resident #4's room. -He/she went soon after and Resident #4 said Family Member B hit him/her with a cane. -He/she did not see the actual incident. -Many staff members had come to the area and Resident #4 was taken to safety. Record review of the Resident #3's Nurses Notes, dated 8/29/22 at 2:43 P.M., showed: -At 1:30 P.M. Resident #3 notified Family Member A by phone that Resident #4 had returned from the facility and he/she was upset Resident #4 had not been moved yet to a different room. -Resident #3 was instructed by whomever was on the phone not to talk to any of us and they would take care of it. -Several of our staff tried to talk with the family member on the phone to assure them that they were handling the situation, the family member began to scream at the staff on the phone and refused to listen or converse with staff. -By 1:45 P.M. Family Member B came into the facility with a cane, the family member asked Resident #3 where Resident #4 was and Resident #3 told Family Member B that he/she was down in their room. -Before staff could talk with Family Member B, he/she walked down and hit Resident #4 with a cane. -The family member was highly irate and would not listen to reason. During an interview on 8/30/22 at 11:49 A.M., Resident #3 said: -The nurse stated he/she would be moving to another room as soon as Resident #4 came back from the hospital. -The next day Resident #4 came back from the hospital and when he/she realized he/she was back in the room with Resident #4, he/she left the room. -He/she did not feel good about it, felt scared, and unsafe. -The staff should not have let Resident #4 back in the room. -He/she called Family Member A and Family Member B came to the facility. -He/she was very upset and on the phone with Family Member B because Resident #4 was in my room. -He/she was not sure what happened with Family Member B and Resident #4. During an interview on 8/30/22 at 1:47 P.M., the DON said: -He/she had been notified of the altercation between Resident #3 and Resident #4. -He/she had spoken with LPN A who described the incident as poking and jabbing. -He/she was told of minor scratching to Resident #3 and Resident #4 did not have injuries. -The management team had developed a plan to move Resident #3 to the 200 hall area when Resident #4 came back. -He/she had told LPN E to complete the room move and this did not get completed. -Resident #3 called Family Member A the room move did not get done. -This all escalated due to the room move not getting completed. -Family Member B came to the facility and went to the resident's room. -He/she did not witness the incident, but thought LPN E had witnessed Family Member B assault Resident #4. -He/she went down to the room and told Family Member B he/she could not assault residents. -Staff removed Resident #4 from the room to separate him/her from Family Member B. -LPN F was finally able to de-escalate Family Member B. -Family Member B was escorted out of the facility and spoke with the police. -Resident #4 was assessed by nursing and no injury at that time. -Resident #3 should have been separated from Resident #4 upon his/her return from the hospital. -The staff were busy and the residents did not get separated. -The residents should have been separated and not placed back in the room together when Resident #4 had come back from the hospital. -There was no documented monitoring completed on Resident #4 when he/she returned from the hospital. During an interview on 8/30/22 at 2:35 P.M., Hospitality Aide A said: -On 8/29/22 when Resident #4 had come back from the hospital he/she was placed back in the room with Resident #3. -He/she had seen the residents out at different times, but was not sure how much they were together that morning. -He/she had been told to remove Resident #4 from the room after Family Member B went down towards the room. -Family Member B was standing over Resident #4 yelling at him/her like he/she was going to hit the resident. -Family Member B was yelling things like you think it's funny to beat up on people and he/she will show what it is like to get beat up. -Family Member B had a cane in his/her hand, but he/she did not see Family Member B hit the resident. -Resident #4 said he/she had been hit with the cane. -He/she immediately got between Family Member B and the resident. -He/she tried to calm Family Member B down and he/she kept yelling and saying where were all of you last night (when incident occurred between Resident #3 and Resident #4). -Another staff member removed Resident #4 from the room. -LPN F was able to calm Family Member B down. -Family Member B packed Resident #3's belongings and was escorted out of the building. -Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/31/22 at 8:16 A.M., LPN F (also a Unit Manager) said: -He/she was coming down the hall and heard Resident #3 on the phone hollering, yelling, and cursing. -Family Member B came in and talked to Resident #3 then went down the hall towards the residents' room. -Family Member B was walking fast like he/she was going to do some stuff. -Family Member B was standing in front of Resident #4's wheelchair yelling you hit my family member and I am going to hit you. -Family Member B had a black cane in his/her hand. -He/she did not see Resident #4 get hit. -He/she stepped in and wheeled Resident #4 out of the room. -There was so much commotion with the incident. -Family Member B kept cussing, yelling, and screaming in the DON's face. -Family Member B packed Resident #3's belongings and was escorted out of the building. -Resident #4 should not have been placed back in the room with Resident #3. -Resident #4 should have been placed on one on one monitoring after he/she returned from the hospital. -Not separating the residents escalated the situation. During an interview on 8/30/22 at 1:05 P.M., Family Member A said: -He/she had not been told the details of what happened during the altercation. -He/she had tried multiple times to get through to management that morning, but no one called back. -The residents should not have been placed back together in the same room. -He/she was received a phone call from Resident #3 stating Resident #4 had been placed back in the room after the altercation. -Resident #3 was upset. -He/she sent Family Member B to the facility to pick Resident #3 up along with the police and ambulance. -He/she wanted to make sure Resident #3 was not injured because he/she had a previous head injury. -He/she was not in the building when Family Member B was in the facility. During an interview on 8/30/22 at 12:55 P.M., Resident #4 said: -He/she had been hit in the back by Family Member B. -Family Member B had poked him/her with a cane on his/her back. -Family Member B was yelling you hit my boy with a cane. During an interview on 8/31/22 at 10:20 A.M., the Administrator said: -The DON was responsible for putting interventions in place after incidents occur. -Resident #3 was supposed to be moved to another hall after the incident with Resident #4. -Resident #4 was moved out of the room after aggressive behaviors towards staff from other residents he/she resided with previously. -Staff would try to do cares on other dependent roommates at night and Resident #4 would be aggressive towards staff. -Staff did not report to him/her Resident #10 had been backed up against the wall and yelled at by Resident #4. -He/she had not been made aware of the extent of Resident #4's aggressive behaviors. -The staff should have reported the details to management after every incident. -The staff did not put in immediate interventions when Resident #4 had come back from the hospital. -Interventions should have been put in immediately. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO 7

Based on observation, interview, and record review, the facility failed to prevent staff to resident abuse for one sampled resident (Resident #1) out of three sampled residents, when Certified Nurse Aide (CNA) A admitted to hitting the resident several times in the face resulting in pain, swelling, and discoloration of the resident's left lateral (side) orbital (eye) area and a black eye. The facility census was 167 residents. On 3/31/22 at 12:57 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 3/29/22. On 3/29/22 the facility administration was notified of the incident and the investigation was started. CNA A was suspended on 3/29/22 and terminated on 3/30/22. No employees were allowed to work prior to re-education. The IJ was corrected on 3/30/22. Record review of the facility policy titled Compliance with Reporting Allegation and Abuse/Neglect/Exploitation, dated 3/29/22, showed: -The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. -New employees will be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. -Annual education and training will be provided to all existing employees. -Front line supervisors will provide education as situations arise. -The facility will provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. -The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. 1. Record review of Resident #1's facility face sheet showed he/she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Polyosteoarthritis (a joint disease that involves at least five joints with signs of inflammation, pain, movement restriction, swelling and redness). -Cognitive Communication Deficit (problems with communication that have an underlying cause in a cognitive deficit). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -[CONDITION(S)] Disorder (a mental health condition including [CONDITION(S)] and mood disorder symptoms). -Post Traumatic Stress Disorder (a condition in which a person has a difficult time recovering after experiencing a terrifying event). -[CONDITION(S)]. