Every finding on record at Carriage Square Rehab and Healthcare Center

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment when the facility staff failed to change gloves and perform hand hygiene between dirty and clean tasks when staff did not wipe all areas affected by urine while staff performed perineal hygiene incorrectly for one resident (Resident #1); when the facility failed to provide a barrier between the residents' catheter drainage bag (a tube inserted into the bladder to drain the urine to an external collection device) and the floor for one resident (Resident #2); when the facility staff failed to wear an isolation gown when transferring or providing cares to residents that required Enhanced Barrier Precautions (EBP-infection control measures used to prevent the spread of infection to those at increased risk) for two residents (Residents #3, #4). This affected four sampled residents. The facility census was 85.Review of the facility's Standard and Enhanced Precautions Policy, dated 04/01/24, showed:-Standard precautions apply to all residents regardless of suspected or confirmed presence of infectious diseases.-EBP refers to an infection control intervention that ensures gown and glove use during high contact resident care activities.-For residents that EBP is indicated, EBP should be worn when dressing, bathing, showering, providing hygiene, incontinence cares or toileting, device care or use: central line (a long, flexible tube inserted into a vein in the and advanced until it rests inside the heart), urinary catheter or during dressing changes or wound care. Review of the facility's Perineal Care Policy dated 10/24/22, showed that staff are to wash hands, provide privacy, put on gloves, provide perineal care by spreading the labia and cleaning the urethra, using care to wipe from front to back and away from vaginal opening or wash the penis from urethral opening at tip to base; wash and dry buttocks without contaminating perineal area, place dry linens or brief, remove gloves and wash hands or use Alcohol Based Hand Rub (ABHR), put on new gloves, gather dirty supplies and place in proper container, remove gloves and wash hands. 1.Review of Resident #1's Significant Change Minimum Data Set (MDS- a federally mandated assessment completed by facility staff) dated 05/15/26, showed:-Severe cognitive impairment;-Resident dependent on nursing staff for all transfers, toileting, hygiene and grooming;-Diagnoses included stroke, high blood pressure and Non-Alzheimer's dementia. Review of the resident's care plan dated 06/04/26, showed:-He/She required assistance from nursing staff for dressing, grooming, toileting and hygiene;-He/She was at risk for skin breakdown related to urinary and bowel incontinence;-He/She required assist of staff for bed mobility (repositioning and turning when in bed). Observation of the resident on 06/04/26 at 11:21A.M., showed:-Certified Nurses Assistant (CNA) #1 and Assistant Director Of Nursing (ADON) transferred the resident into bed using a mechanical lift, while the resident was suspended in the lift sling, his/her pants were saturated with urine and the protective pad in wheelchair was wet with urine;-CNA #1 pulled the residents wet pants down around resident's calves when lying in bed;-CNA #1wiped both sides of the groin down and tucked wipes into the incontinent brief;-CNA #1 wiped the perineal area without separating the labia and cleaning the vaginal opening/cleaning the urethral opening, and tucked wipe in between resident's legs;-ADON rolled resident to the right, CNA #1 removed gloves and put on new without performing hand hygiene;-CNA #1 wiped resident's left buttock from the bottom of his/her back towards urethral opening and tucked wipe in between legs;-CNA #1 removed soiled brief, placed in trash and placed a clean brief underneath the resident;-Resident was rolled to the left, staff repositioned the clean brief and did not wipe the right buttock;-Resident was assisted onto his/her back, CNA #1 removed the wet pants from resident's legs and placed directly on resident's bed;-CNA #1 reached into his/her pocket, obtained a roll of trash bags, opened a bag and placed soiled pants inside the trash bag;-ADON removed gloves, applied new gloves and put pants on the resident;-ADON and CNA #1 used mechanical lift to transfer resident into wheelchair, CNA #1 removed gloves, did not perform hand hygiene, took mechanical lift from room, came back to retrieve resident and pushed him/her to dining room. 2.Review of Resident #2's Comprehensive MDS, dated [DATE], showed:-Mild cognitive impairment;-Resident had an indwelling catheter related to neurogenic bladder;-He/She required extensive assist with toileting, grooming and hygiene tasks;-Diagnoses included heart disease, high blood pressure, and arthritis. Review of the resident's care plan dated 06/04/26, showed:-He/She required assistance from staff for dressing and transfers;-He/She was dependent on staff to care for urinary catheter;-He/She required EBP for indwelling catheter and wounds. Observation on 06/04/26 at 10:23A.M., showed resident in room, with catheter drainage collection bag, hanging from wheelchair and resting on the floor. There was no signage posted or indication that the resident required EBP when providing cares. Observation on 06/04/26 at 1:43P.M., showed resident in room, with catheter drainage collection bag, hanging from wheelchair and resting directly on the floor. 3.Review of Resident #3's Significant Change MDS, dated [DATE], showed:-Mild cognitive impairment;-Incontinent of bowel and bladder;-Dependent on staff for all transfers, hygiene, eating and bed mobility;-He/She had a Stage II Pressure Injury (open wound, it can look like a scrape, blister, or a shallow crater in the skin; at this stage, some skin may be damaged beyond repair or may die);-Diagnoses included Parkinsons, Non-Alzheimer's dementia and malnutrition. Review of the resident's care plan dated 06/04/26, showed:-He/She able to transfer self to toilet or bed from wheelchair;-He/She needed assist with toileting hygiene;-He/She had a pressure ulcer to the buttocks and right hip;-No interventions or changes implemented specific to the listed ulcers. Observation on 06/04/26 at 1:45P.M., showed signage on resident's door that EBP was indicated for use when caring for resident. Observation on 06/04/26 at 1:49P.M., showed CNA #2 and ADON transferred the resident from wheelchair to bed using a mechanical lift, provided incontinence care utilizing proper technique, ensured resident had all needs met, and then exited room; staff wore protective gloves during cares, did not have on protective isolation gowns. 4.Review of Resident #4's Comprehensive MDS dated [DATE], showed:-No cognitive impairment;-Independent with transfers and mobility;-He/She has a central line for continued IV antibiotics;-Diagnoses included osteomyelitis, high blood pressure and chronic kidney disease. Review of the resident's care plan dated 06/04/26, showed:-He/She was at risk for falls related to gait instability;-He/She was incontinent of bowel;-He/She had chronic wounds to foot and ankle;-No interventions, goals or orders related to long-term antibiotic use, chronic wounds, EBP or central line use and care. Observation on 06/04/26 at 10:00A.M., showed no signage or indication that resident required additional precautions such as EBP. Observation on 06/04/26 at 3:03P.M., showed RN A entered the room to change dressing to central line without applying protective gown. RN A exited and entered resident room several times during observation, and he/she did not apply a gown for any cares provided to resident. During an interview on 06/04/26 at 5:05P.M., CNA #1 said:-EBP is used for any resident with skin breakdown;-EBP means that staff are to thoroughly clean the resident and apply creams and dressings;-A gown is not needed for a transfer of a resident that requires EBP;-When providing care, staff should change gloves and wash hands between dirty and clean tasks;-Wipe away from the urethral opening, either male or female;-Wipe all areas urine had touched;-Urinary collection bag should hang below the bladder and never touch the floor. During an interview on 06/04/26 at 4:43P.M., RN A said:-EBP includes isolation gowns and gloves to prevent infection for residents with a draining wound or tubing of any sort, such as a urinary catheter, central line or colostomy;-A gown is required for transfer of a resident with EBP;-Staff should change gloves and perform hand hygiene between dirty and clean tasks when providing cares to residents;-Staff should dispose of each wipe in the trash after use, not tuck in between resident's legs or in brief;-Wipe away from the urethral opening, either male or female;-Wipe all areas urine had touched;-Urinary catheter tubing should have a dependent loop, no kinks and collection device kept off of the floor. During an interview in 06/04/26 at 4:55P.M., the ADON and Infection Preventionist (IP) said:-EBP is required for residents with wounds, catheters and central lines;-EBP means staff are to wear a gown and gloves with high contact activities;-Residents that require EBP have signage on their doors indicating use of EBP;-EBP and guidance should be in each resident's care plan;-Gloves are kept in each resident room and gowns are kept at a centralized location, such as the nurses station;-No gown is required for transfer or incontinence care of an EBP resident, only if manipulating or caring for the device (catheter, central line, wound);-Protective gowns are to be worn during central line dressing changes;-IP provided EBP education at the all staff in-service in May 2026;-Urinary catheter collection bag should not touch the floor, tubing should be kept off the ground and not form a dependent loop as that can cause urinary reflux and increase chance of infection to resident;-Gloves should be removed, hand hygiene performed and new gloves applied when changing from dirty to clean tasks when providing cares to residents;-Hand hygiene could be washing with soap and water or use of Alcohol Based Hand Rub (ABHR). During an interview on 06/04/26 at 5:17P.M., the Director of Nursing said:-EBP residents have signage on their room doors and supplies are kept within line of sight;-Staff are not required to wear a gown when transferring residents, only with care of device that triggered EBP use (emptying catheter, wound care);-Gloves should be removed, hand hygiene performed and new gloves applied when changing from dirty to clean tasks when providing cares to residents;-Wipes should be disposed of after use, not tucked in between resident's legs or inside brief;-Wipe away from the urethral opening, either male or female;-Wipe all areas urine had touched;-Urinary catheter tubing and collection device should never touch the floor. Intakes 3031338 and 3031624

Based on observation, interview and record review, the facility failed to provide services that met professional standards of quality when the facility staff failed to follow physician orders to be notified of high blood glucose levels (Resident #5), when the facility staff failed to prime the needle of an insulin pen prior to administration (Resident #6) and additionally when the facility staff failed to ensure they had all required supplies for central line (a long, flexible tube inserted in a vein and into the heart) dressing change prior to initiation of dressing change (Resident #4). This affected three residents. The facility census was 85.Review of the facility policy titled Care and Services dated 10/24/22, showed the facility will have sufficient staff to provide services to residents with the appropriate competencies and skill sets to provide nursing services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being and that the licensed nurses are to document and notify physicians and responsible parties of changes in condition, refusal of cares or services and unusual circumstances. Review of the facility policy titled Diabetic Care dated 10/24/22, showed:-Blood glucose levels will be monitored at specific intervals as ordered by the physician;-When a resident's blood glucose is greater than 400, the physician must be notified;-Facility staff are to document in the resident's medical record: any symptoms, interventions, response to treatment and physician notification. Review of the facility policy titled Subcutaneous Injection/Insulin or Heparin dated 10/24/22 showed no information, guidance, regulations, policy or procedures for insulin pens (portable devices used to inject insulin). Review of the facility policy titled Dressing Change for Vascular Access Devices dated 08/21, showed-Dressing changes are completed to prevent local and system infection related to the Intravenous (IV) catheter;-Supplies needed: Central Line Dressing Change Kit, Engineered stabilization device (Stat-Lock), clean gloves, sterile gloves;-Staff are to wash hands, put on clean gloves, remove the old dressing including impregnated gauze sponge (BioPatch) and stabilization device;-Apply sterile gloves, clean area larger than dressing to be applied, apply BioPatch and sterile tape or stabilization device if applicable;-Apply transparent dressing, remove gloves, perform hand hygiene and document dressing change and resident response to procedure in medical record. Review of Resident #5's Significant Change Minimum Data Set (MDS-a federally mandated assessment completed by facility staff), dated 06/02/26, showed:-No cognitive impairment;-He/She was dependent on staff for toileting, transfers, hygiene, mobility and transfers;-Incontinent of bowel and bladder;-Received insulin injections daily;-Diagnoses included heart failure, chronic kidney disease and Diabetes. Review of the resident's care plan dated 06/04/26, showed:-He/She required assistance from staff for all grooming and personal cares;-He/She required oral medications and insulin injections to manage Diabetes;-Staff are to provide and document continued Diabetes education. Review of the residents' Electronic Medical Record (EMR) dated 05/23/26-06/04/26 showed:-Physician order dated 05/23/26 that provider to be notified each time Bedside Blood Glucose (BSBG) was greater than 400;-BSBG greater than 400 on the following dates and times: 05/24/26 at 1:00P.M., 05/25/26 at 8:13P.M., 05/26/26 at 4:17P.M., 05/27/26 at 8:35P.M., 05/28/26 at 9:09A.M. and 12:35P.M., 05/29/26 at 8:30A.M., and 8:23P.M., 05/30/26 at 7:57A.M., and 4:39P.M., 05/31/26 AT 7:27A.M. and 12:11P.M., 06/01/26 at 1:04P.M. and 5:43P.M., 06/02/26 at 9:01A.M., 12:21P.M., and 5:59P.M., 06/03/26 at 7:40A.M. and 11:10A.M.-05/26/26 nurse's note that a call was placed to the Nurse Practitioner (NP) and NP was notified of elevated BSBG;-05/28/26 two additional comments on insulin administration records that provider had been notified of elevated BSBG;-05/29/26 nurse's note that the facility's nurse practitioner was in house and increased insulin dosages;-06/02/26 nurse's note that an order was received to increase insulin dosage;-06/03/26 nurse's note that there were new insulin orders and oral anti-diabetic medications added. Review of Resident #5's Comprehensive MDS dated [DATE] showed:-No cognitive impairment;-Assistance needed from staff for toileting and hygiene tasks;-Diagnoses included heart failure, kidney disease and Diabetes. Review of the resident's care plan dated 06/04/26, showed:-He/She required assistance with bathing, hygiene and transfers;-He/She required oral medications and insulin injections to manage Diabetes;-He/She had an alteration in neurological status related to seizure disorder. Observation on 06/04/26 at 11:40A.M., showed RN A preparing insulin for administration:-RN A assessed BSBG, reviewed physician order to confirm dosage;-RN A opened insulin pen, wiped rubber seal with an alcohol pad and then applied disposable insulin needle;-RN A did not prime the insulin needle;-RN A turned dial on insulin pen to dosage for administration, RN A administered insulin, disposed of needle in sharps container, exited room and documented insulin administration. Review of Resident #4's Comprehensive MDS dated [DATE], showed:-No cognitive impairment;-He/She had a central line for long-term antibiotic use;-Diagnoses included osteomyelitis, high blood pressure and chronic kidney disease. Review of the resident's care plan dated 06/04/26, showed:-He/She was at risk for falls related to gait instability;-He/She had chronic wounds to foot and ankle;-No interventions, goals or orders related to long-term antibiotic use, chronic wounds or central line use and care. Observation on 06/04/26 at 3:03P.M., showed:-RN A entered and exited room several times prior to start of central line dressing change to obtain supplies;-RN A removed old dressing and asked surveyor to ask nurse in hall to obtain additional supplies;-RN A exited resident's room, with central line insertion site open to air, to obtain additional supplies;-Licensed Practical Nurse A (LPN) came into resident's room without wearing a protective gown, gloves or mask;-Resident's central line insertion site was exposed/without a covering or dressing for greater than ten minutes. During an interview on 06/04/26 at 4:04P.M., RN A said that the facility's nursing leadership was unable to find additional supplies (Stat Lock), so a piece of sterile tape was utilized to stabilize the central line before a transparent dressing was placed and additionally, that the facility's pharmacy was notified and supplies had been ordered. During an interview on 06/04/26 at 4:43P.M., RN A said:-There is no need to prime an insulin needle prior to use;-Each time a resident has a BSBG greater than 400, the provider should be notified;-The nurse should document in resident's medical record each time the provider was notified;-He/She should have read the central line dressing change kit inventory more thoroughly as the items that he/she thought were missing needed to be obtained individually as those items were not included in the pharmacy provided kit. During an interview on 06/04/26 at 5:17P.M., the Director of Nursing (DON) said:-Staff are to prime insulin needles with two units and then expel insulin prior to each insulin administration to ensure patency of needle;-Each time a resident has a BSBG greater than 400, a physician or their representative should be notified;-Each time the provider is notified of elevated BSBG, the nurse should document that in a nurse's note whom he/she spoke with and the provider response. Intakes 3031338 and 3031624