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 1/13/22, showed: -BIMS (Brief Interview of Mental Status) score of 6, which indicates the resident had severe cognitive impairment. -Required supervision only for ADL's (Activities of Daily Living - a persons self care activities). Record review of the resident's care plan, dated 9/30/21, showed: -Resident had the potential to be verbally aggressive (curses and yells at staff and other residents) and physically aggressive (threw room furniture on the floor, has attempted to hit staff and other residents) related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident was seen by psychiatrist/psychologist related to [CONDITION(S)] and dementia. Record review of the resident's physician orders, dated 3/22, showed: -Monitor for signs and symptoms of depression every shift such as: anxiety, apathy, general discontent, guilt, hopelessness, loss of interest or pleasure in activities, mood swings. -Monitor for agitation, excessive crying, irritability, restlessness, social isolation, and notify the Doctor or Nurse Practitioner (NP) if resident had signs and symptoms. Record review of the facility's investigation, dated 3/29/22, showed: -At approximately 5:15 P.M., the Long Term Care Unit Manager (Registered Nurse - RN D) stated Licensed Practical Nurse (LPN) C reported to him/her that the resident had a black eye and his/her face was swollen and abuse was suspected. -The resident was assessed by the Director of Nursing (DON) and the facility NP. -The resident noted to be calm with no apparent distress, sitting in the open dining room at a table. -The resident was noted to have severe swelling and bruising surrounding the left orbital socket and extending back towards his/her temple and down his/her face to the left jaw. -The left conjunctiva (inside of eyelid) was noted to be bright red. -The resident reports the left side of his/her face hurts, and rated his/her pain at four out of ten on a one to ten scale. -The resident denied blurred vision, dizziness, or lightheadedness. -The resident's pupils were equal, round, and reactive to light and accommodate. -There was an area of swelling noted to the left lateral side of his/her head parallel to his/her ear, approximately two to three centimeters from the ear. -There was an area of swelling noted to the right lateral/posterior portion of his/her head. -The resident had a flat affect. -The resident stated he/she was punched repeatedly. -The resident stated it was a male, approximately six feet tall who punched him/her. -The resident was unable to point out which person it was that hit him/her. -Orders were received from the NP to send the resident to the hospital for medical evaluation. -LPN C stated that he/she asked Resident #1 what had happened and the resident told him/her that someone pushed him/her out of the chair and hit him/her, and said it was a male. -At approximately 9:20 P.M., RN D and CNA B came to the DON's office, and RN D stated that CNA B had something to tell him/her. -CNA B stated that CNA A had told him/her that he/she was the one that assaulted Resident #1. -The DON was notified that CNA A was not currently in the building and had gone on a break. -RN D waited on the dementia unit for CNA A's return. -The DON contacted the local police department of the situation and requested an officer be dispatched to the facility at 9:30 P.M. -At 9:40 P.M., CNA A reentered the facility and was immediately escorted to the DON office. -At 9:41 P.M., CNA A was interviewed by Regional Director of Operations. -At 9:48 P.M., CNA A walked out of the DON's office and entered the reception area of the facility, which was free of residents, and was escorted by Regional Director of Operations and DON. -At 9:50 P.M., police arrived to the facility as CNA A was walking out of the front door, and stopped CNA A to speak with him/her. -At 10:30 P.M., Resident #1 returned to the facility from the hospital with with no major injury sustained, no new orders. --Resident #1 spoke with the police, and police reported that he/she stated that he/she and a CNA had fought, and was able to describe CNA A in detail, and how CNA A had hit her/him in his/her room. --Resident #1 stated he/she remembered speaking with the DON and giving the above statement that he/she had been attacked by a male. Record review of the resident's hospital records, dated 3/29/22 at 7:32 P.M., showed: -The resident reports to the physician that someone assaulted her/him from behind and struck him/her on the left side of the face and head and also tried to choke her/him. -Contusion (a region of injured tissue or skin in which blood capillaries have been ruptured, a bruise). -CT scan (a computerized tomography combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues inside the body). -No acute intracranial findings. -Moderate soft tissue swelling identified in the soft tissue of the left anterior inferior to the left orbital globe (around and below the left eye). -No acute fracture of facial bones. -All other body systems assessed are within normal limits. -Patient complained of pain to his/her left side of the face and head. Record review of the local police department report, dated 3/29/22 at 9:20 P.M., showed: -Arrival at the facility regarding an assault. -Upon arrival he/she contacted CNA A outside. -When asked, CNA A said that he/she did not remember what happened. -CNA A did not want to make a statement at this time. -The DON shared the following account with the officer: --He/she had spoken with CNA B and he/she told him that CNA A admitted to him/her that he/she assaulted the resident. --CNA A told the DON that the resident came out of his/her room and was saying slurs to him/her such as fag and faggot, and was pushing him/her. --CNA A told the DON that he/she had blacked out and lost it and that he/she must have punched the resident a couple of times. --CNA B told the DON that the resident came out of his/her room very angry and causing a scene. --CNA A and CNA B escorted the resident back to his/her room, where CNA A told CNA B to shut the door and mind your own business. --CNA B stated that CNA A later exited the room and would not say anything to him/her. --CNA B said later the resident was in the dining room, had a black eye and it was swollen shut. -Officer attempted to speak with CNA A again and he/she refused to say anything other than if he/she would have hit him/her, he/she would have marks on his/her hands. -Officer observed CNA A to have a large adhesive strip on his/her right hand that appeared to be old, and a small scratch on his/her left hand that appeared to be fresh. -Officer attempted to speak with the resident, however, he/she was confused on what day the assault happened, could not tell them who assaulted him/her other than a worker in the building that was a male. During an interview on 3/30/22 at 11:15 A.M., the DON said: -He/she received a call about 5:20 P.M. on 3/29/22 from RN D. -He/she reported LPN C on the dementia unit reported that a resident had a black eye and that he/she suspected abuse. -When he/she arrived at the facility RN D had already obtained statements from the staff. -LPN C reported the resident kept changing the story of what happened to him/her. -He/she spoke with the resident and observed swelling and discoloration that were obvious to the eye and left side of the face. -RN D came to his/her office with CNA B about 9:20 P.M., saying CNA B had something to tell him/her. -CNA B appeared hesitant and nervous and stated CNA A did it. -CNA B said CNA A was the one who punched the resident. -CNA B said he/she knew this before he/she wrote his/her prior statements. -The DON asked CNA B why he/she had told a different story, and CNA B said, he/she didn't want to be a snitch. -The DON let CNA B know that he/she had put residents at risk. -CNA B said he/she came forward, because he/she was feeling guilty. -CNA B said he/she still felt hesitant as CNA A and he/she were friends. -The DON called the police and let them know that there was an allegation of employee to resident abuse. -CNA A was standing outside the facility, came into my office and he/she admitted that he/she had done it. -CNA A said he/she and CNA B were in the hall and the resident repeatedly called him/her a fag and shoved him/her. -CNA A said he/she told the resident to [OBSCENITY] off, blacked out and said he/she must have punched the resident. During an interview on 3/30/22 at 7:10 P.M., LPN C said: -He/she reported the incident to RN D, as soon as he/she was aware that something had occurred. -The whole situation was very confusing as at that point, he/she thought a resident had hit Resident #1. -He/she took the resident into a vacant room and assessed him/her. -The NP was in the facility at the time, so he/she called him/her to assess the resident as well. -The NP gave orders for the resident to go to the hospital for an evaluation. -After he/she assessed the resident he/she asked the resident to sit in the dining room, in hopes the resident would be able to let him/her know who hit him/her, as the residents were coming in there for dinner. -The resident kept changing the story from a white male hit him/her to a black male hit him/her and then back again. -When emergency transport arrived, the resident was placed on the gurney, half way out the door, and he/she said, there he/she is! -The resident had pointed to CNA A outside. -About the same time, CNA B came forward and said that he/she needed to talk to him/her or the DON about the incident. During an interview on 3/30/22 at 12:40 P.M., CNA B said: -Him/her and CNA A were on 700 hall (dementia unit) when Resident #1 came out and called CNA A a fag. -CNA A followed the resident back to his/her room and shut the door. -He/she just thought maybe he/she was going to talk to the resident and settle him/her down. -About five minutes later the resident came out of the room with his/her eye swollen. -He/she told LPN C and then he/she reported it to RN D. -He/she did not see anyone else go in the resident's room. -He/she was surprised, because he/she thought that CNA A wouldn't do anything like that. -He/she just told the nurse. During an interview on 3/30/22 at 1:10 P.M., CNA A said: -He/she was not sure what happened as he/she was smoking when all this went down. -He/she never went in Resident#1's room. -There would be no reason for him/her to go in that room, because the resident was pretty independent. -All he/she knows, was that when he/she came back from smoke break, LPN C told him/her the resident got hit. -He/she never went in the resident's room, and would never hit him/her or any other resident. Observation on 3/30/22 at 1:35 P.M., showed: -The resident had injury to the left side of his/her face: -Discoloration and swelling to the left lateral orbital area of the eye. -Swelling and discoloration extended from the orbital area, to the left temple, with under the skin bleed down (blood pooling under the skin below the injury) on the upper left cheek. During an interview on 3/30/22 at 1:40 P.M., the resident said yes he/she called that [NAME] a fag, because of the way they looked and moved around. During an interview on 3/30/22 at 2:45 P.M., Hospitality Aide C said: -Previously when he/she had worked on the dementia unit, CNA A and Resident #1 always bantered back and forth. -CNA A called the resident a man and the resident called CNA A a fag. -They had been getting along just fine. -He/she saw the resident's face and asked him/her what happened, The resident said that two guys jumped her/him in his/her room, and then said, no wait some guy hit him/her in the dining room. During an interview on 3/30/22 at 7:30 P.M., the NP, who assessed the resident said: -The resident had dementia and was very confused. -During the course of the examination the resident told him/her that a tall white guy had hit her/him, then changed it to a black male. -He/she wanted the hospital to perform a CT scan just to make sure that the resident's injuries were superficial. -The resident was a poor historian, but someone definitely hit him/her. During an interview on 3/30/22 at 11:00 A.M., the Administrator said: -The incident was unwitnessed. -CNA B said he/she thought CNA A was involved in the incident. During an interview on 3/31/22 at 12:30 P.M., the Regional Director of Operations said: -The DON called him/her to let him/her know he/she had an employee to resident altercation. -He/she came to the facility to ensure police were called and making sure that CNA A was out of the building. -The police were on the way. -When he/she spoke with CNA A, he/she said he/she must have blacked out and thought that he/she hit the resident a couple of times. -CNA A said the resident had called him/her names and that he/she was not going to take it. -He/she spoke with CNA B and let her/him know he/she was disappointed. -CNA B was suspended for actions and putting residents at risk with CNA A. MO 157 MO 158 MO 145