Based on interview and record review the facility failed to provide timely access to resident electronic medical records (EMR), staff list, and resident matrix (a document listing all resident's and their clinical characteristics) from 1/27/2026 at 9:50 A.M. through 1/27/2026 at 12:00 P.M. This resulted in the surveyors being unable to timely review necessary records to conduct the survey and review of care provided to residents. The facility census was 98. No policy regarding providing access to medical records in a timely manner was provided by the facility.During an Interview on 1/27/26 at 9:50 A.M. the Administrator and Director of Nursing (DON) were provided with a list of items needed that included a resident matrix (a comprehensive, mandated document used by nursing homes to list all current residents and track key clinical care categories including resident room numbers. The document defines patient care categories for residents, aiding in the selection of a sample, for surveys.) and access to EMR so the surveyors could conduct the abbreviated survey process.During an Interview on 1/27/26 at 11:19 A.M. the Administrator provided the surveyors with a list of staff and said he would provide surveyors access to the electronic medical records, resident roster, and resident matrix when he received authorization from his regional team members to provide surveyors with that information.Observation on 1/27/26 at 12:42 P.M. showed surveyors were provided EMR access and a resident matrix. During an Interview on 1/27/26 at 5:12 P.M. the Administrator said the protocol of the company is that documentation is reviewed by regional corporate team members before information is provided to surveyors.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure enhanced barrier precautions (EBP) and infection control measures were used during high-contact care for residents with wounds ( Resident #3 and 4) and indwelling devices Resident #1 and 3), were being utilized for three (Resident's #1, 3, and 4) of four sampled residents. The facility census was 89. Review of the facility policy titled, Standard and Enhanced Precautions, dated 7/1/23, showed: -Enhanced precautions will be used for residents with indwelling urinary catheters and for residents with wounds or presence of unhealed pressure ulcer;- The facility staff were supposed to perform hand hygiene when providing cares;- The staff were supposed to wear a gown when providing resident cares that were likely to generate a splay or splash of bodily fluids. 1. Review of Resident #3's Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility staff), showed:-The resident had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment;- Diagnoses included: Cellulites (inflammation of the skin) of the left and right leg, chronic venous insufficiency (the blood does not pump through the veins properly), weakness, and need for assistance with personal cares, and wounds to both legs. Review of the resident's Enhanced Barrier Precaution (EBP) care plan dated 7/21/25 showed:- The resident was on EPB precautions;- The staff were supposed to wear personal protective equipment (PPE) when performing high contact resident care. Review of the resident's physician order sheet (POS) dated December 2025 showed:- 11/11/25 Resident is on catheter (tube that enters the body to drain urine outside of the body) and wounds;- 12/2/25 Clean right lower leg ulcers (wounds) with hydrochlorus acid (wound cleaning solution), Allow hydrochorus soaked gauze to sit on the wounds for three minutes, then wipe out in a circular motion. Apply adaptic screen (wound dressing) over the wounds, Cover the screen with Aquacel Alginate (wound covering) cut to the size of the wound, secure with an abdominal pad and roll gauze. Change the dressing every shift and as needed;- 12/2/25 Clean left lower leg ulcers (wounds) with hydrochlorus acid (wound cleaning solution), Allow hydrochorus soaked gauze to sit on the wounds for three minutes, then wipe out in a circular motion. Apply adaptic screen (wound dressing) over the wounds, Cover the screen with Aquacel Alginate (wound covering) cut to the size of the wound, secure with an abdominal pad and roll gauze. Change the dressing every shift and as needed. During an interview on 12/23/25 at 9:25 A.M. the resident said:- He/She had issues with staff completing his/her wound care;- The staff don't always wash their hands or wear gowns when they complete his/her wound care;- He/She just returned to the facility from the hospital after being treated for wound infections. Review of the resident's hospital records dated 10/23/25 showed:- The resident was admitted to the hospital on [DATE] with wound infections of both legs;- The resident was discharged back to the facility on [DATE]. Review of the resident's hospital records dated 11/21/25 showed:- The resident was admitted to the hospital on [DATE] with cellulitis of both legs and infection of the legs wounds of both legs;- The resident was discharged back to the facility on [DATE]. Observation on 12/23/25 at 10:34 A.M. showed:- Registered Nurse (RN) A entered the resident's room, did not perform hand hygiene and did not put on a protective gown;- RN A put on a pair of gloves;- RN A pulled back the resident's blanket;- Both of the resident's lower legs were wrapped in roll gauze that was dirty with a red/ brown substance;- RN A began removing the old dressing from the resident's right leg;- RN A touch his/her face, nose and glasses with his/her contaminated gloved hands and continued to remove the dressing from the resident's right leg;- RN A removed the resident's dressing to his/her right leg and threw the dressings in the trash can;- RN A then picked up the trash bag from the can with his/her gloved hand and set the bag on the foot of the bed;- RN A did not change his/her gloves or perform hand hygiene;- RN A removed his/her gloves and left the resident's room at 10:47 A.M., RN A returned to the resident's room at 10:50 A.M. with additional wound supplies;- RN A put on clean gloves, did not perform hand hygiene, picked up the trash bag with his/her gloved hand from the foot of the bed and set the bag on the floor;- RN A placed a new wound dressing to the resident's right leg with his/her contaminated gloves;- RN A removed his/her gloves at 10:56 A.M. and left the residents room again and returned a few minutes later with Licensed Practical NUrse (LPN) A;- Neither RN A or LPN A performed hand hygiene or put on a protective gown;- LPN A put on gloves and lifted the resident's right leg;- RN A placed clean dressing to the back of the resident's right leg;- RN A touch his/her nose with his/her gloved hand and then placed a new dressing to the resident's wounds;'- RN A removed his/her gloves went to the sink and washed his/her hands with perineal wash (wash intended to be used for personal care), and put on clean gloves;- RN A removed the dressing from the resident's left leg and threw the old dressings to the floor;- The dressings made a splat sound when they hit the floor;- RN A did not change his/her gloves after removing the old dressing and began applying a clean dressing to the front of the resident's left leg;- LPN A lifted the resident's left leg and RN A cleaned the back of the leg and threw the used cleaning supplies to the floor;- RN A wiped his/her nose on the back of his her gloved hand, clear drainage could be seen on the back of RN A's glove;- RN A did not change his/her gloves or perform hand hygiene;- RN A continued to apply clean dressing to the resident's left leg;- LPN A removed his/her gloves, did not perform hand hygiene, and left the resident's room;- RN A completed the dressing change, removed his/her gloves and left the room. During an interview on 12/23/25 at 1:34 P.M. RN A said:- He/She should have worn a gown when he/she provided wound care for the resident;- He/She should have washed his/her hands with each glove change;- He/She should not have touched the trash bag with his/her gloved hands;- He/She should not have thrown used wound dressings on the floor;- He/She should have changed his/her gloves and washed his/her hands after touching his/her face and wiping his/her nose. During an interview on 12/23/25 at 1:15 P.M. the Director of Nursing (DON) said:- She expected all staff that participate in the resident's wound care to wear a protective gown and gloves;- She expected the staff to wash their hands with each glove change;- She expected the staff to change their gloves between taking an old wound dressing off and placing a new dressing on;- She expected staff to remove their gloves, perform hand hygiene and place new gloves on when staff touch their face, wipe their nose on their gloves, and touch the trash can;- She expected staff to throw old wound dressing in the proper receptacle, not on the floor. 2. Review of Resident #4's face sheet dated December 2025 showed diagnoses included a Pressure Ulcer (wound) to his/her left heel and reduced mobility. Review of the residents EBP care plan dated 3/11/25 showed:- The resident was on EBP precautions for a wound;- The staff were supposed to wear PPE when performing high contact resident care. Review of the resident's POS dated December 2025 showed the following:- 2/20/25 EBP precautions;- 11/11/25 Cleanse the left heel with normal saline (wound cleanser), blot dry. Apply skin prep (a skin protectant) around the wound edges, apply calcium alginate to the wound bed, and cover with a foam dressing. Change every Tuesday on day shift. Observation on 12/23/25 at 2:30 P.M. showed:- Infection Preventionist (IP) entered the residents room with the dressing change supplies on a plastic tray;- The resident was in his/her wheel chair wearing socks and no shoes on both feet, facing the bed;- The IP placed the tray on the resident's bed;- The IP put on clean gloves;- The IP squatted in front of the resident, picked the resident's left foot up and removed the resident's sock;- The IP placed the dirty sock on top of the clean dressings on the plastic tray;- The IP removed the old dressing from the resident's heel, removed his/her gloves, applied hand sanitizer and put on a clean pair of gloves;- The IP cleaned the wound on the residents heel, removed his her gloves, performed hand hygiene and put on clean gloves;- The IP moved the dirty sock from on top of the clean dressings with his/her gloved hand and placed the sock on the end of the bed;- The IP did not change his/her gloves and continued with the dressing change. During an interview on 12/23/25 at 3:00 P.M. The IP said:- He/She should not have laid a dirty sock on the clean wound dressing supplies;- He/She should have gotten clean supplies once he/she contaminated them with the dirty sock;- He/She should have removed his/her gloves, performed hand hygiene and put on clean gloves when he/she touched the dirty sock;- He/She should not have continued changing the residents dressing once she touched the dirty sock. During a follow up interview on 12/23/25 at 3:15 P.M. The DON said:- She would have expected staff to retrieve new dressing supplies when the current supplies were contaminated with a dirty sock;- She would have expected staff to change their gloves and perform hand hygiene when they touched a dirty sock and before they touched the resident wound; 3. Review of the facilities Catheter-Care of policy, dated 10/24/22, showed: -Purpose: to prevent catheter associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary; -Cleanse the outside of the catheter wiping away from the meatus; -Take care to ensure the collection bag does not touch the floor at any time. 4. Review of Resident #1's care plan, revised 09/19/25, showed: -The resident was dependent on nursing staff for catheter care and personal hygiene and grooming needs; -The resident was incontinent of bowels; -The resident had a suprapubic catheter (a tube placed directly in the bladder through a small incision in the abdomen used to drain urine); -The resident was on EBP precautions for urinary catheter. Observation on 12/23/25 at 10:25 A.M. showed: -The resident's urinary catheter bag was touching the floor underneath his/her wheelchair while the resident sat in the hallway; -Licensed Practical Nurse (LPN) A brought the resident to the nurses station in his/her wheelchair, LPN A did not secure the resident's urinary catheter bag off of the floor during this encounter. Observation on 12/23/25 at 12:21 P.M. showed: -Certified Nursing Assistant (CNA) A performed urinary catheter care to resident's suprapubic catheter; -CNA A used hand sanitizer, and applied gloves, CNA A did not wear an isolation gown during catheter care; -CNA A then picked up the trash can in the resident's room wearing the same gloves initially applied when beginning catheter care; -CNA A cleansed the resident's catheter tubing in a back and forth motion using the same soiled wipe while wearing the same gloves used to pick up and move the trashcan. 5. Review of Resident #3's care plan, revised 10/8/25, showed: -The resident was incontinent of bowels; -The resident had an indwelling urinary catheter (a tube inserted through the urethra into the bladder to drain urine); -The resident was on EBP precautions for the urinary catheter; - The resident was dependent on nursing staff to maintain and provide urinary catheter care and personal hygiene needs. Observation on 12/23/25 at 12:04 P.M. showed: -CNA A performed urinary catheter care for the resident; -CNA A used hand sanitizer and applied clean gloves, CNA A did not apply an isolation gown; -CNA A picked up the trashcan in the resident's room and moved it closer to the bed; -CNA A scrubbed the tubing of the catheter in a back and forth motion using the same gloves used to pick up the trashcan. 6. During an Interview on 12/23/25 at 12:35 P.M. CNA A said: - Urinary catheter bags and tubing should not be touching the floor; -He/She should have changed gloves after picking up and moving the trashcan before providing catheter care; -He/She should have worn an isolation gown along with gloves when performing catheter care. During an Interview on 12/23/25 at 1:14 P.M. LPN A said: -An isolation gown and clean gloves should be worn when performing catheter care; -The catheter bag and tubing should not be touching the floor. During an Interview on 12/23/25 at 1:20 P.M. CNA B said: -An isolation gown and clean gloves should be worn when doing catheter care; -Catheter tubing and catheter bags should not touch the floor. During an Interview on 12/23/25 at 2:00 P.M The Director of Nursing (DON) said: -An isolation gown and clean gloves should be worn when performing catheter care; &nb

Based on observation, interview, and record review the facility failed to ensure that two resident's (Resident # 1 and #3) who had urinary catheter (a tube inserted into the bladder to drain urine from the body), received appropriate treatment and services to prevent urinary tract infections when the facility failed to provide proper catheter care management. This deficient practice affected two of the four sampled resident's. The facility census was 89. Review of the facility polity titled, Catheter-Care, dated 10/24/22, showed: -Purpose: to prevent catheter associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary; -Cleanse the outside of the catheter wiping away from the meatus; -Take care to ensure the collection bag does not touch the floor at any time. 1.Review of Resident #1's care plan, revised 9/19/25,showed: -The resident had limited physical mobility related to weakness; - The resident was incontinent of bowels; -The resident had a suprapubic catheter (a tube placed directly in the bladder through a small incision in the abdomen used to drain urine); -The resident was dependent on nursing staff to manage and care for the suprapubic catheter.Review of The Resident's After Visit Summary from the Emergency Department, dated 10/25/25, showed: -The resident had been seen for urinary retention; -The resident had a diagnosis of a urinary tract infection associated with indwelling suprapubic catheter; -The resident was prescribed Cefpodoxime (an oral antibiotic medication used to treat the urinary tract infection); -A new catheter was inserted while at the Emergency Department.Observation on 12/23/25 at 10:25 A.M. showed: -The resident's catheter bag (a bag that holds the collected urine) was touching the floor underneath his/her wheelchair while the resident sat in the hallway, rather than up off the floor in a collection dignity bag cover; -Licensed Practical Nurse (LPN) A pushed the resident to the nurses station in his/her wheelchair to put topical medication on the resident's knees, LPN A did not secure the resident's catheter bag off of the floor during this encounter.Observation on 12/23/25 at 12:21 P.M. showed: -Certified Nursing Assistant (CNA) A performed catheter care to the resident' suprapubic catheter; -CNA A cleansed the resident's catheter tubing in a back and forth motion using the same soiled wipe and with the same gloves used to pick up and move the trashcan.2. Review of Resident #3's care plan, revised dated 10/08/25, showed: -The resident was incontinent of bowels; -The resident had an indwelling urinary catheter (a tube inserted through the urethra into the bladder to drain urine); -The resident was dependent on nursing staff to care for the resident's catheter and incontinence needs.Observation on 12/23/25 at 12:04 P.M. showed: -CNA A performed catheter care on the resident's urinary catheter; -CNA A scrubbed the tubing of the catheter in a back and forth motion using. During an Interview on 12/23/25 at 12:35 P.M. CNA A said: -There is usually a rubber band that holds Resident #1's catheter bag and tubing off of the ground, the rubber band keeps falling off and then his/her bag and tubing touches the ground; -He/She did not know that a wipe was only to be used for one swipe when performing catheter care. -Catheter bags and tubing should not be laying on the floor.During an Interview on 12/23/25 at 1:14 P.M. LPN A said: -An isolation gown and clean gloves should be worn when performing catheter care; -When cleaning catheter tubing one wipe should be used to clean down the tubing wiping away from the resident, then a new wipe should be used each time cleaning down the tubing; -It was hard to keep resident's catheter bag and tubing off of the floor; -Catheter bags and catheter tubing should not touch the floor. During an Interview on 12/23/25 at 1:20 P.M. CNA B said: -An isolation gown and clean gloves should be worn when doing catheter care; -When performing catheter care wipe down the catheter tubing away from the insertion site using a new wipe each time; - Catheter tubing and catheter bags should not touch the floor.During an Interview on 12/23/25 at 2:00 P.M The Director of Nursing (DON) said: -When performing catheter care wipe down the tubing cleaning away from the body using a new wipe each time; -Staff should wash hands and change gloves after touching other items before performing catheter care. -Catheter bags and tubing should not touch the floor.Intake 2690286

Based on interview and record review the facility failed to follow their policy for medical record requests when staff reported they printed and gave copies of electronic medical records without a formal written record request. The facility also failed to provide requested medical records in a timely manner for one previous resident (Resident #1). The facility census was 130.Review of the facility provided policy titled,Resident Access to PHI or Financial Records, dated October 24,2022 showed:-The facility recognizes the resident's right to have access to his/her Protected Health Information (PHI); -All requests for access must be in writing; -All requests by a resident or a resident's personal representative for access to PHI must be directed to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Officer;-A resident who requests access to his/her records shall be given a copy of HP-08-Form A-Resident Request for Access to Protected Health Information or Financial Records. The facility may accept a written request submitted in another form;-If the resident and/or their personal representative requests a copy of the resident's medical record, the HIPAA privacy officer will provide the resident and/or their personal representative with a copy of the medical record within the state specified time period. During an interview on 11/12/25 Resident Representative A said:-He/She requested medical record information by mail August 14, 2025 included a written request;-He/She faxed a medial record request for Resident #1 on 9/17/2025; -He/She called the facility on 9/25/25 and did not connect with anyone;-He/She called the facility on 10/8/25 and spoke with Medical Records Director who said the request had been received and records were being gathered; -He/She called the facility on 10/23/25, requested the status of Resident #1's records; -Medical Record Director said he/she would check on the status of the records; -On 10/27/25 the Medical Records Director said he/she would have the records by the end of the week; -He/She called the facility the morning of 11/10/25; -The Medical Record Director said he/she was awaiting approval to send the resident's records; -The afternoon of 11/10/25 no records had been received. Review of Resident #1 medical record showed no completed HP-08-Form A-Resident Request for Access to Protected Health Information or Financial Records.During an interview on 12/3/2025 at 3:05 PM Licensed Practical Nurse (LPN) A said:-If the resident requests the record themselves, he/she would print a copy and give the records to the resident;-If the Durable Power of Attorney (DPOA) requests a medication list he/she would print it and give it to the DPOA;-Other requests must be sent through Medical Records;-Medical Record requests can only be completed during the week with Medical Records staff.During an interview on 12/3/25 at 4:22 PM the Medical Records Director said:-He/She had no direct way to receive medical record requests; -He/She did not get record requests quickly, and had found requests from months ago at the nurses stations; -He/She was aware of the multiple record requests for Resident #1; -Those requests had to be sent to the corporate office for approval; -He/She received approval to send Resident #1 medical records, but was unsure of the exact day; -Resident #1's medical records should have been sent 12/3/25, but had not done it yet;-He/She was not aware nurses were printing records for residents, that was not the correct procedure for processing record requests; -He/She had multiple conversations with Resident Representative A in regards to the resident's medical records; -He/She told Resident Representative A, he/she was not able to release the resident's medical records until corporate approved the release of the records. During an interview on 12/3/25 at 5:00 P.M. the Clinical Nurse Consultant said:-He/She was not aware of any requests for Resident #1 records prior to November 2025; -He/She was unaware nurses were printing records and giving them to resident's and resident representatives; -Nursing staff should never print records to give to residents or resident representatives; -He/She clarified the process with Medical Records Director, and all requests had to be made in writing on the required form;-He/She believed records are sent in a relatively desired time frame, did not want to say something inaccurate and could not define a time.Intake 2666871

Based on observation, interview, and record review the facility failed to ensure that resident's who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible when improper incontinent care was provided to three Residents (Residents #1, #2, and #3) of the three sampled residents. The facility census was 91. Review of the facility's Perineal Care policy, dated 10/24/2022, showed: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need; The purpose of perineal care is to maintain cleanliness of the genital area, reduce odor, and to prevent infection or skin breakdown. Staff are to use clean soapy washcloths when providing perineal care, moving from front to back, using a clean area of the washcloth for each stroke. The facility's current policy did not address the use of disposable wipes. 1.Review of Resident #1's Quarterly MDS (minimum data set), a federally mandated assessment tool, completed by facility staff, dated 10/29/2025., showed:The resident was frequently incontinent of urine and bowel.The resident required nursing assistance with personal care.The resident had a diagnosis of urinary tract infections. Review of the Resident's Care Plan, revised on 9/3/25, showed:The resident was on diuretic (a medication to assist the body in removing excess fluid through urination) therapy.The resident had impaired cognitive function and was dependent on staff to meet emotional, physical, and psychosocial needs.Review of Physician's Orders dated 9/8/25, showed the resident was recently prescribed cephalexin 500mg (antibiotic) one capsule by mouth three times a day for the treatment of a urinary tract infection.Observation on 11/3/25 at 1:52 P.M. showed: -The wound nurse and the regional wound nurse provided perineal care to Resident #1.-The regional wound nurse used a wet wipe to clean down the middle of the perineal area, folded the wet wipe that was soiled with urine and wiped down the middle of the perineal area;-The regional wound nurse took a new wet wipe and cleaned down the middle of the perineal area, folded the dirty urine-soaked wet wipe and wiped down the middle of the perineal area again, folded the wet wipe again and cleaned down the middle of the perineal area for a third time using the same soiled wet wipe.-The regional wound nurse took a third wet wipe out of the package and cleaned down the middle of the perineal area, folded the wet wipe and wiped down the middle of the perineal area again with the same soiled used wipe.2. Review of Resident #2's Quarterly MDS, dated [DATE], showed:-The resident was occasionally incontinent of bowel and bladder.-The resident required nursing assistance with personal care and hygiene.Review of Resident's Care Plan, revised 7/22/25, showed:-The resident was on diuretic (a medication to assist the body in removing excess fluid through urination) therapy.-The resident is dependent on two staff members for personal cares and hygiene.-The resident was dependent on staff to meet emotional, physical, and psychosocial needs.Observation on 11/3/25 at 11:18 A.M. showed:-CNA (Certified Nursing Assistant) A and CNA B provided perineal care to Resident #2.-CNA A used a wet wipe to clean down the left side of the perineal area, folded the wipe, then used the same contaminated folded wipe to clean down the right side of the perineal area.-After perineal care was provided to the resident, CNA A put a new incontinent brief on the resident wearing the same soiled gloves that were used to provide perineal care. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed:-The resident was always incontinent of bowel and bladder.-The resident required assistance with personal cares and hygiene.Review the resident's Care Plan, revised 6/26/25, showed:-The resident required assistance from nursing staff to perform personal hygiene cares.-The resident had a potential for impairment to his/her skin due to incontinence of bowel and bladder.-The resident was dependent on staff for meeting emotional, physical, and psychosocial needs.Observation on 11/3/25 at 11:34 A.M. showed:-CNA A and CNA B provided perineal care to Resident #3.-CNA A used a wet wipe to clean down the right side of the perineal area, folded the contaminated urine-soaked wipe, then used the folded wipe to clean down the right side of the perineal area.-After perineal care was provided to the resident, CNA A put a new incontinent brief on the resident wearing the same gloves that were used to provide perineal care. During an interview on 11/3/25 at 11:43 A.M. CNA A said, when performing perineal care, he/she cleans down one side of the perineal area then will fold the wipe and clean the other side of the perineal area with the same wipe. He/she will then get a new wipe to clean the middle of the resident's perineal area. During an interview on 11/3/25 at 1:00 P.M. Certified Medication Technician (CMT) A said:-When performing perineal care, a wipe is to be used once then discarded.-After performing perineal care on a resident, he/she will change gloves before getting a resident dressed.During an interview on 11/3/25 at 2:04 P.M. CNA B said:Wipes are to be used once and then thrown away when performing perineal care on residents.Gloves are to be changed after cleaning a resident and before putting clean clothes on a resident.During an interview on 11/3/25 at 2:40 P.M. The Director of Nursing (DON) said staff are to use a wipe once when providing perineal care then get a new wipe to continue cleaning the resident, using each wipe once.Intake 2652352Intake 2652388

Based on interview, record review, and review of the facility's policy, the facility failed to notify the physician timely when a resident had a change of condition, failed to start an antibiotic that was ordered by the resident's physician, and failed to obtain a physician ordered urinalysis (UA) timely for one resident (Resident (R) 63) of 33 sampled residents. These failures resulted in R63's hospitalization due to sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) related to a urinary tract infection (UTI). The facility census was 93. The facility's Administrator and Director of Clinical and Reimbursement Services were informed on 03/13/25 at 3:23 P.M. of an Immediate Jeopardy, which began on 03/08/25. The Immediate Jeopardy was removed on 03/14/25, as confirmed by surveyor onsite verification. Findings include: Review of the facility's policy titled, Change of Condition Notification dated October 24, 2022, revealed To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's 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. 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: . B. A significant change in the resident's physical, cognitive, behavioral, or functional status. Procedure: III. Notifying the Attending Physician: A. The Attending Physician will be notified timely with a resident's change in condition. B. Notification to the Attending Physician 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. Review of R63's undated Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R63 was admitted to the facility on [DATE] with diagnoses which included pneumonia, urinary tract infection (UTI), and retention of urine. R63 was emergently discharged from the facility to the hospital on 03/10/25. Review of R63's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/27/25, located under the MDS tab of the EMR documented the facility assessed R63 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS indicated R63 had a diagnosis of pneumonia and UTI within the last 30 days; and had an indwelling catheter. Review of R63's Baseline Care Plan, located under the Assessments tab of the EMR and initiated on 02/25/25 revealed R63 was at risk for complications with the urinary tract. The interventions on 02/25/25 included: Observe for signs and symptoms of UTI such as burning, dysuria, increased frequency, odor, hematuria, etc.Encourage fluids. Administer medications as ordered. Notify primary physician if any changes in condition. Review of R63's Vital Signs located in the resident's EMR under the Vitals tab were as follows: 03/07/25 at 10:38 A.M. Blood Pressure (BP) 100/53, pulse 67, this was the resident's baseline. 03/07/25 at 6:54 P.M. BP 109/56. 03/07/25 at 8:17 P.M. BP 94/64, pulse 86. 03/08/25 at 9:53 A.M. BP 94/60, Pulse 89. 03/08/25 at 5:56 P.M. BP 96/48, Pulse 83. 03/08/25 at 6:38 P.M. BP 81/57. 03/09/25 at 9:11 A.M. BP 88/47, Pulse 54. 03/09/25 at 3:47 P.M. BP 70/50. 03/09/25 at 5:47 P.M. BP 85/50, Pulse 73. 03/09/25 at 8:54 P.M. BP 116/62, Pulse 90. 03/10/25 at 8:38 A.M. BP 121/63, Pulse 81. Review of R63's Physicians Orders, located under the Orders tab of the EMR revealed an order dated 03/09/25 at 12:16 AM, to replace catheter and get UA [urinary analysis]. Review of R63's Progress Notes located under the Prog [progress] Notes tab of the EMR, revealed a Nursing Note, dated 03/09/25 at 1:10 P.M., which documented .the resident's Foley was changed to obtain a urine sample to rule out infection. The resident's urine was dark amber colored. Family was in the facility and requested an order for an antibiotic. New order for cipro [antibiotic] was received. family notified. continue with plan of care . Further review of R63's Physicians Orders, located under the Orders tab of the EMR revealed an order, dated 03/09/25 at 3:49 P.M., for Cipro HCl (ciprofloxacin hydrochloride, an antibiotic) oral tablet 250 milligrams (MG) give one tablet by mouth two times a day for infection until 03/17/25. The medication was not started on 03/09/25 due to the staff not having access to the pyxis (the electronic safe for emergency medications requiring password to access), then the resident was sent to the emergency roiagnom on the morning of 03/10/25. Review of R63's Skilled Nursing Note, dated 03/09/25 at 11:10 P.M. and located under the Assessments tab of the EMR revealed under section A Vital Signs from 03/09/25 at 8:41 P.M. revealed the resident's pulse was 90, BP 116/62; she was alert and oriented. However, not to time or place. New order for cipro for UTI. Further review of R63's Skilled Nursing Note, dated 03/10/25 at 12:03 A.M. and located under the Assessments tab of the EMR revealed the resident's blood pressure was 116/62 on 03/09/25 at 8:41 P.M. and her pulse was 90. She was alert and oriented with impaired decision making and was confused. Bladder function was unchanged and Foley catheter care was provided. Review of R63's Lab Results, provided by the facility showed a UA sample was collected on 03/10/25 at 5:25 AM; over 24 hours after it was ordered by the resident's physician on 03/09/25 at 12:16 AM. The results showed the urine was yellow and clarity was turbid [cloudy], and positive for blood and leukocytes. The white blood cells (WBCs) were elevated. The results indicated a culture and sensitivity (C&S) would be completed. Review of R63's Nurse Practitioner Progress Notes, Care at Home Provider Visit provided by the facility dated 3/10/25 revealed under Assessment/Plan: History of UTIs: Dark amber urine in Foley. UA was not sent until early this morning and results not available yet . [He/She] was ordered to start Cipro 500 mg BID yesterday, but it had not been received from the pharmacy yet . Resident's family member came into facility after I had seen her and when she learned that UA results and Cipro had not been started, asked for resident to be sent to be sent to emergency room (ER), which she was. Review of R63's Progress Notes, dated 03/10/25 at 11:54 A.M. and located under the Prog Notes tab of the EMR revealed a Discharge Summary documented Resident condition declining since lab and UA obtained. [Family Member (FM) 1] here, concerned with resident's condition and wants her sent to ER [emergency room ] for eval/tx [evaluation/treatment]. [Advanced Practice Registered Nurse (APRN) 1], in [the] building and received verbal order to send. EMS [emergency medical services] here at 11:15 A.M. to transport resident. [FM1] will meet resident at hospital. During an interview on 03/12/25 at 11:50 A.M., the emergency room (ER) Nurse stated when R63 arrived at the ER, she had minimal urine output and had fluid in her lungs. R63 was started on three intravenous (IV) antibiotics and IV blood pressure medication to raise her blood pressure. The ER nurse stated R63 was admitted to the hospital with a diagnosis of sepsis, pleural effusions, and UTI. During an interview on 03/12/25 at 12:37 P.M., FM1 stated R63 was alert and oriented when visited on 03/07/25. FM1 stated that on 03/08/25, R63 was disoriented when she visited and R63 had said crazy things to family members later that day. FM1 stated on 03/09/25, R63 was more lethargic, and nurses were replacing the Foley catheter when she visited the resident. FM1 also indicated the nurse stated they had not gotten any physician orders for urine lab test or for any antibiotics and they were still waiting for a call back from the physician. FM1 stated she arrived at the facility on 03/10/25 at 10:45 AM and found R63 was unresponsive, with brown, dry secretions around her mouth. FM1 stated she demanded R63 be sent to the ER. During an interview on 03/12/25 at 5:23 P.M., Licensed Practical Nurse (LPN) 2 stated on 03/08/25, R63 could not keep her eyes open, had slurred speech, increased confusion, hallucinations, and slightly dark urine. LPN2 also stated the nurse aides reported to her that R63 was not drinking fluids, so she intervened by giving her sips of water through a straw. LPN2 indicated she did not notify APRN1 of R63's condition on 03/08/25; however, she did notify APRN1 on 03/09/25 of R63's amber colored urine, and to request an antibiotic per FM1's request. LPN2 also indicated she did not inform APRN1 of R63's low blood pressure of 70/50 on 03/09/25. LPN2 stated she did not administer the antibiotic because she did not have access to the medication. During an interview on 03/12/25 at 4:57 P.M., LPN1 stated on 03/10/25, FM1 informed her she wanted R63 to be sent to the hospital due to her decline in level of consciousness (LOC). LPN1 also stated an ARNP was in the building and was notified of FM1's request. During an interview on 03/12/25 at 6:03 P.M., LPN3 stated she was assigned to R63 on the nights of 03/08/25 and 03/09/25. LPN3 stated R63's mental status was about the same, and her blood pressure was within normal range on both evenings. LPN3 indicated R63's urine was light tea colored and cloudy on 03/08/25. LPN3 also indicated she did not feel the need to contact the doctor for a change in the condition. LPN3 said there was an order for a UA on 03/09/25 which was collected on the early morning of 03/10/25 and picked up on 03/10/25. LPN3 stated she did not administer the antibiotic, because she did not have access to the medication. During an interview on 03/12/25 at 6:41 P.M., the Director of Nursing (DON) stated a drastic change in blood pressure or mental status would indicate a change of condition. The DON also stated she expected the nursing staff to inform the physician, obtain orders, and document change in condition in the progress notes. The DON further stated R63's physician should have been notified of R63's change of condition on 03/08/25. During an interview on 03/12/25 at 8:10 P.M., APRN1 confirmed she received a call on 03/08/25 at 2:38 P.M. about R63's confusion and hallucinations, but was not informed of R63's BP or urine. ARNP1 indicated she received another call FM1 requested an antibiotic for R63 on 03/09/25 at 3:03 P.M. and she ordered Cipro. APRN1 stated she was not informed of R63's low blood pressure or that a urine sample had not yet been collected. APRN1 also indicated that she should have been informed of the low BPs and decreased fluid intake, and she would have sent R63 to the hospital. APRN1 stated she was not aware R63's urine was not sent to the lab until 03/10/25. APRN1 stated she expected the ordered antibiotic to be started immediately. APRN1 also stated if she had been informed of the resident's low BP, she would have sent the resident to the hospital immediately to rule out sepsis. During an interview on 03/12/25 at 7:29 PM, Medical Doctor (MD) 1 stated he was not contacted by the nursing staff at the facility about R63; however, one of the APRN's were contacted. MD1 also stated he expected the nursing staff to inform him of a resident's change in condition which included low BPs and mental status changes, to rule out sepsis. He stated if he had been notified of the low BP, he would have sent the resident to the hospital immediately to rule out sepsis. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. At the time of exit, the severity of the deficiency was lowered to the D level. MO00250844