Based on observation, interview, and record review, the facility failed to provide supervision and individualized interventions for one sampled resident (Resident #1) to address his/her exit seeking behavior. The resident was admitted to the facility on [DATE] with a history of wandering behaviors and no immediate care plan was developed to address the resident's wandering. The resident exited the unit five times prior to eloping from the building on 6/24/21. The resident was found by the local law enforcement near a busy traffic intersection and returned to the facility. The facility census was 161 residents. The Administrator was notified on 6/30/21 at 1:45 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 6/24/21. On 6/24/21, the Administrator became aware of the resident elopement, followed facility policy initiating the return of the resident to the facility by local law enforcement. The facility in-serviced staff on the elopement policy, developed a resident care plan for intervention specific to the resident, including expectation on monitoring resident wandering behaviors. The IJ was removed and corrected on 6/25/21. Record review of the facility's Care Planning policy, dated June 2020, showed: -The facility's Interdisciplinary Team (IDT) would develop a Baseline and/or Comprehensive Care Plan for each resident. -The care plan served as a course of action where the resident (residents' family and/or guardian or other legally authorized representative), resident's attending physician, and IDT worked to help the resident move toward resident-specific goals that addressed the resident's medical, nursing, and mental and psychosocial needs. -A licensed nurse would initiate the care plan, and the plan would be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. -The facility would develop a person-centered baseline care plan for each resident within 48 hours of admission. -The baseline care plan would include at least the following: --Initial goals based on admission orders. --Physician orders. --Dietary orders. --Therapy services. --Social services. --Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) recommendations, if applicable. -Once the Baseline Care Plan was completed, the facility must provide the resident and/or the resident's representative with a written summary of the baseline care plan that includes: --Initial goals of the resident. --Summary of medications and dietary instruction. --Services or treatments to be administered. -The resident's medical record must contain evidence that the summary was given to the resident and/or the resident's representative. Record review of the facility's Wandering and Elopement policy, dated August 2020, showed: -The facility would identify residents at risk for elopement and minimize any possible injury as a result of elopement. -The licensed nurse, in collaboration with the IDT, would assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wandering/elopement. -The resident's risk for elopement and preventative interventions would be documented in the resident's medical record, and would be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition. -IDT could consider interventions listed in Elopement Risk Reduction Approaches for residents identified to be at risk for elopement. -Residents with a history of wandering or who the IDT had assessed to be at risk for wandering or elopement would have a photograph maintained in their medical record and the Elopement/Wandering Risk Binder. -The licensed nurse most familiar with the incident would document in the resident's medical record how the elopement occurred. Record review of the facility's Elopement Risk Reduction Approaches, undated showed: -As necessary, provide new residents with additional staff assistance until they are comfortable in their new environment. -Ensure that residents are able to move about freely, are monitored and remain safe. -Develop a care plan and an update process to promote choice, mobility and safety. -Base the care plan on assessments and family and caregiver involvement. 1. Record review of Resident #1's hospital records showed: -He/she was admitted to the hospital on 6/9/21 for dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) after presenting to the emergency room (ER) with a history of rapidly progressive cognitive decline and personality changes and wandering away from home; On 6/9/21, he/she eloped from his/her home three times and became lost. -Diagnostic tests showed encephalomalacia (a type of serious brain damage that results in the softening or loss of brain tissue). -On examination he/she had severe recent and remote memory loss; he/she overcompensated by confabulating (filling in gaps in memories, especially when compensating for memory loss) or changing the conversation tangentially (diverging from a previous course or line). -His/her family agreed to skilled nursing care and he/she was discharged to the facility on [DATE]. Record review of the resident's Level One Nursing Facility Pre-Admission Screening for Mental Illness/Mental [CONDITION(S)] or Related Condition (PASSR - a federally required screening form to determine appropriateness of the nursing facility placement), dated 6/16/21, showed: -He/she did not show any signs or symptoms of major mental disorder. -He/she had never been diagnosed as having a major mental disorder. -Dementia was the primary reason for his/her nursing facility placement. -Wandering or elopement was not identified on the PASSR. Record review of the resident's facility undated Admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of other specified (a term used when the information in the medical record provides detail beyond the specificity of diagnostic codes) disorders of the brain, dementia with behavioral disturbance (symptoms including anxiety, agitation, pacing and wandering) other disease, and [CONDITION(S)] disorder (a mental health condition affects a person's thoughts, mood and behavior). Record review of the resident's medical record showed no wandering assessment completed between 6/16/21 and 6/24/21. Record review of the resident's Skilled Nurse's Note, dated 6/17/21 at 5:15 A.M., showed he/she had wandering behavior. Record review of the resident's Baseline Care Plan, electronically, signed on 6/17/21 by Licensed Practical Nurse (LPN) D and the Director of Nursing (DON) showed: -He/she was cognitively impaired. -He/she could communicate easily with staff. -He/she was independent with activities of daily living (bed mobility, transferring, walking, dressing, personal hygiene, eating, and bathing), did not use assistive devices (cane/walker, wheelchair) and was continent of bladder and bowel. -The baseline care plan had a list of pre-selected choices for each area of concern. There was no area to identify wandering or elopement and there was no area to add areas not already available in the template. Record review of the resident's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 6/17/21, showed: -He/she was admitted to the hospital for elopement and memory decline including, eloping and getting lost in his/her own neighborhood. -He/she was at high risk for falls. -He/she need increased assistance at that time due to his/her decreased safety judgement and decreased coordination. Record review of the resident's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 6/17/21, showed: -He/she had tangential thinking and speaking throughout. -Redirection was needed. -He/she had 3 to 5 deficits in areas of physical, cognitive, psychosocial skills resulting in activity limitation or participation restrictions. -He/she had impairments in balance, gross motor coordination, mobility and strength resulting in limitation and/or participation restrictions in the areas of mobility and self-care. Record review of the resident's Admission Assessment, dated 6/18/21, at showed: -He/she was oriented to person (knew who he/she was). -He/she was not oriented to place, time or situation. -He/she walked independently. -Was severely cognitively impaired. Record review of the resident's Behavior Note, dated 6/18/21 at 7:09 P.M., showed: -He/she followed a staff member off the unit and got as far as the Renew unit (the adjacent rehabilitation unit). -The DON was able to talk him/her back to the secured unit without incident. -He/she was confused and disoriented. -Emotional support was provided. Note-The care plan was not updated with the behavior note to reflect new goals or interventions. Record review of the resident's Skilled Nurse's Note, dated 6/18/21 at 5:15 P.M., showed he/she had wandering behavior. Record review of the resident's Standard Focus Statement (a care plan category) initiated on 6/18/21 showed: -He/she was an elopement or risk wanderer related to dementia. -He/she followed a facility staff member off of the unit and got as far as the Renew unit. -He/she was confused and disoriented, emotional support was provided. -Facility staff should document the resident wandering behavior and attempt diversional intervention. Note- No goals or interventions were identified on the document. Note -The care plan was not updated with the standard focus statement. Record review of the resident's Orders-Administration Note, dated 6/20/21 at 5:34 P.M., showed: -He/she was restless, wound up, irritable, wandering and eloped from the secured unit four times this day. -He/she resisted care and had delusions. Record review of the resident's Behavior Note, dated 6/20/21 at 7:55 