Based on observation, interview, record review, and review of the facility's policy, the facility failed to effectively manage pain for one of one resident (Resident (R) 71) reviewed for pain out of 33 sampled residents. The facility failed to order R71's oxycodone (an opioid pain medication) in a timely manner and the physician ordered pain medication was not administered as ordered. This failure caused R71 to experience terrible pain, was unable to relax enough to sleep, and felt like he was having withdrawals. The facility census was 93. Findings include: Review of the facility's policy titled, Pain Management, dated 10/24/22, revealed, . The nursing staff will implement timely interventions to reduce the increase in severity of pain. Review of the facility's policy titled, Ordering and Receiving Controlled Medications, revised 01/2023, revealed, .Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. Review of R71's quarterly significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/25 and located in the electronic medical record (EMR) under the MDS tab, revealed R71 was admitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R71 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS also indicated R1 had diagnoses that included spinal stenosis and unspecified inflammatory spondylopathy of the lumbar region. It was recorded that R71 had frequent pain at 07 on a numeric rating scale (00-10) and received an opioid as a pharmacological intervention for his pain. Review of R71's physician Order, dated 12/19/24 and located in the resident's EMR under the Orders tab revealed R71 was to receive Oxycodone 10mg [milligram]/325mg every 6 hours for pain management. Review of R71's Care Plan, revised 10/21/24 and located in the EMR under the Care Plan tab revealed, . The resident is at risk for or has acute/chronic pain . Pain will be minimized with the use of scheduled and/or PRN (as needed) pain meds. Review of R71's Medication Administration Note, dated 03/12/25 at 8:31 P.M. and located in the Progress Note tab, revealed, .Oxycodone 10/325mg give 1 tablet four times a day for chronic pain, Drug out. Review of R71's Medication Administration Record (MAR), dated 03/2025 and located under the Orders tab of the EMR revealed the resident missed the following five doses of the oxycodone ordered to treat the resident's pain: 03/12/25 at 8:00 P.M.; 03/13/25 at 2:00 A.M.; 03/13/25 at 8:00 A.M.; 03/13/25 at 2:00 P.M.; and 03/13/25 at 8:00 P.M. Continued review of R71's MAR revealed the only documented pain assessment for the missed doses of oxycodone was for the 2:00 PM missed dose on 03/13/25 and it was documented the resident's pain level was a 9 out of 10 (on a scale of 1-10, with 10 being the most severe pain). During an interview on 03/14/25 at 12:30 P.M., R71 approached the surveyor very upset about missing medications. The resident stated he requested to go to the hospital last night 03/13/25 after he had missed many doses of his pain medication. R71 stated he had a pain level of 10 out of 10 and had not slept the past two nights due to pain. During an interview on 03/14/25 at 1:30 P.M., when asked if she was aware R71 was out of his oxycodone pain medication, Certified Medication Technician (CMT) 2 stated the medication had been ordered a few days before it ran out and she had informed the Assistant Director of Nursing (ADON) on 03/12/25 that she had given R71 his last dose of oxycodone on hand. CMT2 also stated R71 told her he was hurting. During an interview on 03/14/25 at 2:52 P.M., the Director of Nursing (DON) was asked if she was aware R71's oxycodone ran out and R71 had missed five doses of the medication. The DON stated she was informed yesterday, 03/13/25. The DON stated the nurse called the pharmacy and determined the prescription was sent to the wrong physician. The DON stated the nurses should reorder the medication five to six days ahead of time before the last dose, and the nurse should call the physician first for an e-script (electronic prescription). The DON stated the physician then sends the e-script to the pharmacy and the nurse should follow up with the pharmacy. The DON stated her staff should not wait until the last day to start the process. During a follow up interview on 03/14/25 at 5:30 PM, R71 stated he felt terrible pain, still was unable to relax enough to sleep, and felt like he was having withdrawals. R71 also stated, It affects every part of my body. During the interview, R71 stated his current pain level was eight out of 10 at this time and stated his body aches and has stabbing pain.

Based on interview, record review, and facility policy review, the facility failed to have an effective continuing education program for the Certified Nurse Aides (CNAs) to receive the required 12-hour in-service training yearly. This failure potentially allowed CNAs to work without receiving the number of hours required for continuing education and skill sets necessary to care for the resident population. The facility census was 93. Findings include: Review of the facility's policy titled Regular In-service Education for Certified Nursing Personnel, undated and provided by the facility, revealed Purpose: This facility recognizes the importance of identifying, maintaining, and elevating the competency of its certified personnel. This promotes the highest possible level of care to the residents residing in the facility Policy: All Certified nursing personnel will be required to complete at least 12 hours of in-service education annually from the date of their hire. It will be the responsibility of each individual certified employee to meet this requirement by attending in-service education as it is made available. 2. The facility will schedule regular in-service training throughout each month of the year, providing ample opportunity for staff members to meet this requirement. 3. The facility will track each certified staff member's attendance and will provide this attendance information when requested by the staff member to assist the individual in tracking hours completed and the hours required to meet the 12-hour standard. 4. Certified staff members who do not meet this requirement will be removed from the schedule. Those staff members with extenuating circumstances may be given an opportunity to complete remedial training. Each case will be handled individually based on the presenting facts. Review of the facility's Performance Improvement Plan (PIP), dated 12/13/24, revealed the facility identified the annual 12 hours of training required by regulation has not been consistently scheduled to ensure it is being offered and completed by all staff. The PIP stated the plan was for Human Resources (HR) and the Administrator to obtain the list of the required in-service trainings per regulation and schedule the in-services the second pay period each month. The PIP also stated HR will keep track of the attendance at each meeting. Review of the Facility Assessment, dated 08/06/24, provided by the facility, revealed the CNAs would receive education/in-services annually on the following topics: Communication, Resident Rights, Abuse, Neglect and Exploitation, Infection Control, Feeding Assistants, Identification of Resident Changes in Condition, Cultural Competency, Person Centered Care, Activities of Daily Living, Disaster Planning, Measurements - Vitals and Intake and Output, Caring for Residents with Dementia, Alzheimer's and Cognitive Impairments, Caring for Resident with Mental and Psychosocial Disorders, Non-pharmacological Management of Responsive Behaviors, and Caring for Residents with Trauma/PTSD. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed not all of the in-services were provided on the training calendar, and the facility did not track the length of the in-service or the CNAs that attended the in-service. During an interview on 03/14/25 at 7:22 PM, the Administrator stated she developed a PIP because they identified that all the training topics on the 2024 in-service calendar were not provided to the CNAs to meet their 12-hour training requirement, and they did not have a tracking system in place to identify the CNAs that didn't receive the training. The Administrator also stated the facility did not have a staff educator and the former Director of Nursing (DON) provided some of the required education but couldn't continue to do it all.

Based on interviews, record reviews, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on compliance and ethics program annually. This failure resulted in staff not receiving the required training on the compliance and ethics program standards, policies, and procedures. The facility census was 93. Findings include: Review of the facility's Performance Improvement Plan (PIP), dated 12/13/24, revealed the facility identified the annual 12 hours of training required by regulation had not been consistently scheduled to ensure it is being offered and completed by all staff. The PIP stated the plan was for Human Resources (HR) and the Administrator to obtain the list of the required in-service trainings per regulation and schedule the in-services the second pay period each month. The PIP also stated HR will keep track of the attendance at each meeting. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed there was a training topic on compliance on the calendar for December 2024. However, there was no documented evidence the training was provided to staff in 2024. During an interview on 03/14/25 at 7:22 PM, the Administrator stated she developed a PIP because they identified that all the training topics on the 2024 in-service calendar were not provided to the staff, and they did not have a tracking system in place to identify the staff that didn't receive the training. The Administrator also stated the facility did not have a staff educator and the former Director of Nursing (DON) provided some of the required education but couldn't continue to do it all.

Based on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on the elements and goals of the facility's Quality assurance and performance improvement (QAPI) program. This failure resulted in all staff not receiving the required training. The facility census was 93. Findings include: Review of the facility's Performance Improvement Plan (PIP), dated 12/13/24, revealed the facility identified the annual 12 hours of training required by regulation had not been consistently scheduled to ensure it is being offered and completed by all staff. The PIP stated the plan was for Human Resources (HR) and the Administrator to obtain the list of the required in-service trainings per regulation and schedule the in-services the second pay period each month. The PIP also stated HR will keep track of the attendance at each meeting. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed QAPI was not a training topic on the calendar and not a training that was provided to the staff. During an interview on 03/14/25 at 7:22 PM, the Administrator stated she developed a PIP because they identified that all the training topics on the 2024 in-service calendar were not provided to the staff, and they did not have a tracking system in place to identify the staff that didn't receive the training. The Administrator also stated the facility did not have a staff educator and the former Director of Nursing (DON) provided some of the required education, but couldn't continue to do it all.

Based on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff which included training on communication. This failure potentially allowed staff to continue to work without the skills sets necessary to care for the residents. The facility census was 93. Findings include: Review of the facility's Performance Improvement Plan (PIP), dated 12/13/24, revealed the facility identified the annual 12 hours of training required by regulation has not been consistently scheduled to ensure it is being offered and completed by all staff. The PIP stated the plan was for Human Resources (HR) and the Administrator to obtain the list of the required in-service trainings per regulation and schedule the in-services the second pay period each month. The PIP also stated HR will keep track of the attendance at each meeting. Review of the Facility Assessment, dated 08/06/24, provided by the facility, revealed the CNAs would receive education/in-services annually on the following topics: Communication - effective communications for direct care staff. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed effective communications training was not provided to staff. During an interview on 03/14/25 at 7:22 PM, the Administrator stated she developed a PIP because they identified that all the training topics on the 2024 in-service calendar were not provided to the staff, and they did not have a tracking system in place to identify the staff that didn't receive the training. The Administrator also stated the facility did not have a staff educator and the former Director of Nursing (DON) provided some of the required education, but couldn't continue to do it all.

Based on interview, record review, and facility policy review, the facility failed to maintain an effective training program for all staff consistent with their expected roles annually per the facility assessment. The facility failed to provide training related to cultural competency as identified by the facility assessment as a need. Additionally, the facility provided training related to abuse and neglect, infection control, and behavioral health, however, they failed to develop, implement, and maintain an effective system to monitor what training staff had or had not completed. This failure potentially allowed staff to work without the skill sets necessary to care for the resident population and placed all residents at risk for negative healthcare outcomes. The facility census was 93. Findings include: Review of the facility's Performance Improvement Plan (PIP), dated 12/13/24, revealed the facility identified the annual 12 hours of training required by regulation has not been consistently scheduled to ensure it is being offered and completed by all staff. The PIP stated the plan was for Human Resources (HR) and the Administrator to obtain the list of the required in-service trainings per regulation and schedule the in-services the second pay period each month. The PIP also stated HR will keep track of the attendance at each meeting. 1. Review of the Facility Assessment, dated 08/06/24, provided by the facility, revealed the all staff would receive education/in-services annually on the following topics: Communication, Resident Rights, Abuse, Neglect and Exploitation, Infection Control, Cultural Competency, Person Centered Care, Disaster Planning, Caring for Residents with Dementia, Alzheimer's and Cognitive Impairments, Caring for Resident with Mental and Psychosocial Disorders, Non-pharmacological Management of Responsive Behaviors, and Caring for Residents with Trauma/PTSD. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed the cultural competency training was not provided in 2024. Although the other training topics were provided there was no tracking system in place to determine the staff that had or had not received the training. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed behavior management training was provided to the staff on 01/24/24 for 15 to 30 minutes, however, did not have a tracking system in place to determine the staff that did or did not attend the in-service. 2. Review of the Facility Assessment, dated 08/06/24, provided by the facility, revealed the CNAs would receive education/in-services annually on Abuse, neglect, and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed abuse, neglect, and exploitation and reporting procedures were provided on 01/24/24 and on 12/18/24, however, there was no tracking system to determine the staff that did or did not attend the course. 3. Review of the In-service Calendar and In-services provided in 2024, provided by the facility, revealed staff were trained on enhanced barrier precautions (EBP) on 07/12/24 and on droplet precautions for COVID, hand hygiene, personal protective equipment (PPE) sequence for putting on and removing sequence in November 2024. However, there was no tracking system to determine the staff that did not receive the education. During an interview on 03/14/25 at 7:22 P.M., the Administrator stated she developed a PIP because they identified that all the training topics on the 2024 in-service calendar were not provided to staff per the facility assessment, and they did not have a tracking system in place to identify the staff that didn't receive the training. The Administrator also stated the facility did not have a staff educator and the former Director of Nursing (DON) provided some of the required education but couldn't continue to do it all.

Based on interview, document review, and policy review, the facility failed to ensure there was a designated Infection Preventionist (IP) that had completed specialized training in infection prevention and control that had sufficient time to assess, develop, implement, monitor, and manage the facility's Infection Prevention and Control Program (IPCP). The failure placed all residents in the facility at risk for acquiring diseases and infections. The facility census was 93. Findings include: Review of the Infection Control Preventionist Job Description, provided by the facility, revealed Position Description Responsible for assuming the responsibility for the Infection Control Program of the facility in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Responsible for infection control surveillance, prevention and control. Responsible for the data collection, analysis, and reporting findings to the Director and designated committees. In addition, this position is responsible for infection control education for new hires and staff . Review of the Facility Assessment, revised 08/06/24, provided by the facility, revealed the facility will have one full-time IP. During the Entrance Conference Meeting held on 03/11/25 at 9:02 A.M., the Administrator stated the Minimum Data Set Coordinator (MDSC) was the IP, and the Assistant Director of Nursing (ADON) was being trained for the position. During an interview on 03/14/25 at 9:04 A.M., the MDSC stated she performed the duties of the IP when she held the position of Director of Nursing (DON). The MDSC indicated she had not completed any infection preventionist or infection control training and did not have a certificate as proof of said training. The MDSC also stated a nurse had been hired for the position, but vacated the position within a month. The MDSC indicated the facility had been without an IP since October 2024 and she did not have time to oversee the IPCP and be the MDSC. During an interview on 03/14/25 at 11:52 A.M., the Administrator stated the ADON was recently trained on the IPCP binder and the MDSC was completing the IP duties. During an interview on 03/14/25 at 12:12 P.M., the Regional Nurse Consultant stated she was informed that Licensed Practical Nurse (LPN) 1 was overseeing the program and she had a certificate for completing IP training. During an interview on 03/14/25 at 11:00 A.M., LPN1 stated she was a Charge Nurse on the floor and was the IP from November 2023 to August 2024. LPN1 also stated she completed the infection control training, but was not the current IP and did not oversee the program.

Based on interview, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RR) during admission included a clause that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. This failure affected all residents who had signed the Arbitration Agreement and any future residents who might sign the agreement. The facility census was 93. Findings include: Review of the facility's policy titled Arbitration Agreement, dated 10/24/22, provided by the facility, revealed Purpose To provide a lawful opportunity for a provider of health services and residents/responsible parties to enter into an enforceable written contract to settle a dispute outside of court through an arbitration process. The federal government has expressed a policy of support of arbitration agreements because they reduce the burden on court systems to resolve disputes. Policy I. The Health Care Arbitration Agreement complies with federal and state laws. II. The Arbitration Agreement used by the Facility has been developed approved Governing Body. III. Residents or their responsible parties are not required to sign Arbitration Agreements as a condition of admission to or continued treatment at the Facility . Review of the facility's Arbitration Agreement, revised July 2022, provided by the facility, revealed the agreement did not state that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. During an interview on 03/14/25 at 10:52 A.M., the Admission Coordinator confirmed the arbitration agreement did not contain the statement that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. The Admission Coordinator stated the arbitration agreement was developed by the corporation, used in all of their facilities, and this agreement was revised within the last year. During an interview on 03/14/25 at 11:42 A.M., the Regional Director of Clinical and Reimbursement Services verified the agreement did not include the verbiage that neither the resident or his/her representative are required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. The Regional Director of Clinical and Reimbursement Services stated she was not aware that the verbiage was not in the agreement. During an interview on 03/14/25 at 11:47 A.M., the Administrator stated she was not aware the agreement did not contain the clause, and the agreement was developed by the corporate office.

Based on interview, record review, facility policy review, the facility failed to maintain an effective infection prevention and control program (IPCP) as follows: 1. The facility staff were not recording incidents of infections identified through surveillance, tracking and trending, and the corrective actions taken by the facility. 2. The Maintenance Director did not have measures in place to prevent the growth of water-borne pathogens in the water fountain as identified in the assessment. 3. The facility staff failed to clean and disinfect the multi-use glucometer when performing fingerstick blood glucose testing between residents per the manufacturer's instructions. The facility census was 93. Findings include: 1. Review of the facility policy titled Infection Prevention and Control Program, dated 10/24/22, revealed Purpose To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Policy I. The Facility must establish an Infection Prevention and Control Program under which it - 1. Identifies, investigates, controls, and prevents infections in the Facility; 2. Decides what procedures, such as isolation, should be applied to an individual resident; and 3. Maintains a record of incidents and corrective actions related to infections. II. Infection Prevention and Control Program standards apply to all Facility employees, contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs . During an interview on 03/14/25 at 9:04 A.M., the Minimum Data Set Coordinator (MDSC) stated she had not updated the binder, where infections were recorded, was not tracking and trending incidents of infections, and not recorded the corrective actions of the facility for several months. The MDSC stated the facility had been without an Infection Preventionist (IP) since October 2024 and she was trying to keep the infection surveillance up to date until they trained or hired an IP. During an interview on 03/14/25 at 11:52 A.M., the Administrator stated she was aware that some aspects of the IPCP were not completed due to staffing issues. The Administrator also stated the Assistant Director of Nursing (ADON) was recently trained on the IPCP binder. During an interview on 03/14/25 at 12:12 P.M., the Regional Nurse Consultant stated her role was to oversee the IPCP at the facility and was not aware that infection surveillance had not been completed for several months. The Regional Nurse Consultant also stated she in-serviced the ADON on the IPCP binder recently and Licensed Practical Nurse (LPN) 1 was overseeing the program. During an interview on 03/14/25 at 11:00 AM, LPN1 stated she was a Charge Nurse on the floor and was the IP from November 2023 to August 2024. LPN1 also stated she was not the current IP and did not oversee the program. 2. Review of the facility's policy titled Legionella, dated 10/24/22, provided by the facility, revealed Purpose To inhibit microbial growth in the facility's water systems to reduce the risk of growth and spread of legionella and other opportunistic pathogens in water . Review of the facility's Water Management Program Risk Assessment, dated June 2024, provided by the facility revealed the water fountain was listed as a risk in the assessment. Review of the facility's logbook document titled Testing and Monitoring of Water Management Plan for Legionella, dated 2024 and 2025, provided by the facility, revealed the water fountain's PH levels had not been tested . Observation on 03/14/25 at 12:32 P.M., in the front lobby with the Maintenance Director revealed a water fountain between the men and women's restrooms and the lobby adjacent to the A wing. During an interview on 03/14/25 at 11:09 A.M., the Maintenance Director stated he tested the PH of the water throughout the building weekly, but forgot to test the water fountain. The Maintenance Director stated the water fountain was not used that often. During an interview on 03/14/25 at 12:41 PM, the Regional Director of Plant Operations revealed he monitored the TELS to ensure weekly testing was completed and had not identified that the water fountain was not tested since the risk assessment was completed in June 2024. 3. Review of the facility's policy titled, Blood Glucose Monitoring, dated 10/24/22 indicated, XI If the blood glucose monitor is multi-patient use: A. Clean and disinfect the blood glucose machine according to the manufacturer's directions with an appropriate cleaning product. The disinfection solvent should be effective against HIV, Hepatitis C, and Hepatitis B virus. Note that 70% ethanol solutions are not effective against viral blood borne pathogens. B. If the manufacturer of the device in use does not specify how the device should be cleaned and disinfected, then it should not be shared or reused with a different resident. C. [NAME] (apply) gloves prior to cleaning the blood glucose monitor. D. Following the cleaning, remove gloves and wash hands. Review of the EvenCare G3 Meter glucometer booklet titled, Cleaning and Disinfecting Procedures for the Meter, not dated revealed, The meter should be cleaned and disinfected between each patient .The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EvenCare G3 Meter .Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Review of R10's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of R10's Medication Administration Record (MAR), dated 03/29/2024 and located under the Orders tab of the EMR revealed R10 had physician orders for finger stick blood sugars completed four times a day, before each meal and at bedtime. Review of R25's quarterly Minimum Data Set, with an assessment reference date (ARD) of 01/01/25 and located under the ASPEN MDS Viewer revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The MDS revealed the resident had an active diagnosis of diabetes mellitus and was ordered and received insulin for seven out of seven days during assessment period. During an observation and interview on 03/12/25 at 12:17 P.M., Licensed Practical Nurse (LPN) 2 took one glucometer out of the medication cart with her bare hands and laid the glucometer on top of the medication cart with no barrier. LPN2 then used hand sanitizer and donned gloves. The LPN then completed a blood sugar finger stick on R10 and removed her gloves. She then laid the glucometer on the medication cart. At 12:29 PM LPN2 cleaned her hands with sanitizer, donned gloves, completed a blood sugar finger stick on R25, removed her gloves, and returned to the medication cart. When asked about cleaning the glucometer in between taking the two residents' blood sugars, LPN2 stated, Well .I just forgot to do it. She proceeded to get a Minute Wipe out of the container, wiped off the glucometer, and placed it in the drawer of the medication cart. LPN2 was asked did you clean the glucometer according to the instructions on the Minute Wipe container, she stated, Yes. After retrieving the container and reading the instructions, she stated, No. During an interview on 03/12/25 at 12:35 PM, the Regional Director of Clinical and Reimbursement Services stated, The glucometers should be cleaned with wet time between each resident. That staff are trained in glucometer use. Expectation is that they clean and disinfect the glucometer according to protocol. During an interview on 03/02/23 at 10:05 AM, the Director of Nursing (DON) stated, his/her expectation of the nursing staff was to follow infection control practices and policies. Nursing has competencies for glucometer use.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. The facility also failed to ensure dishes were properly dried after being washed. Additionally, the facility failed to ensure all items in the kitchen's refrigerator, freezer, and dry food storage were sealed, labeled, and dated. These failures placed all residents of the facility at risk for food borne illnesses. The facility census was 93. Findings include: Review of the facility's policy titled, Pot and Pan Cleaning, dated 10/24/22, revealed Invert the pots and pans and place them on a drying rack and allow to air dry. Do not use a towel . Observations on 03/11/25 at 9:01 A.M., with the Assistant Dietary Manager (ADM) revealed the following: -three large metal sheet pans stacked wet. -a plastic container of sugar packets with dried food particles on the container and the container was dirty with dried food particles. -the clean industrial stand mixer was not covered and had empty boxes stacked on top of it that were to go in the garbage. -13 clean metal pots and pans were stored under a table, on a shelf that was dirty with dried food particles all over it. -The walk-in refrigerator contained the following items not labeled, dated, with no use-by-dates: one container of rice, one cup of cream of wheat, one container of beef broth, ketchup not in the original ketchup bottle, soup in a cup, and cream of chicken soup. -The walk-in freezer contained one box of omelets that were not sealed shut. One bag of calzones and sausage with no use-by-dates. -The dry storage room contained one bag of spaghetti with no use-by-dates and individually wrapped slices of bread wrapped in a baggie with no dating. During an interview on 03/11/25 at 9:25 A.M., the ADM confirmed the observations and stated, I have no idea how long the bread had been in the dry storage room. When asked how staff would know if food was still usable if there were no use-by-dates, the ADM stated, We go through things fast. I do not know about use-by-dates. The staff would not know if [the] food was still good or not. During an interview on 03/14/25 at 8:02 PM, the Administrator stated, My expectation of the kitchen is to keep the kitchen clean.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory care equipment was properly maintained; and failed to ensure respiratory care was provided per physician orders for three of four residents review for respiratory care (Resident (R) 15, R53, and R41) out of 33 sampled residents. These failures placed the residents at risk for increased risk of respiratory infections and oxygen saturations not being maintained. The facility census was 93. Findings include: Review of the facility's policy titled Oxygen Administration, dated 10/24/22, revealed A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include the oxygen flow rate; method of administration; continuous or prn; titration instructions; and indication for use .All oxygen tubing, humidifiers, mask, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled, or as indicated by state regulation .Turn on the oxygen at the prescribed rate . 1. Review of R15's undated Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Observation on 03/12/25 at 6:53 A.M., of R15's oxygen concentrator revealed the oxygen concentrator's filter was covered in a white substance that appeared to be dust. During an observation and interview on 03/13/25 at 2:57 P.M., Licensed Practical Nurse (LPN) 4 observed R15's oxygen concentrator's filter and stated, . this filter on the concentrator is dirty with dust. The filter should be cleaned at the time the oxygen tubing is changed. During an interview on 03/14/25 at 6:00 P.M., the Director of Nursing (DON) stated, Every time we change the oxygen tubing (weekly), the filter on the concentrator should be cleaned. 2. Review of R53's undated Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R53 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of R53's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/27/25, located under the MDS tab of the EMR documented the facility assessed R53 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R53's Care Plan, initiated on 12/06/23 and located under the Care Plan tab of the EMR revealed the resident had COPD, chronic respiratory failure, and slept with the head of bed elevated related to feeling short of breath when lying flat. Interventions included oxygen via nasal cannula per doctor's orders. Review of R53's Physicians Orders, located under the Orders tab of the EMR revealed an order dated 11/21/23 to administer oxygen as needed at two liters per minute (LPM) per via nasal cannula to keep oxygen saturations greater than 91% as needed for shortness of breath. During observations on 03/11/25 at 11:50 A.M., 03/13/25 at 11:40 A.M., and 03/13/25 at 4:29 P.M., the oxygen level on R53's oxygen concentrator was set at four LPM via nasal cannula. During an observation and interview on 03/13/25 at 5:17 PM, LPN1 verified R53's flow rate level on the oxygen concentrator was set at four LPM and confirmed the concentrator should have been at set at two LPM. LPN1 adjusted the oxygen concentrator to administer oxygen at two LPM. LPN1 verified R53's physician order for oxygen to be administered at two LPM. LPN1 stated she did not know how or when the oxygen concentrator flow rate was increased. LPN1 also stated she should have checked the oxygen concentrator's flow rate setting during her shift to ensure it was being administered per the physician's order. During an interview on 03/14/25 at 5:56 PM, the Director of Nursing (DON) stated nurses were expected to follow physician orders when administering oxygen. The DON expected nurses to check the oxygen concentrator's level every time the room was entered but at least once in the morning and once in the evening. The DON also stated only a nurse with an order could change the concentrator's oxygen flow rate level and nurses were expected to routinely check oxygen levels to determine the need for oxygen. If the resident's oxygen flow rate was set lower than the physician ordered flow rate, the resident could be hypoxic leading to confusion and if it was too high, the resident could be over-oxygenated and could be just as bad as not having enough oxygen being administered. Residents with COPD could retain carbon dioxide (CO2) and become acidotic and could decrease their breathing. 3. Review of R41's undated Admission Record, located under the Profile tab of the EMR, revealed R41 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and shortness of breath. Review of R41's significant change MDS, with and ARD of 03/06/25 and located in the EMR under the MDS tab, revealed the resident had a BIMS of 13 out of 15, indicating R41 was cognitively intact and was always understood. The MDS also indicated the resident received supplemental oxygen during the assessment period. Review of R41's physician's Order Summary, located in the EMR under the Orders tab revealed an order dated 02/28/25 of oxygen at 3 liters via nasal cannula. During an observation on 03/11/25 at 9:47 A.M., R41's oxygen concentrator's flow rate setting was set 2.5 liters. During an observation on 03/12/25 at 7:28 A.M., R41's oxygen concentrator's flow rate setting was set at 2.5 liters. During an observation and interview on 03/12/25 at 12:48 P.M., LPN2 observed R41's oxygen concentrator flow rate setting and stated it was set at 2.5 liters. LPN2 was unsure what setting it should be on. During an observation and interview on 03/12/25 4:30 P.M., the Regional Nurse Consultant (RNC) observed R41's oxygen concentrator's flow rate setting and stated it was set at 2.5 liters. The RNC then reviewed R41's physician orders and verified the flow rate was ordered to be administered at 3 liters.

Based on interview, record review, and review of the facility's policy, the facility failed to develop comprehensive care plans which reflected residents' current status for two of 33 sampled residents (Resident (R) 74 and R10). R74 was receiving hospice services; however, there was no care plan developed to reflect hospice services. Additionally, R10 had the diagnosis of and receiving treatment for diabetes mellitus; however, the resident's care plan did not reflect the diabetes mellitus treatment. These failures placed the residents at risk of having unmet care needs. The facility census was 93. Findings include: Review of the facility's policy titled Care Planning, dated 10/24/22, revealed The purpose is to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs .The care plan serves as a course of action where the resident (resident's family and/or guardian), resident's attending physician, and the facility's Interdisciplinary Team (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 will initiate the care plan, and the plan will be 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 . 1. Review of the facility's undated policy titled Hospice Program, revealed Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . Review of R74's Admission Record, located under the Profile tab of the Electronic Medical Record (EMR) revealed R74 was admitted to the facility on [DATE] with diagnoses which included stroke affecting the right dominant side, diabetes, and schizophrenia. Review of R74's physician Orders located under the Orders tab of the EMR revealed R74 started receiving hospice services on 11/01/24. Review of R74's Care Plan located under the Care Plan tab of the EMR revealed a care plan was not developed to reflect the resident receiving hospice services. During an interview on 03/13/25 at 8:31 A.M., the Minimum Data Set Coordinator (MDSC) stated He [R74] should have had a care plan for Hospice. I do not know why this was not completed. I was not the MDSC at the time [when the resident started receiving hospice services]. During an interview on 03/14/25 at 6:00 P.M., the Director of Nursing (DON) stated The hospice care plan should have been completed when the resident started on hospice. 2. Review of R10's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of R10's Medication Administration Record (MAR), dated 03/29/2024 and located under the Orders tab of the EMR revealed R10 had physician orders for finger stick blood sugars completed four times a day, before each meal and at bedtime. Review of R10's Comprehensive Care Plan, located in the resident's EMR under the Care Plan tab revealed no documented evidence a care plan was developed for the resident's diabetes mellitus diagnoses to include a focus, measurable goals, or interventions. During an interview on 03/14/25 at 3:45 PM, the Minimum Data Set Coordinator (MDSC) stated a resident with a diagnosis of diabetes, receiving blood sugar checks, and taking insulin should have diabetes on her care plan. The MDSC confirmed R10's care plan was not developed to include the resident's diabetic care.