P.M., showed: -He/she had eloped from the locked unit four times on 6/20/21; Each time he/she was following another person coming into or leaving the secured unit as he/she watched the double doors. -He/she was getting more irritable after each occurrence and at the last occurrence he/she looked as if he/she was going to raise his/her arm and become physical, but did not. -He/she speaks delusional and stated he/she needed to call 911 as he/she was a visitor and had been kidnapped. -Attempts to redirect and reorient him/her were unsuccessful. -Staff were instructed to be on the alert and aware of his/her location when entering or leaving the secured unit. -Staff intercepted several attempts of him/her attempting to exit the secured unit. Note- The care plan was not updated with the behavior note to reflect new goals or interventions. Record review of the resident's Skilled Nurse's Notes, dated 6/21/21 at 4:23 P.M.; 6/22/21 at 12:23 A.M.; 6/22/21 at 10:09 A.M. and 6/22/21 at 12:23 A.M., showed he/she had wandering behavior. Record review of the resident's facility Speech Therapy (ST) Speech and Language (SLP) Evaluation and Plan of Treatment, dated 6/22/21, showed: -Reason for Referral: --He/she was referred to ST due to significant exacerbation (worsening) of his/her cognitive-communicative deficits, decreased safety, increased need for supervision and assistance from others placing him/her at risk for falls, further decline in function and increased dependency upon caregivers; he/she exhibited distress/negative statements about his/her situation associated with cognitive/memory impairment, expressed that he/she was shackled, head covered and was forced to come. -History/Complexities: --He/she was admitted to hospital on 6/9/21 for elopement and memory decline. --Per his/her significant other said he/she started having memory issues at the beginning of 2020 further decline in the last few weeks including eloping, getting lost in his/her neighborhood and could not remember things. -His/her problem solving reasoning in new situations was less than 25%. Impressions: --He/she required skilled SLP services for cognition/communication to improve cognitive linguistic (language) skills, facilitate memory, develop and instruct in compensatory strategies and adaptation techniques in order to enhance his/her quality of live to enhance and improve carryover of safety techniques within tasks. Record review of the resident's Skilled Nurse's Note, dated 6/23/21 at 1:09 P.M., showed he/she had wandering behavior. Record review of the resident's Nurse's Note, dated 6/24/21 at 6:34 P.M., showed: -He/she was noted to be absent from the secured unit at 5:15 P.M. -After all secured unit staff searched the secured unit and the halls outside of the secured unit, other nearby staff were informed including the Nurse Practitioner (NP - licensed, autonomous clinician focused on managing health conditions and preventing disease), the facility social worker and a Code Pink was called overhead (announced audibly throughout the facility). -After further searching, the Administrator was notified while searching inside and outside continued. -The Administrator arrived at the facility and the local police department was notified. Record review of local law enforcement incident report, dated 6/24/21 at 5:31 P.M., showed the facility administrator had contacted regarding a missing person. Record review of local law enforcement incident report, dated 6/24/21 at 6:05 P.M., local law enforcement officers found the resident walking Southbound near a busy intersection. Record review of the resident's Nurse's Note, dated 6/24/21 at 7:34 P.M., showed. -He/she returned to the facility at approximately 6:20 P.M. via police escort. -He/she was escorted to the secured memory care unit by staff. -He/she appeared clean, cool with no sweat noted to his/her visible skin. -His/her breathing was even and unlabored. -He/she was calm, talkative and in no apparent distress. -He/she was dressed in clothing proper for the weather with no visible signs of dirt, scuff marks, or debris. -A skin assessment was completed upon his/her return; no abnormalities were noted. -He/she denied falling and denied pain. -He/she stated he/she was attempting to go home to a city adjacent to the city the facility was located in (the facility is located in a large metropolitan area) to take care of his/her lawn and bills. -He/she had no memory of how he/she exited the locked unit or the building. During an interview on 6/25/21 at 10:50 A.M., the Administrator and DON said: -The resident had early onset dementia. -When he/she came to the facility, he/she complained about being brought to the facility in shackles and was being held at the facility against his/her will. -The resident had left the secured unit a couple of other times; he/she had followed staff off the secured unit on 6/18/20 and on 6/20/21 had followed people out the door. He/she was brought right back to the secured unit on those occasions. -On 6/24/21, he/she left the facility at 4:30 P.M. -The Administrator was notified of the resident's elopement at 5:10 P.M. and returned to the facility and called 911 at 5:20 P.M. -Police arrived at the facility at 5:40 P.M. and took information regarding the resident. -At 6:01 P.M. the officer called the facility and said the resident had been found. -The resident had no injuries. -When the resident was returned to the secured unit on 6/24/21, he/she said he/she was going to his/her apartment and that he/she would be checking out tomorrow. -The police had found him/her about three miles from the facility (Google Maps and Google Earth showed the intersection was 3.9 miles from the facility and was a heavily traveled residential intersection with four traffic lights and four left turn lanes). -They had not figured out from which door the resident exited the facility. -All the facility doors were checked last evening and again that morning and all the doors operated properly. -Facility staff were told to be vigilant. -The facility exit door nearest the secured care unit was alarmed, there was a keypad to use prior to opening the door, but that door was not a common egress (an exit). -A sign was posted prior to the elopement near the inside entry/exit door in bold print that read When entering or leaving (the secured unit), please make sure that a resident does not follow you out of the unit. Visitors must be let in and out of the unit by staff. Staff must ensure the doors are locked and alarmed color indicator is red. Thank you for ensuring our residents are safe. During an interview on 6/25/21 at 11:40 A.M., Restorative Aide (RA) A said: -The resident was friendly, new to the facility, walked up and down the secured unit halls pretty good, and does not cause any problems with others. -Today after breakfast, he/she noticed that the resident was by the secured unit entry/exit doors; he/she told the resident that he/she could not go out and he/she walked away from the doors. During an interview on 6/25/21 at 11:50 A.M., LPN B said: -The resident walked the unit and secured unit staff had to watch him/her because he/she was exit seeking prior to the elopement and now. -The resident was exit seeking daily, he/she stood by the unit entrance/exit doors and looked out the glass in the doors. -The resident had asked him/her, How do I get out of here two times this morning and had asked that of him/her once or twice previous to 6/25/21. -The resident had gotten off the unit prior to 6/24/21. -When he/she was admitted it was in his/her admission paperwork that he/she wandered away from his/her home. -He/she did not know if wandering was in the resident's care plan; he/she would have to look at his/her care plan. -He/she tried to keep an eye on the secured unit entry/exit door to ensure resident safety and prevent elopement. -He/she did not identify who was supposed to update the care plan or how often he/she was to review. During an interview on 6/25/21 at 1:20 P.M., CNA A said: -He/she thought the resident was aware of peoples' location and when people come in and out the doors. -The resident watched the doors and watched everything the staff did and knew he/she was being watched. -He/she did not identify if he/she was told the resident was a wandering elopement risk prior to the elopement. During an interview on 6/25/21 at 1:36 P.M., the Administrator said: -The baseline care plans were usually done within 72 hours of a resident's admission. He/she did not identify what was expected on the baseline care plan. During an interview on 6/25/21 at 2:26 P.M., the social worker said: -He/she goes over the baseline care plans with residents and provides a copy to the resident and to residents' families. -Baseline care plans were updated as needed. -Baseline care plans were to be completed within 48 hours of a resident's admission. -Baseline care plans should be updated with interventions only as needed with significant changes. During an interview on 6/25/21 at 3:09 P.M., the social worker said: -He/she discussed the resident's baseline plan of care with him/her and with his/her significant other. -The resident had a history of cognitive decline. -He/she had read the resident's hospital records. -He/she did not recall seeing anything in the resident's hospital records regarding him/her getting away from home. -He/she had not seen anything in the resident's history that he/she recalled for him/her to address elopement in the resident's baseline care plan; the social worker guessed he/she missed that. -He/she did not identify where the elopement risk should be documented. During an interview on 6/28/21 at 2:31 P.M., LPN A said: -He/she did not know the resident was an elopement risk. -The resident's significant other when alerted to the resident elopement had said prior to the resident's elopement on 6/24/21 that the resident had gotten out and away from his/her home prior to his/her hospitalization and that the resident was very confused over the last month before his/her hospital admission. -The resident did not have safety awareness. During an interview on 6/28/21 at 3:15 P.M., CNA C said: -Prior to the elopement he/she had always been told to watch the resident. During an interview on 6/28/21 at 10:49 A.M., the resident's NP said: -He/she was in the facility on 6/24/21 at the time the resident eloped and until the resident's return to the facility. -He/she expected that the facility would have put in place a care plan to address the resident's history of wandering away from his/her home and being lost. During an interview on 6/28/21 at 2:19 P.M., the resident's NP said: -The resident had poor safety awareness. -He/she was a safety and elopement risk. During an interview on 6/28/21 at 