Based on interview and record review, the facility failed to provide adequate personal attention and nursing care for one resident (Resident #1), who the facility assessed and identified as needing the assistance of two staff for cares. On [DATE], one staff member, Nurse Aide (NA) A provided care to the resident without securing assistance from a second staff member. The NA rolled the resident onto his/her side and the resident rolled off the bed onto the floor landing face down. The NA left the room to alert the charge nurse of the accident. The charge nurse, Licensed Practical Nurse (LPN) A and a second nurse, Registered Nurse (RN) A pronounced the resident deceased . The facility census was 68. The administrator was notified on [DATE] at 3:33 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site. Review of the Activities of Daily Living (ADL's) policy, dated [DATE], showed: - Care and services will be provided for residents who are unable to carry out their ADL's independently with the consent of the resident and following the plan of care. - Resident's ability to perform ADL's will be measured using clinical tools, including the Minimum Data Set (MDS) Review of the abuse and neglect policy, dated [DATE], showed: - Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - The nurse will assess the resident for injury. - The nurse will report findings to the physician. - The facility staff will investigate alleged abuse and neglect. - Facility management and staff will address the needs of the residents and minimize the possibility of abuse and neglect. Review of the Change in Condition policy, dated [DATE], showed: - The nurse will assess the following: Vital signs, neurological assessment, and level of consciousness. - The nursing staff will contact the physician based on the urgency of the situation. For an emergency situation, the nurse is to call the physician within 30 minutes or less. - The nursing staff will call the medical director if the primary physician does not respond with a timely response. 1. Review of Resident #1's annual MDS, a federally mandated assessment completed by facility staff, dated [DATE], showed: - Diagnoses included: Chronic obstructive pulmonary disease (COPD), a disease of the lungs making it difficult to breathe at times, muscle weakness, osteoporosis (bones become fragile from loss of tissue), diabetes mellitus (a disease in which the body does not process blood sugar appropriately), and anxiety. - He/she had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. - He/she required the assistance of two or more staff while repositioning in bed, transfers, getting dressed, using the toilet and bathing. - He/she did not have a history of falls while he/she was a resident in the facility. Review of the resident's undated care plan showed: - He/she had a code status of do not resuscitate (DNR). - He/she required extensive assistance from two staff for bed mobility. - He/she used the mechanical lift to maximize independence with turning and repositioning in bed. - He/she required assistance of two staff to get dressed. - He/she transferred with the mechanical lift and two staff. - He/she was at risk for falls. - Staff were to keep the low bed in the lowest position. - He/she was incontinent of bowel and bladder. - Staff are to provide perineal care after each incontinent episode. Review of the resident's Physicians Order Sheet (POS), dated [DATE], showed: - [DATE] DNR. - [DATE] Discharge from hospice services. - [DATE] Received an order to release the resident's body to the funeral home. Review of the resident's medical record included the following: - LPN A documented on [DATE] at 6:15 A.M., he/she was called to the resident's room by NA A. The resident was on the floor lying face down between the bed and the window. The resident's left arm was under his/her body and a pool of blood was under his/her head. His/her bed was in the low position. He/she requested RN A and LPN B to assist him/her. LPN B called the hospice provider. LPN A and RN A did not observe respirations, was unable to find a pulse (heartbeat), and saw that the resident had mottling (various shades of color of the skin). LPN A and RN A pronounced the resident as deceased at 6:20 A.M. He/she notified the physician. - RN A documented on the County Medical Examiner Death Report that was provided to the coroner, the manner of death was an accident. - There was no skin assessment documented. During an interview on [DATE] at 10:36 A.M., LPN A said: - On [DATE] at 6:15 A.M., NA A ran to him/her and reported that Resident #1 had rolled out of bed while he/she was cleaning the resident by him/herself. - The resident required two staff to turn him/her while in bed, but most staff turn him/her with one staff member. - He/she arrived in the room, found the resident lying on the floor between the bed and the window, face down, with his/her left arm tucked under him/her. - The bed was in the lowest position. - His/her head was crooked, his/her face was blue, and his/her body was warm and mottling and blood pooling under his/her head. - LPN A requested the help of two of the oncoming nurses. - RN A arrived to the resident's room and LPN B called hospice. - LPN A was not able to find a pulse by touching the right side of the resident's neck. He/she was not able to obtain a blood pressure, and did not observe respirations. - RN A listened for breath sounds with a stethoscope (a medical instrument used to hear breath sounds and heart tones). - LPN A and RN A pronounced the death of the resident. - LPN A and RN A turned the resident over after 10 to 20 minutes. - LPN A said that he/she and RN A delayed turning the resident over because they were concerned the resident may have broken his/her neck. - LPN A noted two large lacerations (cuts) to the resident's forehead. - LPN A and RN A did not listen for heart tones once the resident was turned onto his/her back. The resident did not make any sound. - Both nurses stepped out of the resident's room to discuss the resident's code status and hospice status. - LPN A, RN A, LPN B did not call 911, and did not attempt cardio-pulmonary resuscitation (CPR), because the resident had a code status of DNR and the staff thought the resident was receiving hospice services. - He/she called the on-call physician and obtained an order to release the resident's body to the funeral home. - LPN A said if the resident would have had a pulse or was struggling to breath he/she would have called 911. Review of the facility investigation, dated [DATE], showed: - NA A reported that the resident rolled out of bed and fell to the floor. - NA A reported that the resident did not make any sounds or attempt to stop his/her fall. - NA A yelled for the nurse. - LPN A and RN A assessed the resident and was noted to have no vital signs. - His/her code status was verified as a DNR. - He/she had two lacerations to his/her forehead and mottling to his/her lower extremities. - His/her bed was in the lowest position. - He/she was placed back into bed and cleaned up. - The resident's physician, hospice, and the Assistant Director of Nursing (ADON) were notified. - NA A documented in a statement on [DATE] he/she was in the room with the resident when he/she rolled off the bed onto the floor. - The resident did not make any sound or attempt to stop his/her fall. - It appeared as if the resident lost consciousness and collapsed. - He/she immediately ran to get the nurse. - LPN A documented in a statement on [DATE] he/she was called to the resident's room by NA A. - The resident was lying face down on the floor next to his/her bed. - His/her bed was in the lowest position. - Blood was under his/her head. - No pulse or respirations were noted. - He/she requested the help of RN A and LPN B. - RN A and LPN A pronounced the resident deceased at 6:20 A.M. - LPN B called the hospice provider. - ADON was in the facility and notified. - RN A documented in a statement [DATE] LPN A and NA A called from the resident's room requesting help. - Resident was on the floor by right side of the bed, bed was in the lowest position. - Head trauma noted on the resident's left side. - RN A called out the resident's name, felt for a pulse on the right side of his/her neck and did not feel a pulse. - At 6:40 A.M. the resident did not have a pulse, no respirations, and unable to obtain a blood pressure, his/her face was blue in color, his/her right eye pupil fixed. - RN A pronounced the resident's death. During an interview on [DATE] at 11:25 A.M., Nurse Aide (NA) A said: - On [DATE] at 6:15 A.M. he/she entered Resident #1's room to provide perineal care, the resident said Hi to him/her. - He/she was not supposed to turn the resident by him/herself, but there was only one other Certified Nurse Aide (CNA) working on the B and C hall that night and he/she was with another resident. - He/she knew the resident required two staff when turning in bed. - He/she raised the bed to knee height, turned the resident on his/her side away from NA A. - NA A was standing on the left side of the bed, the resident's back was towards NA A. - He/she finished providing perineal care. - His/her hand remained on the resident's left hip at all times. - The resident went off the side of the bed and landed on the floor on his/her stomach and face between the bed and the window. - It happened fast, the resident did not make a sound. - NA A ran to the nurses' station and reported the incident to LPN A. - LPN A arrived to his/her room and instructed NA A to step out of the room, because he/she was upset and crying. - The ADON was in the facility and made aware of the incident. - The ADON requested a statement from NA A. - Later the morning of [DATE], corporate reminded him/her that the resident was supposed to have two staff turn him/her. - He/she provided the resident's perineal care by him/herself, because there were two aides working on the resident's wing and the other aide was helping another resident. - He/she did not wait for the second aide to assist him/her with the resident's cares. - He/she had turned the resident in bed by him/herself in the past and did not have any problems. - Most of the aides provided the resident's cares alone. During an interview on [DATE] at 1:58 P.M., CNA B said: - He/she, NA A, and LPN A were the only staff for halls B and C on [DATE]. - He/she arrived at the resident's door after the incident. - NA A was crying and he/she consoled him/her. - He/she was unaware if the resident required two staff to roll in bed, because he/she did not work with the resident often. - He/she thinks that the resident care plans are found in the electronic medical record. During an interview on [DATE] at 4:55 P.M., RN A said: - He/she reported to duty on [DATE] at 6:30 A.M. - LPN A called him/her to the resident's room saying that the resident had fallen and he/she needed help lifting the resident off the floor. - The resident was lying on the floor between the bed and window lying face down. - It appeared as if the resident rolled from the bed to the floor. - The bed was in the low position. - He/she could see the resident's right side of his/her face. - His/her face was blue in color, and warm to the touch. - He she attempted to feel for a pulse in the right side of the resident's neck and was unable to feel a pulse. - He/she did not see the resident breathe. - He/she listened for breath sounds on the resident's back using his/her stethoscope and did not hear any breath sounds. - He/she was unable to obtain a blood pressure reading. - The resident right pupil in his/her eye was fixed (the pupil did not expand or contract when a light is shined on the eye). - He she saw a pool of blood under the resident's head. - He/she pronounced the resident dead. - RN A, LPN A, and the former ADON rolled the resident onto his/her back. - RN A saw two lacerations to his/her forehead. - He/she did not listen for breath sounds or heart sounds once the resident was turned to his/her back. - RN A, LPN A, and the former ADON lifted the resident back into bed. - LPN B called the hospice provider and the physician. - He/she did not call 911 because he/she thought the resident was receiving hospice services and was unable to find vital signs when he/she assessed the resident. During an interview on [DATE] at 4:08 P.M., LPN B said: - He/she reported to his/her work area on [DATE] at 6:32 A.M. - RN A arrived at the same time. - LPN A was standing outside of the resident's room. - LPN A reported that the resident had fallen and he/she needed help getting the resident off the floor. - LPN B arrived to the resident's room, saw the resident on the floor lying on his/her stomach, the right side of the resident's face was exposed. - The bed was in the lowest position. - He/she had a pool of blood under his/her head. - LPN A said that NA A was rolling the resident in bed and he/she rolled off of the bed. - LPN B asked if he/she should call an ambulance and send the resident to the emergency room . LPN A told LPN B that the resident was receiving hospice services. - LPN B left the room to call the hospice provider. - He/she reached the hospice nurse by phone, explained what he/she knew. - The hospice nurse said that he/she would arrive to the facility to assess the resident. - The hospice nurse discovered after his/her arrival that the resident was not receiving hospice services. - LPN B did not call 911 or the physician. - LPN B returned to the room and was told that the resident was dead. - LPN A, RN A, and ADON were in the room when LPN B arrived, the resident was still on his/her stomach. - The ADON was on the phone with a person from corporate and was instructed not to move the resident's body until corporate told them to. - Ten to 20 minutes later, LPN A, RN A, and the ADON picked the resident's head up, log rolled him/her onto a mechanical lift sling using the mechanical lift to get the resident back onto the bed. - The resident's face was purple, he/she had two large lacerations to his/her forehead. - The hospice nurse arrived at the facility at 7:00 A.M. provided post mortem care (care of the body after death), and at that time LPN B was made aware by the hospice nurse that the resident was not on hospice services. - The resident's face sheet showed that the resident was on hospice services. During an interview on [DATE] at 10:19 A.M., CNA A said: - Resident #1 did not fall very often. - He/she was immobile and dependent on staff for all cares. - He/she required two staff to turn while in bed and the mechanical lift to transfer. During an interview on [DATE] at 1:46 P.M., the Regional Director of Operations said: - He/she received a telephone call notifying him/her that the resident had a fall. - He/she said NA A was tucking the incontinent brief under the resident and the resident rolled off of the bed and onto the floor face first. During an interview on [DATE] at 4:30 P.M., the former ADON said: - He/she arrived to work that A.M. and was working as a CNA. - LPN A reported to him/her the resident had fallen and died . - He/she went to the resident's room. The resident was lying on the floor face down with his/her left arm under him/her. - He/she did not remember the positioning of the resident's neck. - The resident's head of bed was elevated to 30 to 40 degrees and the bed was in low position. - His/her face was purple in color and there was a pool of blood under his/her head. - He/she called the regional nurse, who instructed him/her to place the resident in bed. - He/she, LPN A, and RN A rolled the resident over onto a mechanical lift sling and lifted the resident into bed. - LPN A reported to him/her that NA A was providing perineal care to the resident by him/herself and the resident rolled out of bed and onto the floor face down. - He/she did not call 911 or the physician. - He/she did not write a statement. - He/she called the Director of Nursing (DON) first, then called the regional nurse. - He/she did not call 911 because the resident's code status was DNR and he/she thought the resident was receiving hospice services. During an interview on [DATE] at 4:33 P.M., the former DON said: - He/she was on vacation when the incident occurred. - The former ADON called him/her and reported that a NA was providing care to the resident by him/herself and the resident rolled out of bed and died . - The DON returned to work on [DATE]. During an interview on [DATE] at 2:53 P.M., Nurse Practitioner (NP) A said: - The resident was dependent on staff for all cares. - The resident required two staff to provide bed mobility, incontinent care. - The resident required two staff and the mechanical lift to transfer. - He/she expected the facility staff to notify the physician immediately. - He/she expected the facility to call 911, regardless of the resident's DNR status when there was an accident. During an interview on [DATE] at 1:20 P.M., the hospice LPN said: - He/she received a call from the facility nurse on [DATE] at 6:38 A.M. stating that the resident had fallen, hit his/her head and died . - He/she notified the resident's family of the resident fall as he/she was in route to the facility. - He/she arrived at the facility at 7:00 A.M. and saw the nurses and aides at the nurses' station. - NA A was at the nurses' desk crying and said that the resident had a bad fall and there was a lot of blood. - The resident was in his/her room alone lying in bed face up with blood on his/her gown and sheets. - The top of the resident's forehead was covered in blood and extended into the resident's hair. - His/her face was pale, he/she was warm to the touch. - He/she had a large laceration to his/her forehead that measured two inches long by ,d+[DATE] of an inch wide, and a second laceration to the bridge of his/her nose. - He/she contacted his/her supervisor to clarify the resident hospice service status, because he/she was unable to find the resident was receiving services. - He/she was notified that the resident had been discharged from hospice services on [DATE]. - He/she finished cleaning the resident's body and placed a bandage over the lacerations on his/her head. - LPN A told him/her that he/she did not know the resident was not receiving hospice services. - He/she exited the facility once he/she finished cleaning the resident and covered the lacerations so the family would not see the resident in that condition. During an interview on [DATE] at 1:36 P.M., the Administrator said: - He/she was out of town at the time the incident occurred. - He/she reported to work on [DATE] at 2:00 P.M. - He/she was told that NA A was in the resident's room talking with the resident and changing the resident's incontinent brief and suddenly the resident fell off the side of the bed. - He/she was told that the resident's code status was a DNR and he/she was receiving hospice services. - He/she expected the nurses to call the physician and follow the physician's orders. During an interview on [DATE] at 9:44 A.M., Family Member A said: - On [DATE] he/she was called by Hospice LPN A saying that the facility called and reported that the resident had died . - He/she thought it was strange that the hospice nurse would call, because the resident was not receiving hospice services. - He/she arrived at the facility and the resident looked terrible. - He/she had a large bandage on his/her forehead, his/her face was grimaced, and there was bruising around both eye sockets and his/her nose. - Later in the morning of [DATE], the regional director of operations called him/her and told him/her that it appeared as if the resident died in bed and then rolled to the floor. - He/she was not satisfied with the explanation. - He/she talked with the regional director of operations again on [DATE] seeking an answer as to what happened to the resident. - The regional director of operations told him/her that he/she would report to the family once the investigation was completed. - He/she had not been told the investigation findings. During an interview on [DATE] at 12:15 P.M. Family Member B said: - The former DON told him/her that a staff member was providing perineal care on the resident alone, the staff member turned him/her on his/her side. - The resident rolled off of the bed onto the floor, cracked his/her head open, and died . - The Regional Director of Operations told him/her that it appeared as if the resident was on his/her side, passed away and then rolled onto the floor. - The Regional Director of Operations told him/her the nurse caring for the resident after the accident said that the resident could have had a stroke or heart attack while lying on his/her side, passed away and then rolled off of the bed onto the floor. - He/she did not find that a reasonable response and asked further questions. - At that time, the regional director of operations advised that he/she should pose his/her questions in an email and declined to answer further questions. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite 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(s). MO202149

Based on record review and interviews the facility failed to ensure one of three sampled residents (Resident #1) obtained his/her highest level of psychosocial well-being when staff failed to meet the needs needs of the resident and seek appropriate placement after the resident displayed an increase of physical and verbal behaviors and was a danger to others despite medication adjustments and non-pharmaceutical interventions. The facility census was 72. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/29/16, showed: - [DIAGNOSES REDACTED]. - Behaviors included delusions, physical behaviors directed towards others, did not put others at risk for injury, did not disrupt the care or living environment, wandered and significantly intruded on the privacy and activity of others. Review of nurses' notes showed: - On 9/23/16 At 9:09 A.M., the resident was argumentative. At 5:58 P.M., the resident became aggressive with the nurse and pinched and squeezed the nurse's arms and hands and elbowed the nurse in the jaw; - On 9/25/16, at 1:41 P.M., the resident was aggressive with staff during cares and took a blanket off another resident; - On 10/3/16, at 8:18 P.M., became aggressive with staff during care and caused a skin tear to staff; - On 10/4/16, at 4:36 A.M., the resident was restless and staff could not redirect with a cookie or a photo album. The resident tipped his/her recliner over and sat on the footrest of the recliner. Staff could not redirect him/her with toileting and the resident was brought to the nurses' station for closer monitoring; - On 10/12/17, at 1:52 P.M., the resident refused to get out of the recliner and sat in the recliner with only an incontinent brief, blanket and t-shirt on. When approached by staff he/she grabbed and pushed staff; - On 10/15/16, at 11:15 A.M., the resident hit an aide in the face and shoved the aide against the wall when the aide tried to assist the resident to the restroom; - On 10/22/16, at 1:22 P.M., the resident ambulated without staff and when staff attempted to assist the resident, the resident became aggressive and doubled up his/her fist and tried to hit staff in the face and cursed at them. The resident wandered the halls in wet pants and would not allow staff to provide assistance. After several attempts the physician was called and received an order for [REDACTED].>- On 11/1/17, at 1:27 A.M., the resident grabbed two aides' arms during a shower and twisted their arms and dug his/her finger nails into them, hit one aide with a wet washcloth and drew back his/her fist and said I'll kill you; - On 11/11/17, at 10:25 P.M., the resident was extremely agitated. When staff brought the resident from the dining room down the hall, the resident grabbed one of the aide's arms and started to twist it and he/she could not get loose. Once he/she got loose, the resident grabbed another aides arm and did the same thing to him/her. Another nurse called the resident's name and the resident let go. The resident was allowed to move on about his/her business until the resident tried to get out of the wheelchair without assistance. The nurse went to help the resident and the resident tried to hit him/her. Another staff member came to help and the resident grabbed and squeezed his/her arm and when he/she got loose the resident did the same to the nurse. The nurse attempted to give medication to see if it would help. Before he/she could give the medication, the resident tried to swing and hit him/her and the aide in the face. They decided to leave the resident alone but that did not work because the resident tried to get out of his/her wheelchair on his/her own. Another nurse went to help and the resident slapped the nurse in the face. The nurse called the Family Nurse Practitioner (FNP) and asked for an order for [REDACTED]. - On 11/22/16, at 12:59 A.M., the resident was anxious and wandered into other residents' rooms and stood up. Medication given to calm the resident down; - On 12/1/16, at 4:07 A.M., the resident wandered the halls and stood up by him/herself and walked the halls. Staff could not easily redirect the resident and the resident swung at a couple of staff members. The resident was given an antianxiety medicine and calmed down; - On 12/29/17, at 1:21 A.M., the resident was restless, got up and down from the recliner; - On 1/4/17, at 9:29 P.M., stood up from the wheelchair several times and staff were not able to redirect the resident; - On 1/9/17, at 12:42 A.M., the resident tried to get up from his/her wheelchair in the hall. Staff had to sit with him/her most of the evening and tried to do an activity to redirect him/her but the activity was not successful. Review of the physician notes dated 1/16/17 showed a [DIAGNOSES REDACTED]. Increase [MEDICATION NAME] (antipsychotic) to 50 mg (milligrams) in the morning. Review of the nurses' notes showed: - On 1/26/17, at 12:21 A.M., the resident wondered in the hallway and tried to get up from his/her wheelchair; - On 1/28/17, at 4:28 A.M., the resident tried to get up from the wheelchair by him/herself and swung at staff. Staff gave the resident an antianxiety medication and it did not work. After assisting the resident to the restroom, the resident finally settled down; - On 1/31/17, at 5:57 A.M., the resident wandered the halls and attempted to get out of the wheelchair without assistance. Staff could only redirect the resident for a short period of time; - On 2/2/17, at 1:37 A.M., the resident was restless and tried to get out of his/her wheelchair and tipped the wheelchair over and lay on the floor; - On 2/3/17, at 10:19 A.M., the resident was physically combative with staff during a bath; - On 2/6/17, at 12:26 A.M., the resident wandered and tried to get out of his/her chair and climbed out of bed. Staff gave the resident an antianxiety medication; - On 2/7/17, at 1:17 A.M., the resident was restless and tried to get out of his/her chair. Staff was not able to redirect so they gave the resident an antianxiety medication. The resident hit staff in the face while they attempted to assist the resident with changing his/her wet pants; - On 2/8/17, at 7:44 A.M., staff heard the resident's alarm and after investigating found the resident using the toilet in a female resident's room. The resident was very agitated and attempted to hit several staff. Staff gave the resident an antianxiety medication; - On 2/18/17, at 12:45 P.M., the resident scratched and dug his/her finger nails into a staff members arm and would not let go of the staff member while attempting to get out of bed. Review of the psychiatrist notes dated 2/15/17, showed the resident was uncooperative, had agitation, hopeless, easily distracted, judgment impaired, had delusions and behavior problems. Recommendations included to decrease [MEDICATION NAME] (antipsychotic) 50 milligrams (mg) at bedtime, increase [MEDICATION NAME] (antidepressant) 22.5 mg at bedtime, and [MEDICATION NAME] (antipsychotic) 2.5. mg every four hours as needed. Review of the Social Services Designee (SSD) notes dated 3/1/17, showed the resident was very difficult to redirect, very impulsive and takes off walking at times. The resident had been physically abusive to others by grabbing a hold of them and refused to let go and does not understand he/she is hurting them. The resident did not understand redirection so it was difficult to get him/her to let go. The resident had had some falls and saw the psychiatrist as needed. Review of the nurses' notes showed: - On 3/1/17, at 6:04 A.M., the resident stood up in his/her chair and the aide went to help the resident and the resident tried to hit the aide and another aide. The aide followed the resident while the resident followed another resident into the dining room and kicked another resident's wheelchair; - On 3/4/17, at 12:40 P.M., the resident punched the nurse in the side of the face while the nurse applied medication to the resident's abdomen. The resident seemed cooperative at first and then hit the nurse in the side of the face; - On 3/11/17, at 4:32 P.M., the resident remained very agitated and staff gave the resident antianxiety medication; - On 3/12/17, at 9:47 A.M., the resident was found in another resident's room sitting in a laundry basket trying to have a bowel movement. The resident became combative when staff removed the resident from the other resident's room; - On 3/20/17, at 11:36 A.M., the resident punched and squeezed staff when they got the resident up; - On 3/23/17, at 4:19 A.M., the resident wandered the halls and cried. Staff could not understand the resident so staff gave the resident a snack and the resident went to bed. Review of the care plan updated 3/23/17, showed: - Problem of elopement risk, wanderer, impaired safety awareness and significantly intrudes on the privacy and activities of others. Interventions included Review of the Family Nurse Practitioner (FNP) notes dated 3/20/17, showed the resident had a [DIAGNOSES REDACTED]. The plan for the resident was to add [MEDICATION NAME] sprinkles (used as a mood stabilizer) once a day and reevaluate in a couple weeks. The medication changes were discussed with the DON . Review of the care plan updated 3/23/17, showed the resident's problems included elopement risk, wanderer, impaired safety awareness and significantly intrudes on the privacy and activities of others. Interventions included: - Approach with a male staff member to offer guidance. The resident may listen more than with a female; - Identify patterns of wandering, is the resident is looking for something or needs something; - The resident could become agitated when combative. Re-approach the resident when it is safe; - Redirect the resident if he/she approaches the exterior of another resident's room; - Last revised 10/18/16; Another problem was impaired cognitive function. Interventions included: - Staff could call family to sit with the resident when the resident was agitated; - Discuss concerns about confusion and nursing home placement with the resident's family; - Too many staff members assisting the resident would overwhelm the resident and the resident may become combative; - Last revised 10/18/16; Problem with resistance to care and combativeness related to adjustment to nursing home. Interventions included; - Charge nurse may call family for support; - Do not surround the resident with too many staff members if agitated or combative. This will only agitate the resident more; - If the resident resists care, leave for five or 10 minutes and try again; - The resident had a history of [REDACTED]. - Re-approach with a male staff member when needed. The resident may listen to a male more than a female; - Last revised 10/18/16. Review of the nurses' noted showed: - On 4/1/17, at 2:33 P.M., staff assisted the resident who was agreeable at first and then the resident grabbed the staffs hand and started twisting their fingers and would not let go. Additional staff assistance obtained to get the resident to let go of the staffs fingers; - On 4/2/17, at 12:07 P.M., staff assisted the resident to the restroom and the resident became agitated and swung at the staff; Review of the psychiatrist notes dated 4/5/17, showed the resident had been agitated and combative. Discontinue the Quetiapine (antipsychotic) and [MEDICATION NAME] (antianxiety) and increase the [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antidepressant). Review of the SW notes dated 4/6/17, at 8:53 A.M., showed the psychiatrist visited and made medication suggestions for behaviors and said if the behaviors do not improve, a geriatric psychiatric admission may be the answer. Review of the nurses' notes showed on 4/6/17, at 10:30 A.M., a condition report was called to the FNP. The FNP wants input from the DON prior to increasing the resident's [MEDICATION NAME] and [MEDICATION NAME]. The resident kicked and punched the nurse when he/she tried to get the resident up for lunch. During an interview on 4/11/17, at 11:30 A.M., Certified Nurse Aide (CNA) A said the resident started having behaviors shortly after coming to the facility. The resident had good and bad days. The resident did not like redirection and it set the resident off. The resident had kicked, punched and hit him/her with a wet wash cloth. The resident punched him/her in the jaw and head one time and it hurt for a few days. He/she knows to be careful with the resident because the resident was very strong. The night shift just left the resident alone if the resident was asleep, so they didn't set the resident off. The resident wandered into other residents' rooms. During an interview on 4/12/17, at 10:45 CNA B said the resident was fine one minute and not the next. He/she assisted the resident in the restroom and when the resident got up off the toilet the resident hit him/her with his/her fist directly in the stomach knocking him/her into the wall. During an interview on 4/11/17, at 5:30 P.M., CNA C said the resident has always had issues but they seemed to have gotten worse lately. The resident has hit him/her in the face, punched him/her in the stomach and knocked him/her into the bathroom wall. The resident's mood changed from minute to minute. The resident has been belligerent to other residents but had never hurt another resident as far as he/she knew. There are a lot of residents who are scared of the resident. Another resident asked to have their door closed the other day because they were scared. During an interview on 4/11/17, at 5:37 P.M., CNA D said the resident had behaviors every day and hits, cries, bites, smacks, kicks and punches staff. Staff walked the resident to assist with the behaviors. The resident hit him/her with a call light one time. The resident is very strong and goes into other resident rooms. During an interview on 4/12/17, at 10:25 A.M., Resident #2 who had a Brief Interview for Mental Status (BIM's) score of 15 on 2/13/17, indicating the resident was cognitively intact said Resident #1 came into his/her room one time and held onto his/her arm and scared him/her. After that when he/she saw the resident in the hall he/she closed his/her door so the resident would not come into his/her room. During an interview on 4/12/17, at 10:35 A.M., Resident #3 who had a BIM's score of 14 on 3/20/17, indicating the resident was cognitively intact said the resident came into his/her room one time while he/she was laid in bed and stood over the bed and stared at him/her. Staff came in and had the resident leave. During an interview on 4/12/17, at 4:55 P.M., Family Member A said on 4/7/17, Resident #1 came into his/her family member's room and would not leave. The resident braced his/her feet against the wall so he/she could not push the resident out of the room. The resident did not get much further than the door way and he/she was not going to let the resident get any further in the room. He/she feared for his/her family members safety who is bed bound unless a mechanical lift is used to assist them out of bed. The resident tried to punch him/her several times and he/she managed to dodge the punches. The resident is dangerous to staff and other residents and has been for a long time. He/she is very unhappy about the situation and reported it to the administrator first thing on Monday morning 4/10/17. Review of the nurses' notes showed: -On 4/7/17, at 9:50 A.M., the resident went into other resident's rooms and hit and kicked staff when they tried to remove the resident; - On 4/9/17, at 9:22 A.M., P.M., the resident walked around without assistance. The resident hit an aide with his/her fist while the aide assisted the resident to the restroom. At 1:11 P.M., the resident went into other resident rooms and went through the first set of the outside doors. At 4:37 P.M., the resident went into another resident's room and tried to take the oxygen off the other resident and became very agitated and twisted staffs arms. During an interview on 4/10/17, at 3:45 P.M., the activity director assistant (ADA) said the resident had good and bad days. The resident did have behaviors and hit her in the chin about two months ago. She reported it to the DON. The resident had been up and down all day on 4/9/17, and she walked with the resident and even took the resident outside and gave the resident a soda. The resident tried to get up out of the wheelchair in the dining room during dinner and she went to assist the resident. The resident bent her over the table and punched her in the mouth breaking her lip open and then flipped her over and put her in a choke hold. She told the only other staff member in the dining room to go get help. There were four female residents at the table eating dinner where it happened. The resident still had her in a choke hold when staff arrived. The resident let her go and got another CNA's arm and twisted it behind the CNA's back. She thought the resident was going to break the CNA's arm. During an interview on 4/11/17, the dietary aide (DA) A said on 4/9/17 the ADA asked him/her to go get help to assist Resident #1 to sit down. He/she used the phone and called for help. He/she turned around and the resident had the ADA in a choke hold and the ADA's face was red. He/she yelled down the hall to staff and said now. When staff came in the resident let go of the ADA and grabbed a CNA and twisted the CNA's arm while the CNA screamed. Staff did not have time to move any of the other residents out of the way. During an interview on 4/11/17, at 5:37 P.M., CNA D said after the resident choked a staff member in the dining room, he/she tried to calm the resident down and the resident got a hold of his/her arm and twisted it behind his/her back and would not let go. He/she cried out in pain and had tears in his her eyes from the pain when the resident had a hold of his/her arm. He/she always told the nurse when the resident became aggressive because it happened several times each shift. During an interview on 4/11/17, at 2:25 P.M., Resident #4 who had a BIM's score of 15 on 2/6/17, indicating the resident was cognitively intact, said the resident choked the ADA in the dining room on the dining room table during lunch. He/she was scared and who wouldn't be. The ADA did not do anything and is always so nice to everyone and tries to help them. Review of the nurses' notes dated 4/9/17, showed at 5:35 P.M., staff tried to assist the resident in the dining room and the resident pushed a staff member over the dining room table and hit the staff member in the mouth with his fist causing the staff members lip to bust open. The resident turned the staff member over on the table and put the staff member in a choke hold. The resident was very aggressive with all of the staff and got another staff member by the arm and twisted it while she tried to provide first aid. Staff called the on call doctor and received an order for [REDACTED].>During an interview on 4/11/17, at 11:00 A.M., Licensed Practical Nurse (LPN) A said the resident was aggressive hitting, pushing and punching staff for the last few months. The resident has pushed, twisted his/her arms and punched him/her. After the resident choked staff, he/she called the administrator and the administrator told him/her to keep the resident on a one to one until the resident went to bed. He/she gave the resident IM [MEDICATION NAME] and notified the DON. He/she did not know if the resident needed to be a one to one the next day when he/she got off shift in the morning. During an interview on 4/10/17, at 3:45 P.M., the ADA said when she came to work at around 8:30 A.M., the resident was still asleep. He/she wheeled him/herself into the dining room around 10:00 to 10:30 A.M., and the resident hit the Activity Director (AD) in the face with his/her fist. The resident pulled his pants down and wet all over the floor. Staff took the resident to his/her room after that. During an interview on 4/11/17, at 12:21 P.M., CNA E said the resident slept until about nine on 4/10/17. The resident started to get up on his/her own and he/she got the resident out of bed and dressed. He/she took the resident to the dining room and sat the resident at the resident's seat for breakfast and left. Nobody told him/her the resident was a one to one. After breakfast another staff member put the resident in his/her recliner and the resident slept for a while. Staff got the resident up for lunch and sat the resident at the nurses' station so staff could keep an eye on the resident. During an interview on 4/11/17, at 10:30 A.M., the activity director (AD) said on 4/10/17, the resident was in the dining room. The resident tried to stand up in his/her wheelchair and she went to assist the resident. She stood in front of the resident and suggested for him/her to sit down and the resident hit her in the face with his/her fist. Review of the physician notes dated 4/10/17, showed the resident had increased behaviors, agitation, and combativeness and struck a nurse last night. Review of the physician orders [REDACTED]. - [MEDICATION NAME] sprinkles (mood stabilizer) 125 mg four times a day for Alzheimer's; - [MEDICATION NAME] (antipsychotic) 1 mg inject the medication IM every four hours as needed for combativeness; - [MEDICATION NAME] 2.5 mg every six hours if needed for behaviors; - [MEDICATION NAME] 5 mg a day for behaviors. During an interview on 4/10/17, at 3:15 P.M., the administrator said she was aware the resident hit and choked staff on 4/9/17. She told the nurse to keep the resident on a one to one until the resident went to bed and to use the bed alarm. She had not assessed the other resident's to make sure they were safe and felt safe. She wanted the resident to go to a geriatric psychiatric facility for treatment for [REDACTED].#1's family member, did not want the resident to go. After the resident hit another staff member this morning the resident's family member was called in to sit with the resident. Staff sat with the resident until another family member arrived. This morning she received a report from a family member of another resident indicating the resident had got into a residents room on 4/7/17, and blocked the door way and would not leave. During an interview on 4/12/17, at 1:30 P.M.,the administrator said residents should feel safe at the facility. The facility had difficulty deciding to send the resident out for additional treatment because the resident was a family member of the DON's. MO 2