1:07 P.M., the DON said he/she had told staff prior to the resident elopement on 6/24/21 to keep the resident in observational sight, to make sure to note the exit doors were closed, and not to track the resident too closely because it would escalate him/her. During an interview on 6/29/21 at 10:43 A.M. the facility social worker said: -The Administrator and DON decided regarding a resident being admitted to the secured unit based on if the resident is forgetful, or is a wandering/elopement risk. -All the residents on the secured unit had dementia and were elopement risks. -Regarding the secured unit doors, staff were to make sure no resident was near when putting in the door code, to make sure a resident did not come out when the door was opened, and make sure the door resets after exiting the secured unit. -He/she asked why the secured unit was requested; usually there was a previous care giver or a doctor to ask. -He/she had talked to the resident's family member and the resident's significant other. -The resident's significant other said the resident was forgetful. -He/she had not asked regarding wandering/elopement history and the resident's family member and significant other did not say the resident had any history. -He/she did not know the resident wandered away from his/her home and got lost before being hospitalized . -He/she had looked at the resident's hospital information and did not remember seeing anything about elopement or wandering, if it was in the hospital paperwork, he/she had missed seeing that. If he/she had seen the elopement or wandering history she would have addressed it. During an interview on 6/29/21 at 11:41 A.M., the DON said: -On 6/24/21 the resident had been found near a busy intersection. -The facility staff were involved with his/her admission at the time of his/her discharge from the hospital on 6/16/21. -The resident had a Wandering Risk Scale completed on the day of his/her facility admission on 6/16/21 which showed he/she was at high risk for wandering. -The resident baseline care plans were done by unit licensed nurse's and were reviewed when the resident's comprehensive care plan was completed. -He/she did not identify if the baseline care plan should include wandering or elopement risk. -He/she looked at comprehensive care plans to be sure everything was addressed, he/she could not say he/she looked at every baseline care plan. -The resident was admitted to the secured unit because of his/her dementia and because the resident's significant other requested he/she be admitted to the secured unit. -The resident had safety awareness as far as not standing in traffic or on train tracks when a train is coming; he/she would get confused outside the facility about where he/she was and in unknown surroundings get lost. During an interview on 6/29/21 at 12:46 P.M., MDS/Care Plan Coordinator A said: -He/she was notified the same day when any resident in the facility got off the secured care unit. -He/she was probably notified when the resident got off the secured care prior to the resident elopement on 6/24/21. -Nurses who do the residents' admissions initiate baseline care plans. -He/she did not identify if wandering or elopement should be placed in the baseline care plan. -He/she was responsible for completing residents' comprehensive care plans. -He/she would not have done the resident's comprehensive care plan until seven days after his/her admission MDS assessment (which had been completed on 6/23/21); The only care plan the resident would have had prior to that would have been his/her baseline care plan. -Licensed Nurses use a form facility computer software to create and update baseline care plans. -The facility software for baseline care plans does not have a selection for wandering/elopement and there is not a way to add a problem area for elopement/wandering or for any other problem not already in the software. -The resident did not have any safety awareness; his/her Brief Interview for Mental Status (BIMS - a structured cognitive interview completed as part of MDS assessments that provides staff with a numerical score as an estimate of the resident's cognitive function) score was very low. -The resident's Wandering Scale completed on 6/16/21 showed he/she was at high risk for wandering. -There was not a way to add problem areas not already available as selections in the facility base line care plan software. -There was not a mechanism for addressing elopement/wandering on the facility baseline care plans. MO 162

Based on interview and record review, the facility failed to identify a change in condition in a resident including a decrease of alertness, decreased blood pressure, and decreased oxygen saturation; to notify the resident's physician of the resident's change in condition in a timely manner; to transfer a resident to a hospital when requested by the resident's family in a timely manner, resulting in the resident requiring transportation to the hospital by Emergency Medical Services (EMS) and admission to the Intensive Care Unit (ICU) due to critically low blood pressure for one sampled resident (Resident #316) out of 32 sampled residents. The facility census was 164 residents. Record review of the facility Change of Condition Notification policy dated February 2019 showed: -The purpose of the policy was to ensure that residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. -An acute change of condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive behavioral, or functional domains. -Clinically important means a deviation that, without intervention, may result in complications or death. -Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent and ACOC. -The facility will promptly inform the resident, consult with the resident's attending physician and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to a significant change in the resident's physical cognitive, behavioral or functional status, a significant change in treatment and/or a decision to transfer or discharge the resident from the facility. -The licensed nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental or psychosocial status, e.g. deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications; a need to alter treatment significantly, a decision to transfer or discharge the resident from the facility. -The licensed nurse will assess the resident's change of condition and document the observations and symptoms. -The attending physician will be notified timely with a resident's change in condition. -Notification to the attending will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. -In emergency situations, (e.g., a resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray) the licensed nurse will immediately call the attending physician; notify the nursing supervisor of an emergency situation. -The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-maker of any changes in the resident's condition as soon as possible. -The licensed nurse will document the date, time and pertinent details of the incident and the subsequent assessment in the Nursing Notes. -The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, the response time, and whether or not orders were received. -The licensed nurse will update the care plan to reflect the resident's current status. -The licensed nurse will include the incident and brief details in the 24-Hour Report (a communication document between different shift charge licensed nurses regarding important resident condition and care needs). -If a resident is transferred to an acute care hospital the licensed nurse completes an inter-facility transfer form. -A licensed nurse will communicate any changes in required resident interventions to the IT members involved in the resident's care. -A licensed nurse will document each shift for at least 72 hours. -Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report. Record review of the facility Negative Pressure Wound Therapy (NPWT - also known as wound VAC - vacuum-assisted closure - an high level wound treatment for [REDACTED]. -Licensed nurses will initiate and maintain NPWT as ordered by the attending physician. -The physician's orders [REDACTED]. -Dressings should be changed every 48 to 72 hours per physician order, but should not be less than two times per week. -The NPWT dressing should be removed if negative pressure is off for a period exceeding two hours; replace with a traditional dressing. 1. Record review of Resident #316's Admission Record showed he/she: -Was admitted to the facility on [DATE]. -Had [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) region, and morbid (severe) obesity. Record review of the resident's Order Summary Report showed the following orders dated 2/11/20: -Admit to facility with a [DIAGNOSES REDACTED]. -Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine). -[MEDICATION NAME] (anticonvulsant medication also used for pain management) 300 milligrams (mg), give one tablet by mouth three times a day for neuropathic pain (a complex, chronic pain state that usually is accompanied by tissue injury). -[MEDICATION NAME] ([MEDICATION NAME] - an opioid, sometimes called narcotic medication for moderate to severe pain with [MEDICATION NAME]) 5-325 mg, give one tablet by mouth every four hours for pain, give while awake, hold for sedation. -Complete blood count (CBC - a blood test used to evaluate overall health and detect a wide range of disorders including [MEDICAL CONDITION] and infection) and a comprehensive metabolic panel (CMP - a group of blood tests that provide an overall picture of your body's chemical balance and metabolism, i.e. the chemical processes in the body that use energy). Record review of the residents Nursing Note date 2/11/20 at 4:14 A.M. showed: -The resident was admitted to the facility. -He/she had a Foley catheter. -He/she complained of pain. -No mention of the resident's dressing/NPWT or his/her left buttock pressure ulcer. -No assessment of the resident's level of alertness. --NOTE: The facility staff documented the resident stage IV pressure ulcer was on his/her sacral area on his/her admission record dated 2/10/20. Record review of the resident's Physician Admission Progress Note dated 2/11/20 at 2:36 P.M. showed: -He/she was new to the facility coming from another skilled nursing facility with a history of the following Diagnoses: [REDACTED]. coli) bacteria live in the intestines of people and animals, and are key to a healthy intestinal tract. Most E. coli strains are harmless, but some can cause diarrhea through contact with contaminated food or water while other strains can cause urinary tract infections, respiratory illness and pneumonia). --Stage IV pressure ulcer. --Paralysis (loss of the ability to move, and sometimes to feel anything, in part or most of the body, typically as a result of illness, or injury). --Gastrointestinal (GI) bleed (any type of bleeding that starts in the digestive tract) related to perianal fistula (an abnormal tunnel that begins in the anus and exits through the akin near the rectum). --Hypoxemia (abnormally low oxygen concentration in the blood. -The resident was awake and alert, and his/her cognitive status showed no dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -His/her stage IV pressure ulcer had a dressing and wound VAC. Record review of the resident's Progress Notes dated 2/11/20 through 2/15/20 showed: -No licensed nurse notes regarding the resident's wound VAC dressing. -No mention of the presence of or non-presence of his/her wound vac. -No notation regarding notification regarding the resident being sedated or having a decrease/change in his/her alertness/mental status. -No notation regarding a decrease in the resident's blood pressure. -No notation regarding a decrease in his/her oxygen saturation (blood oxygen level measured with a small device placed on a finger) . -No notation regarding the resident having repeated loose stools. -No notation regarding the resident's family being present at the facility, having concerns regarding the resident's condition and requesting the resident be transferred to hospital on [DATE]. -No notation of notification to facility management or to the resident's physician regarding a change in the resident's condition and the family requesting the resident be transferred to hospital on [DATE]. Record review of the resident's Medication Administration Record [REDACTED] -[MEDICATION NAME] 5/325 mg - give one tablet every four hours while awake for pain, hold for sedation. --Documentation showed staff administered one tablet on 2/15/20 at 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. Record review of the residents Nursing Note dated 2/15/20 at 11:13 P.M. showed: -The resident's family called 911 to take him/her to the hospital. -Emergency medical staff were at the facility at 9:30 P.M. and told the licensed nurse that a family member called 911 to send the resident to the hospital. -Emergency medical staff took the resident's blood pressure with a result of 107/43 (an abnormally low bottom/diastolic reading - normal range for a healthy adult at rest is 90/60 to 120/80), a low oxygen saturation of 88% (normal range is 90 to 100%). -He/she was responding to conversation and questions. -After the emergency medical staff took the resident's vital signs, they took him/her to the hospital. -The resident's physician and the Director of Nursing (DON) was notified. Record review of the resident's Situation, Background, Assessment, Recommendation Communication Recommendation (SBAR -a framework for communication between members of the health care team about a resident's condition) Form and progress note dated 2/15/20 at 10:00 P.M. showed: -The resident's family called 911 and the resident was taken to hospital. -He/she had prescribed pain medication and had taken medication prior to the family arrival. -The form was blank for things that make the condition or symptom worse, things that make the condition or symptom better, treatment, primary diagnosis, changes in the last week, if resident was on [MEDICATION NAME] (blood thinner) the results of the last international normalized ratio (INR - a laboratory measurement of how long it takes blood to form a clot used to determine the effects of oral anticoagulants on the body's clotting system). -His/her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were in normal range; his/her oxygen saturation level was 92% (low, normal range is 95 to 100%) and the form was blank regarding if the resident was receiving supplemental oxygen at the time of the oxygen saturation measurement and if so, the rate of administration (liters per minute). -The resident had mental status changes of decreased consciousness (sleepy, lethargic/sluggish). -The resident had respiratory symptoms of low oxygen saturations of 88%. -Recent lab results was blank. -Advanced care planning information was blank. -Assessment by Registered Nurse (RN) was that the resident's family called 911 and the resident was taken to the hospital; the resident had prescribed pain medications and had taken medication prior the family arrival. -Nursing Notes for additional information on the Change in Condition was blank. -The resident's Family/Health Care Agent was notified on 2/15/20 at 11:00 P.M. -The resident's change in condition was reported to the resident's Primary Care Clinician on 2/15/20 at 11:00 P.M. -The form was electronically signed by the Assistant Director of Nursing (ADON) on 2/17/20. Record review of the resident's hospital ICU Admission History and Physical (H&P) dated 2/16/20 showed: -He/she was admitted from his/her nursing home with altered mental status (AMS - a disruption in how your brain works that causes a change in behavior. This change can happen suddenly or over days; AMS ranges from slight confusion to total disorientation and increased sleepiness to coma) and buttock pain. -On arrival to the emergency room (ER) his/her only complaint was right buttock pain and he/she reported he/she had a chronic sacral wound. -He/she had a stage IV sacral ulcer, very large and deep and on examination, bone could be palpated (felt by placing a hand over the area and applying pressure). -EMS reported his/her blood pressure had been low during transport to the hospital, 80s over 50s. -On arrival to the ER, he/she reported he/she had not been clean after his/her bowel movement many hours ago and he/she had a chronic wound in that area. -Report from EMS was that the family noted a slight change from his/her normal mental status earlier in the day (2/15/20) at an undetermined time. -He/she was given two liters of fluids intravenously (IV - into a blood vein) with a good response of his/her blood pressure. -His/her wound VAC fell off two days ago per the RN report. -He/she was initially admitted to the hospital medicine team but his/her blood pressure dropped to 70s despite getting two liters of IV fluid in the ER. -She was started on [MEDICATION NAME] ([MEDICATION NAME] - a medication used to treat life-threatening low blood pressure that can occur with certain medical conditions or surgical procedures) temporarily via his/her peripheral IV line until ICU was consulted, placed a right intrajugluar vein (IJ) central line (insertion of a tube into the large vein on the right side of the neck that allows rapid high-volume fluid administration, administration of multiple medications, and hemodynamic monitoring that measures the blood pressure inside the veins, heart, and arteries, how much oxygen is in the blood, checks how well the heart is pumping; and is often used for reliable venous access in ill persons) and admitted him/her to the ICU. Record review of the resident's hospital History and Physical addendum dated 2/17/20 showed: -He/she was critically ill with imminent threat to his/her life. -His/her septic shock was being treated with broad spectrum (those able to treat a wide range of bacteria) antibiotics including [MEDICATION NAME] and Zozyn for urinary tract infection and pneumonia. -His/her urine culture was growing E. coli greater than 100,000. 2. During an interview on 2/15/20 at 8:11 A.M. RN B said: -During shift report for the 7:00 P.M shift change, the off going licensed nurse told him/her that the family wanted the resident to go to the hospital because the resident was sleeping. -He/she went to the resident's room around 7:14 P.M. -The resident said no when asked if he/she needed anything. -He/she went to the next hall and started doing his/her resident care. -Later he/she was told that 911 was in the facility, that the family had called for the resident to go to the hospital so he/she went to the resident's room and EMS told him/her the family had called 911. -EMS staff asked him/her what the resident's baseline was (the resident's usual condition, especially regarding mental alertness) and he/she said the resident could ask for what he/she needed and could use his/her call light. -If the resident had been in distress, he/she would have called the resident's doctor, but the resident was not in distress. -The family did not call him/her; they could have called the facility and asked for the nurse on duty. -The resident's oxygen saturation was 90% to 92%. -He/she could not turn the resident by himself/herself. -He/she first saw the resident at 7:15 P.M. -He/she had 12 residents needing Accuchecks (a blood sugar reading obtained by a small sample of blood from the finger) and residents also came to him/her for pain medications which had to be given on time. -He/she saw the resident at 8:00 P.M. and helped a Certified Nursing Assistant (CNA) to turn the resident in bed; he/she asked the resident if he/she was OK and the resident said yes. -He/she then went to do something else; he/she was always busy. -EMS arrived at the facility at about 9:00 P.M. -EMS checked the resident's vital signs and oxygen saturation and said they had to take him/her to the hospital. -He/she told EMS that he/she had to go print something. -He/she called the resident's family and the resident's Nurse Practitioner (NP), he/she thought this occurred prior the EMS taking the resident to the hospital. During an interview on 3/4/20 at 5:48 A.M. RN B said: -On 2/15/20 the resident's family called 911 to take him/her to the hospital. -EMS arrived at the facility at 9:30 P.M. -EMS told him/her a family member had called 911 to take the resident to the hospital. -EMS took his/her vital signs; his/her blood pressure was low, 107/43 and his/her oxygen saturation was low at 88%. -He/she was responding to commands and questions. -After EMS took the resident's vital signs, they took him/her to the hospital. -He/she notified the resident's physician and facility ADON A. During an interview on 3/4/20 at 6:22 A.M. RN B said: -When he/she came to work for the 7:00 P.M. to 7:30 A.M. shift on 2/15/20 the off going licensed nurse told him/her that the family wanted the resident to go to the hospital. -Later, the family called 911 from outside the facility to take the resident to the hospital. During an interview on 3/4/20 at 8:11 A.M. RN B said: -The family wanted the resident to go to the hospital because he/she was sleeping. -He/she went to the resident's room at around 7:15 P.M.; at that time the resident said he/she did not need anything. -He/she went to the next hall to complete blood sugar testing for residents; staff told her later that EMS was at the facility and that the resident's family had called for him/her to be taken to the hospital. -He/she went to the resident's room; EMS staff told him/her the resident's family had called for the resident to be taken to the hospital. -EMS staff asked what was the resident's baseline, he/she responded that the resident was able to ask for what he/she needed and was able to use his/her call light. -He/she would have called the resident's physician but the resident was not in distress so he/she did not call the resident's physician. -The resident's family never called him/her; the family could have called the facility and asked for the nurse on duty. -He/she told EMS that he/she needed to put a dressing on the resident's wound; EMS told him/her there was no need to put a dressing on the resident's wound. -He/she was told the resident needed a dressing on his/her stage IV pressure ulcer when he/she first came to work for his/her 7:00 P.M. shift. -He/she could not turn the resident by himself/herself. He/she thought the resident had a wound VAC. During an interview on 3/4/20 at 9:21 A.M. RN B said -During the 7:00 P.M. shift change report, the off going licensed nurse told him/her the resident needed a dressing on his/her stage IV pressure ulcer. -He/she told the off going licensed nurse that he/she would put a dressing on the resident's stage IV pressure ulcer. -The off going licensed nurse had not told him/her that the resident was supposed to go the hospital. -After the shift report, he/she completed blood glucose monitoring for 12 residents. -He/she first saw the resident at 7:14 P.M. -Residents came to his/her for pain medication; he/she had to give pain medications on time. -He/she was always busy. -EMS arrived at the facility at about 9:00 P.M.; -He/she then went to the resident's room. -EMS took the resident's vital signs and oxygen saturation, told him/her the numerical results and said they had to take the resident to the hospital. -After EMS took the resident to the hospital, he/she called the resident's Nurse Practitioner (NP). -He/she called the resident's family member who was the resident's DPOA, he/she thought this call was before EMS took the resident to the hospital. During an interview on 3/5/20 at 1:38 P.M. Licensed Practical Nurse (LPN) D said: -The resident had a stage IV pressure ulcer. -The resident's wound VAC was not on when he/she got to work. -He/she discovered at about 11:00 A.M. or maybe around noon that the resident's wound VAC was not on his/her stage IV pressure ulcer; at that time he/she was helping another staff person turn and clean the resident because he/she had had a lot of loose stools. -The resident continued to have loose stools throughout the rest of the 7:00 A.M. to 7:30 P.M. shift. -He/she put a dressing on the resident's stage IV pressure ulcer at about 12:30 P.M. when he/she finished completed blood sugar testing for diabetic residents. -At that time, there could have been an old dressing in the bed but he/she could not remember, but there was not a dressing on the resident's buttocks. -The resident was receiving [MEDICATION NAME] every four hours around the clock, he/she had been tolerating the [MEDICATION NAME] but within an hour of getting her first dose for the 7:00 A.M. shift, the resident seemed sedated. --NOTE: The first dose for the 7:00 A.M. shift was scheduled to be administered at 8:00 A.M. and was documented as administered by the facility staff at 8:00 A.M. on 2/15/20. -He/she remembered taking the resident's vital signs and checking the resident's pupils and skin color. -The resident's skin was moist. -He/she thought he/she had done a blood sugar test for the resident, just to make sure his/her blood sugar was alright. --NOTE: There was no documentation in the resident's medical record of vital signs or blood sugar checks at that time by the facility staff. -He/she thought the resident's blood pressure was OK when he/she took it. -The resident's breathing rate was normal, her pulse was in the low 100s and he/she did not have a fever. -It seemed to him/her that resident's oxygen saturation was initially low; he/she turned the resident's oxygen up a little bit and then the resident's oxygen saturation came up to normal, as he/she slowly became more alert over the next couple of hours while he/she started to wake up more. --NOTE: The resident did not have a valid physician's orders [REDACTED]. of the resident's need for supplemental oxygen. -He/she took the resident's vital signs several times, he/she left the equipment for taking the resident's vital signs in the resident's room. --NOTE: There was no documentation by the facility staff of these vital signs in the residents medical record. -He/she was first aware the resident was without a dressing on his/her stage IV pressure ulcer at around the lunch hour. -He/she put a dressing on the resident's stage IV pressure ulcer at around 12:45 P.M, sometime before 1:00 P.M. -The resident had a family member visitor and told him/her that they were concerned the resident had a decreased level of consciousness. -He/she told the visitor that the resident had been having loose stools and discussed with the resident's family that the resident's decreased level of consciousness could be from a buildup of the resident's narcotic medication that he/she was getting every four hours. --NOTE: There was no documentation in the resident's medical record by facility staff related to concerns of sedation due to scheduled [MEDICATION NAME] administration and no documentation staff notified the resident's physician related to concerns of sedation or decreased levels of consciousness related to scheduled [MEDICATION NAME] administration). --NOTE: Documentation showed staff administered [MEDICATION NAME] 5/325 mg at 8:00 A.M., 12:00 P.M. and 4:00 P.M. on 2/15/20. -The resident started becoming more alert at about 4:00 P.M. -The family member wanted the resident to be sent out to the hospital to be evaluated sometime between 5:00 P.M. to 6:00 P.M. -At about 5:00 P.M. or 6:00 P.M. there was flooding in the building, on the 300 Hall (the resident's room was on the 100 Hall). -He/she told ADON A that the resident's family member wanted the resident to be sent out to the hospital. -ADON A was going to go look at the resident and then the flood on the 300 hall happened. -He/she evacuated residents on the 300 hall out of their rooms and did not know if ADON A made it to the resident's room. -He/she told the resident's family member that he/she was not trying to ignore the resident; he/she thought the family member was going to be upset; it was like he/she had just disappeared, he/she was helping with the flood on the 300 hall. -The resident was more alert around that time and it seemed like the resident had come out of her prior state. -He/she became aware the resident did not have a dressing on just before the fire alarm went off because he/she was assisting in turning the resident as he/she had been incontinent of stool again; at that time he/she saw that the resident had bowel movement all over her old dressing and bowel movement was in the residents wound. -He/she made it back to the resident's room at 6:30 P.M., maybe; he/she had gone to the resident's room to check on him/her, the resident's family member had left. -At that time (6:30 P.M.) he/she knew the resident did not have a dressing on his/her stage IV pressure ulcer because his/her dressing came off earlier when he/she was turning the resident; that was at the time he/she put the dressing on the resident. -He/she was really busy and was behind on everything. -He/she remembered that he/she had told the oncoming 7:00 P.M. nurse that he/she had not called anyone yet about the family wanting the resident to be sent to the hospital because ADON A wanted to assess the situation. -ADON A had lost his/her stethoscope, he/she was going to go to the resident's room but then the flood happened. -He/she did think the resident had a wound VAC on because he/she did not need to change the resident's dressing on his/her stage IV pressure ulcer; he/she had looked at the wound VAC the previous day and it was operation correctly. -During the shift report he/she passed on that the resident did not have a dressing on his/her stage IV pressure ulcer. During an interview on 3/6/20 CNA L said: -The resident was not large. -He/she had in the past completed incontinence care for the resident. -He/she always took another staff person with him/her when he/she completed incontinence care with all residents. -The resident's level of alertness and ability to assist in turning in bed depended on the time of day; he/she routinely had to explain to the resident what was being done. -He/she was not aware of the resident ever having a change in condition or having loose stools. -The resident would get confused; he/she never appeared sedated. -The resident used oxygen, the resident had to put oxygen because he/she was short of breath. During an interview on 3/9/20 at 10:50 A.M., the ADON A said: -If a family member requested a resident be sent to the hospital, the licensed nurse was to assess the resident, based on the assessment notify the resident's physician, talk with the resident and the resident's responsible party (DPOA - the person named in a legal document to make health care decisions in the event the resident is unable) of the physician's recommendations and ability to treat the resident at the facility if able; if a the family and the resident still wanted for the resident to be sent to the hospital, the resident should be sent to the hospital by calling 911. -If a resident was showing signs of a change in condition licensed nurses were to assess the resident, notify the ADON or DON, notify the resident's physician, and follow the physician's orders [REDACTED]. -Licensed nurses should act or react to situations in a timely manner. -If an issue is identified, it should be addressed. -Licensed nurses should not wait to assess, treat, or notify the resident's physician of any issues brought to their attention. -The resident's family member who was in the facility who wanted the resident sent to the hospital was not the resident's DPOA. -He/she was in the facility at the time the family member was requesting the resident be sent to the hospital; he/she was on his/her way to assess the resident when an emergency happened and staff had to address the situation. -During the facility emergency the family member called 911. -The family member in the facility who wanted the resident sent to the hospital was not the DPOA. -The ADON was in the facility at the time the family member was requesting the resident be sent. -The ADON was on his/her way to assess the resident when an emergency happened and staff had to address the situation. -During the emergency is when the family member called 911. During an interview on 3/9/20 at 12:59 the DON said: -He/she had not been notified about the resident having a change of condition -He/she was not at the facility when the resident went out to the hospital. -He/she was told by the licensed charge nurse the resident was a little drowsy right before his/her family arrived at the facility. -The resident had received pain medication prior to his/her family member coming to the facility. -The residents oxygen saturations did drop below 90%, then when the licensed nurse talked with the resident, he/she was at baseline with cognition and his/her oxygen level went was back up. -He/she did not remember any reports of what the resident's blood pressure was from the licensed charge nurse. -If the family requested the resident to be sent to the hospital, the resident should be sent. -He/she expected the nurse to assess first and try some changes here, if possible. -He/she was unaware the family had expressed concerns earlier in the shift and had wanted the resident to go to the hospital. -The licensed nurse mentioned to the family that pain medication had been given. -A sprinkler head (a fire suppression device that provides a continuous overhead spray of water) had bust on the 300 hall early in the evening around 4-5 P.M. -The SBAR should be completed and filled out to the license nurse best ability, including all areas of the change of condition. -He/she would have expected the charge licensed nurse to pass on to the oncoming licensed nurse the information regarding the resident's change of condition. -The nurses should notify the ADON

Based on observation, interviews and record review, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being for one resident (Resident #1) who had a [DIAGNOSES REDACTED]. (narcotic pain medication) was available. The facility census was 146. Review of the facility's undated policy, titled Physicians' Orders, showed: - Medication orders will include the name of the medication, dosage, frequency, duration of the order, and the route and the condition/[DIAGNOSES REDACTED]. - The policy did not direct staff to follow physicians' orders. Review of the facility's undated policy, titled Medication Administration, showed: - Medications may be administered one hour before or after the scheduled medication administration time; - Medication administration will be documented on the medication administration record (MAR). Review of the facility policy, titled Medication Ordering and Receiving From Pharmacy, revised December 2009, showed: - Medications and related products are received from the pharmacy on a timely basis. Review of the facility policy, titled Receiving Controlled Substances, revised December 2009, showed: - Controlled substances are reordered when a five day supply remains to allow for transmittal of the required written prescription to the pharmacist. 1. Review of Resident #1's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/21/19, showed: - No cognitive impairment; - Independent with activities of daily living (ADLs); - Occasionally incontinent of bowel and bladder; - [DIAGNOSES REDACTED].>- Receives as needed (PRN) pain medication; - Hospice care. Review of the resident's care plan last updated on [DATE], showed: - The resident is on hospice for a [DIAGNOSES REDACTED].>- Administer pain medication as ordered. Review of the resident's physician order sheet (POS), dated December 2019, showed: - [MEDICATION NAME] concentrate (narcotic pain medication) solution, 100 milligrams (mg)/5 milliliter (ml) give one ml orally every two hours as needed for pain/air hunger (shortness of breath); - [ENTITY]t date 11/21/19: [MEDICATION NAME] (skin patch), [AGE] micrograms (mcg), change patch every [AGE] hours; discontinued on 12/15/19; - [ENTITY]t date 12/15/19: [MEDICATION NAME] (narcotic pain medication) extended release tablet 20 mg, give one tablet orally every twelve hours for moderate to severe pain; - [ENTITY]t date 12/15/19: [MEDICATION NAME] tablet 10 mg tablet, give one tablet orally every six hours as needed for moderate to severe pain; - [DIAGNOSES REDACTED]. Review of the resident's December 2019 electronic-MAR showed: - The [MEDICATION NAME] [AGE] mcg patch scheduled to be removed every three days at 7:25 P.M. and a new patch reapplied at 7:26 P.M.; - On 12/3/19, at 12:11 A.M.: staff documented they removed the [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] and reapplied a new patch at the same time, four hours and 46 minutes late; - On 12/6/19, at 8:36 P.M.: staff documented they removed the [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] and reapplied a new patch at 8:36 P.M.; - On 12/9/19, at 4:40 A.M.: staff documented they removed the [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] and reapplied a new patch at 4:46 A.M.; nine hours and 21 minutes late; - On 12/12/19, at 9:43 A.M.: staff documented the number two (2) which indicates drug refused; - On 12/12/19, at 9:47 A.M.: staff documented [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] was applied ten hours and eighteen minutes too early; - On 12/13/19, staff documented no entries to indicate they removed or reapplied the [MEDICATION NAME] [AGE] MCG [MEDICATION NAME]; - Staff failed to accurately document the removal and administration of the resident's [MEDICATION NAME] [AGE] mcg patch on 12/13/19; - On 12/15/19, [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] was discontinued. Review of the resident's Controlled Drug Record, dated 12/13/19 at 9:35 A.M., showed: - Licensed Practical Nurse (LPN) A signed out and subtracted one [MEDICATION NAME] [AGE] mcg [MEDICATION NAME], leaving four remaining patches. During an interview on 12/13/19 at 8:20 P.M. LPN A said: - Resident # 1's [MEDICATION NAME] was not available when it was due to be changed; - This morning, the pharmacy made a special trip to deliver the medication and he/she applied Resident #1's [MEDICATION NAME] [AGE] mcg [MEDICATION NAME] shortly after it was delivered, around 10:00 A.M.; - It is unclear why the resident's pain medication was not available. Observation and interview on 12/13/19 at 8:45 P.M., showed the resident lying in his/her bed and said the following: - He/she had [MEDICAL CONDITION] and pointed to his/her swollen abdomen which was rounded and protruded through his/her partially buttoned shirt; - He/she has had recent increases in the [MEDICATION NAME]es in an attempt to control his/her pain; - Staff are to change the [MEDICATION NAME] every three days and the last 12 hrs prior to the patch being changed the patch is less effective at controlling his/her pain; - Earlier today, he/she awoke and was in a lot of pain; he/she rated the pain a 9 to 10 on a pain scale; - Again, the resident pointed to his/her swollen abdomen and said it feels like a mule is on the inside kicking me; - The rest of his/her body ached all over; - There have been several instances when the facility did not have his/her [MEDICATION NAME] available; - He/she asked nursing staff yesterday why they did not change his/her [MEDICATION NAME] when it was scheduled to be changed and they informed him/her the facility did not have his/her [MEDICATION NAME] available; - Staff told him/her there had been an issue with the fax machine; - He/she felt this was preventable and wondered why a different fax machine was not used as he/she imagined with a facility this size there was likely an additional fax machine that could have been used; - He/she wondered if his/her [MEDICATION NAME] was available and changed every [AGE] hours consistently would his/her pain be better controlled; - Earlier this month, he/she had to wait until the hospice nurse arrived and the hospice nurse applied the [MEDICATION NAME] because facility staff did not change it when it was scheduled to be changed; - Frequently, he/she goes to the nurses' desk and will wait for his/her pain medication. Review of the resident's nurse's note dated 12/15/19, at 11:09 A.M., showed; - Nurse manager visited with the resident regarding pain management; - The resident stated he/she has been taking pain medication mainly in the morning and evening; - Feels the [MEDICATION NAME] only worked during the first week and is not as effective as it once was anymore; - New orders obtained. Observation and interview on [DATE] at 11:50 A.M., showed the resident sat on his/her bed and said the following: - A few days ago, his/her [MEDICATION NAME] was discontinued; - He/she just hopes that there will not be issues with the new medications being available. During a telephone interview on 12/13/19 at 3:45 P.M., LPN A said: - He/she did not know why Resident #1's MAR reads that the [MEDICATION NAME] [AGE] mcg patch was applied on 12/12/19, at 9:47 A.M., because he/she applied the patch on the morning of 12/13/19; - Resident #1 did not refuse his/her [MEDICATION NAME] [AGE] mcg patch on 12/12/19, and he/she did not know why the MAR indicates the resident refused his/her medication; - It is possible he/she accidentally charted the administration of the [MEDICATION NAME] [AGE] mcg on the wrong day. During an interview on [DATE], at 4:45 P.M., Family Member (FM) A said: - A few days ago, the facility did not have the resident's [MEDICATION NAME] available and now it has been discontinued; - He/she feels that if the resident's [MEDICATION NAME] was changed every [AGE] hours consistently the resident's pain would be better controlled. During an interview on [DATE] at 5:30 P.M., the Assistant Director of Nursing (ADON) said: - He recently reviewed Resident #1's MAR and identified several discrepancies with the administration times of the resident's [MEDICATION NAME]; - Staff have a one hour before or after the scheduled medication administration time to administer a resident's medication; - Physicians' orders should be followed; - On 12/12/19, at 7:25 P.M., the resident was scheduled to have the [MEDICATION NAME] removed and reapplied; - The [MEDICATION NAME] was not available on 12/12/19; - LPN A administered the patch on 12/13/19, at 9:47 A.M. shortly after it was delivered; - Staff incorrectly charted the administration of the resident's [MEDICATION NAME] [AGE] mcg patch on the MAR; - He reviewed the resident's nurses notes and found no documentation to show staff notified the resident's physician on 12/12/19; - Staff should have notified the physician to inform him/her that the resident's medication was not available and that they did not administer it as ordered. During an interview on [DATE] at 6:00 P.M., the Director of Nursing (DON) said: - Staff should follow physicians' orders; - Staff should reorder residents' controlled medications when a 3-5 day supply remains to ensure residents' medication was available. MO 317