Based on interview and record review the facility failed to provide care and services to maintain one alert and oriented resident's (Resident #1) physical, mental, and psychosocial well being. Staff did not consider the resident's refusal to change his/her clothing and incontinence brief, before assisting the resident from chair to a standing position, and changing his/her brief. During this time, the resident physically resist which resulted in multiple bruises on both his/her arms. Additionally, the Licensed Practical Nurse (LPN) charge nurse staff did not report the incident to Supervisory staff to initiate an assessment of the resident's injuries and an investigation of the cause for a period of 12-14 hours. The facility census was 85. 1. Review of the explanation of resident rights provided to residents at the time of admission included: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident including each of the following rights: - The resident has the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights. - A facility must immediately inform the resident; consult with the residents physician, and if known notify the residents legal representative or an interested family member when there is a significant change in the residents physical, mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life threatening condition or clinical complications. - A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. - The resident has the right to self-determination and participation and can make choices about aspects of his or her life in the facility that are significant to the resident. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/17/12 showed the resident: - Demonstrated no difficulty hearing, has clear speech, and makes self understood; - Demonstrated clear comprehension and the ability to understand others; - Brief Interview for Mental Status (BIMS) score of 15 (Score of 13-15 indicate cognitively intact); - Demonstrated no difficulty focusing attention; - Demonstrated no evidence of disorganized thinking; - Demonstrated no trouble concentrating on things such as reading a newspaper or watching TV; - No behavior symptoms directed against others, such as hitting, kicking, pushing, scratching, or grabbing; - Behavior not exhibited for rejection of cares; - Independent in bed mobility, transferring, walking in room and locomotion off unit, dressing, eating, toilet use, and personal hygiene; - Demonstrated good balance during transferring and walking; - Steady at all times during moving on and off the toilet, turning around and facing the opposite direction; - Ambulates with a walker; - Always continent of bowel and bladder; - Height 62 inches, weight 129 pounds; - The resident participated in this assessment. Review of the resident's revised activity preferences dated 7/17/12 and the updated activity assessment on 9/27/12 showed: - The choice of what clothes to wear, and the choice of his/her own bedtime was very important to the resident; - Participation in religious services was very important; - Group activities were very important; - The resident preferred to play games, exercise, and watch TV. Review of the updated care plan on 7/17/12 showed the resident: - Has steady gait and is up as desired; - Transfers as desired; - Independently used a walker for mobility; - Is usually independent with bed mobility; - Continent of bowel and bladder; - Is asked by staff what he/she has done with past/present pain and staff is to assist with his/her ideas. Review of the interdisciplinary progress notes dated 7/17/12 showed the resident: - Is alert and oriented; - Pleasant and cooperative with cares; - Makes wants and needs known with clear speech; - Ambulates with walker and independent with transfers; - Takes self to the bathroom and is continent of bowel and bladder; - Had no recent falls. Review of the nurses notes showed the resident on the following dates: 8/13/12 - Was pleasant and cooperative; 9/1/12 - Requested stronger pain medication; 9/2/12 - Had increased pain and new order received, [MEDICATION NAME] 7.5/500mg, one tablet by mouth every six hours as needed; 9/4/12 - Was pleasant and cooperative with staff; 9/5/12 - Resident constantly complaining of pain; 9/10/12- Medication order changed to [MEDICATION NAME] 7.5/500 mg, one tablet by mouth every four hours as needed; 9/11/12 - Was pleasant and cooperative; 9/15/12 - Resident demanding that he/she gets strawberry ice cream. Resident advised that he/she is on a fluid restriction and would have to give up lemonade and water if he/she wanted the ice cream. Resident stated he/she would not give up his/her water and proceeded to call the nurse a "smart ass [***] ." Resident's spouse notified the resident was being verbally abusive. The resident refuses to change clothes because he/she does not want to change until he/she has taken a shower; 9/17/12 - Refuses to change clothes, calls the nurse stupid when staff attempted to educate on skin breakdown. A note was left by nurse for social services regarding the resident not wanting to change clothes; Review of a note dated 9/17/12 from LPN A to social services (SS) showed LPN A informed SS the resident refuses to change clothes after multiple attempts. (He/she) told me it was stupid and I couldn't make her do it. Review of the resident's nurses notes dated 9/18/12 showed staff documented an assessment of the resident as "alert and oriented times three (oriented to person, place, and time)." At 8:45 P.M., the resident "refused to change clothes, resident very combative." Review of the nurses note dated 9/19/12 at 12:00 noon showed: - Bilateral arm bruising related to incident of the resident's combative behavior on 9/18/12; - Uniform bruising over both arms; - The resident states he/she was fighting with staff; - Nurse practitioner notified; - Stat labs, CBC, CHEM 12, and Urinary Analysis ordered. - The resident is clean and sitting in recliner. In an interview on 10/10/12 at 9:15 A.M., CNA B said on 9/16/12, the resident got up from his/her chair and walked to the residents bathroom that had a shower in it. The resident was aware and "seemed competent." He/she gave the resident his/her shower. The resident's skin was not bruised anywhere. After the shower, he/she put a clean brief on the resident. In an interview on 10/4/12 at 2:25 P.M. and 4:10 P.M., SS said: - On 9/18/12, he/she received a note from LPN A stating the resident refused to change his/her clothes and wanted SS to talk to the resident. He/she was busy that day, did not detect any urgency in the note and "forgot" to respond to the request. - He/she did not recall talking to LPN A about interventions. - He/she did not know the gravity of the situation and later found out about the incident. He/she was expected to respond to resident concerns. He/she typically responds to requests by talking to the resident and investigating to determine what the issue is. -He/she did not know what the guidelines were or what should be done if any residents' brief was soiled but the resident refused care. SS said if any resident is combative, staff should involve the residents family. Staff should not attempt interventions when the resident refuses. Staff should report the problem to the Administration. In an interview on 10/4/12 at 3:25 P.M., LPN A said: - The resident was resistive to care and would not change his/her clothes for three to four days prior to 9/18/12. The clothes had tea/coffee stains on them. - On 9/18/12 during the evening shift, CMT A said the resident's brief was soiled and the resident was refusing to change. He/she was the charge nurse and was worried if they did not change the resident's brief the resident could get a urinary tract infection or he/she could be accused of neglect by the residents family. - He/she talked to social services earlier in the day about talking to the resident and the resident's spouse. SS said they needed to have a care plan meeting. - LPN A notified the on call supervisor (supervisor) by texting him/her about the resident's status. The supervisor told LPN A to call the resident's family. LPN A said he/she did not follow the supervisors instruction and thought he/she would try to change the resident first, to avoid calling the family so late. LPN A, LPN B, and Graduate Nurse (GN) went in the resident's room. He/she told the resident they needed to change his/her pants. The resident said he/she would take a shower in the morning and change his/her pants then. They did not offer the resident a shower. The resident told LPN A that LPN A was yelling at him/her, and said LPN A was stupid. Then, GN and LPN B put a gait belt on the resident in order to assist the resident to stand up from the recliner. When GN and LPN B stood the resident up, the resident screamed "at the top of his/her lungs for help", flailed his/her arms, scratching out and causing a commotion. He/she could not recall anyone holding the residents arms. Other staff came in the room during the incident. He/she thought the other staff were CMT B, CNA A, and a new staff person. The resident kicked GN in the head. The residents brief and incontinence pad in the residents chair were "dirty and wet." LPN A changed the resident's brief but was not able to provide peri-care due to the resident's resistance, and then GN and LPN B sat the resident down in his/her recliner. The resident was fighting and hitting. The resident then went into the corridor and yelled for administration and to call his/her family. The resident undid his/her shirt and showed bruises on his/her forearms. LPN A said he/she thought the resident sustained [REDACTED]. - Right after the incident, LPN A attempted to notify family member (FM) B and could not reach him/her. He/she then notified the resident's spouse who said do what you need to do for the resident's care. The resident talked to the spouse and then said "I guess I'll go back in my room and behave myself." - LPN A did not do a full body assessment. He/she passed the incident information along in report but did not say a body assessment was needed. It probably should have been done. - The bruises on the residents forearms were much worse the next day. The new bruises were purple in color. The bruises looked "really bad." - Looking back on the situation he/she should have called the resident's family and physician before changing the resident's brief. They could have offered the resident a shower. - Since the incident the DON talked to him/her about better options. He/she did not receive any disciplinary action regarding his/her actions or for not following the supervisors direction to call the family. In an interview on 10/4/12 at 11:18 A.M., regarding the incident on 9/18/12, the resident said staff wanted him/her to put on clean clothes the day before he/she was to have a shower. He/she told the staff "No." The staff wrestled him/her around. It was awful. They took my hands and grabbed my arm. The staff wrestled with me and I wrestled back. There must have been five or six staff holding me. He/she could not recall the names of the staff that held him/her. The staff did not care about what he/she wanted and did what they wanted. The staff did not tell him/her about his/her risk of skin break down. It was terrible. It was a fight. It was a frustrating thing. I don't like to be told that I am going to do something when I don't want to. It is not reasonable to make me. Staff did not intend to hurt me, they intended to do what they wanted to do and they hurt me. They wanted to change me and I wanted them to leave me alone. I go to the toilet myself. No one told me I needed anything. I was very upset and I try not to get that way. The staff should have left me alone. I do not tell others what to do. I should be able to do what I want. I was very upset, I tried to fight them off. I don't know if I kicked anyone. In an interview on 10/4/12 at 1:57 P.M., (LPN) B said: - On 9/18/12, LPN A got him/her and GN and told them the resident had not changed his/her clothes or brief in three days and needed to be changed. The three staff entered the resident's room and LPN A told the resident they were going to change his/her clothes he/she had worn for the past three days. The resident started screaming that he/she was not going to change the clothes and screamed for help. LPN B knew it would be a fight. The resident fought the staff the whole time by screaming, scratching, punching and flailing his/her arms. GN and LPN B put a gait belt around the resident's waist. LPN A changed the resident's depend. The depend had a smear of bowel and was soaked with urine. The resident's clothes were not real dirty. The resident had on a long sleeved shirt. - LPN B was not aware of any interventions attempted prior to forcing the resident to change. - After the incident, LPN A tried to call the residents (son) and spouse and called the administrator on call. - LPN B was not aware of when the resident was bruised. - LPN B said they should have waited for the resident to calm down. - The family and the physician should have been notified to see if they could calm the resident down before changing his/her brief. - After the incident, LPN B thought he/she should have intervened at the time to stop it. - LPN B did not tell anyone about the incident. He/she did not, but should have reported the incident to the administrator based on the residents reaction. In an interview on 10/4/12 at 4:45 P.M., GN said: - On 9/18/12, he/she was a nurse aide on the evening shift. LPN A pulled him/her from another hall and asked him/her if he/she could help change the resident's brief and clothes. LPN A said the resident had not changed his/her brief for a few days and did not want to be changed. He/she did not ask LPN A what interventions were attempted to respond to the residents refusal to be changed. GN thought LPN A would have done interventions prior. When they went into the resident's room someone asked the resident if they could change his/her brief and the resident said "No." GN then asked the resident if he/she could change the resident brief and the resident told GN "no too." After the resident said "No", he/she started fighting to get the staff to leave him/her alone. LPN A asked the resident to calm down. GN and LPN B went to stand the resident up by using a gait belt. At some point, CNA A, CMT B, and a new staff person came in the room. During the process of standing the resident up the resident was kicking from his/her chair. GN let go of the gait belt in order to help LPN A, who was pregnant, change the resident. The resident can stand on his/her own. GN bent down to help change the residents brief and the resident grabbed GN's hair, kicked GN in the head, and scratched GN's arm. The resident tried to bite. LPN A changed the resident brief. The brief was saturated and very soiled with a soft small to medium sized bowel movement. The resident was confused, angry, and upset as the residents authority was questioned. The resident said he/she was angry. Anytime a person is not responsible to make their own decisions they have a right to be angry. GN did not touch the resident. GN did what LPN A told him/her to do because he/she was not the nurse that day and was acting as an aide. - The situation could have been handled differently. They were trained to use family, physician, change wording when talking to the resident, and call the supervisor. -LPN A should have reviewed options to change the residents brief considering the resident's potential for skin break down in comparison with residents rights to refuse care. LPN A should have called the resident physician and family to assist. Something needed to be done for the residents benefit because he/she was soiled. - The resident has a right to refuse care and to be informed of health risk. Then it is nursing judgment to determine what is best for the resident. The instruction given to him/her by LPN A was that the residents brief needed to be changed. - GN did not know how the resident could be bruised. - After the incident a head to toe assessment should have been done on the resident when he/she was calm. LPN A should have passed it on at shift change for the on-coming nurse to do. During an interview on 10/4/12 at 7:10 P.M., the nurse supervisor said: - On 9/18/12, LPN A called him/her between 10:15 P.M. and 10:30 P.M., stating the resident was very upset. The resident was incontinent of bladder and bowels that went all over including the resident's chair. The resident did not want to change his/her clothes. The supervisor told LPN A to call someone in the resident's family to help and then call the physician on call if medication to calm the resident was needed. - LPN A did not call the supervisor back that night. The nurse supervisor assumed everything was okay. - LPN A expected to be notified if there was a problem. LPN A should have informed him/her about the incident. - He/she expected his/her instructions to be followed. It was not okay that LPN A did not follow his/her instructions. - LPN A should not have changed the resident's brief when the resident did not want him/her to. - A head to toe assessment should have been done after the incident. In interviews on 10/5/12 at 7:30 P.M. and 8:04 P.M., regarding the incident on 9/18/12, CMT A said the resident refused to change his/her brief. The resident preferred to put toilet paper in his/her brief and switch with clean toilet paper as needed instead of changing his/her brief. The resident insisted he/she would not change the brief until he/she took a shower the next day. CMT A had certified nurse aide (CNA) A ask the resident if he/she could change him/her and the resident refused. LPN A, GN, and LPN B, went to the residents room to change the resident. CMT A said he/she was not there and could not say what happened. CMT A could hear the resident screaming for a minute. CMT A thought it was best not to go in the residents room and upset him/her more. CMT A did not think the resident should be made to change his/her clothes, but needed his/her brief changed. CMT A did not tell anyone about the incident. CMT A did not know if he/she should report because LPN A was his/her charge nurse. In an interview on 10/5/12 at 10:15 P.M., regarding 9/18/12, CMT B said: -The resident's call light was on and he/she was screaming in pain. GN and LPN B were beside the resident with a gait belt and CMT A was beside the resident. LPN A was pulling down the resident's pants. The resident said "they won't leave me alone." It was not normal for the resident to be combative. The resident was arching his/her back. The incident lasted about "five to six minutes." "I did not report the incident because I knew LPN A was going to report it." CMT B thought staff "should have called the Physician before changing the resident's clothes. The resident is alert and oriented and "in his/her right mind." In an interview on 10/5/12 at 8:35 P.M. regarding 9/18/12, CNA A said: - He/she was assigned to work on the resident's hall. He/she got along well with the resident. The resident was able to toilet him/herself. The resident's arms had some purple spots but were not solid purple. The resident had diarrhea and did not want to waste the brief he/she wore. The resident preferred to keep toilet paper in the brief. When the paper got dirty, he/she threw it out and replaced it with clean paper. The resident's brief was a little soiled "but not that bad." When he/she offered to change it, the resident refused. He/she and LPN A communicated about the soiled brief and LPN A "took over." Later, she was two doors down from the resident's room and could hear yelling. He/she opened the resident's door and found LPN A, GN, LPN B, CMT A, and CMT B with the resident. LPN A was sitting on the floor, GN was behind the resident's chair and off to the side of the resident holding on to a gait belt around the resident's waist. The resident was standing holding a walker and yelling "your killing me." The resident swung his/her arms, trying to bite and fight. The resident did not want his/her brief changed. The resident seemed to know what was going on. After the incident, the resident said he/she was going to call his/her family. LPN A called the resident's spouse who scolded the resident. The resident told his/her spouse "If you don't give a dam, I'll just do what they say." - He/she thought residents had a right to refuse care. They were trained to walk away and not to fight with residents and return later. -He/she thought the incident could have been avoided by leaving the resident alone to have time to deescalate. - The incident with the resident confused him/her because the nurses said they were trying to look out for the resident's skin. The nurses are in charge and instruct aides on what to do. He/she did not think residents should have to abide by what the nurses wanted. In an interview on 9/18/12 at 10/10/12, the Administrator said the 9/18/12 twenty-four hour communication sheet used to inform the next shifts staff of resident concerns and statuses, was "missing." In an interview on 10/10/12 at 11:00 P.M., CNA C said he/she gave the resident a shower on 9/20/12 in the afternoon. The resident walked into his/her bathroom on his/her own. He/she found the resident had purple bruising all the way up and down and all the way around the resident's left forearm and left wrist. The resident's right arm had a couple of purple bruises. The resident kept saying be careful because his/her arms were "real sore" and caused him/her "pain." Observation and interview on 10/4/12 at 11:18 A.M., showed: - The posterior side of residents left wrist had brownish bruising and both posterior forearms had brownish areas but were mostly clear. - Family member (FM) A said on 9/19/12 he/she informed the DON of bruising on the resident's arms. The DON was not aware of the resident's condition. The first thing the DON said to him/her was they noticed a change in the resident behavior. FM A said, "If a resident does not want to do something leave them alone until they settle down." FM A said the resident told him/her that he/she had a spot on his/her pants, did not know if it was soiled, did not want to put on fresh clothes without a shower." FM A said the resident said, "Even if there was a soil, what could it hurt." FM A said staff should have left the resident along until he/she calmed down. The resident is coherent but may not understand what staff want because he/she is hard of hearing. Staff needs to have severe re-training and training on how to handle behaviors. In interview and record review on 10/4/12 at 10:54 A.M. and 4:40 P.M., and 10/11/12 at 2:33 P.M., the Administrator: - Provided copies of photos he received from the resident's family showing the resident's arms after the 9/18/12 incident. Observation of photos taken by the resident's family showed both the resident's arms contained large bruises covering the skin surface on the anterior (top) portion of the arms, between the elbows and wrists. The pictures also include the residents left and right posterior (back) forearms and the posterior of the residents left hand. Review of the pictures showed 100 percent black, purple, and red bruising, covered the left forearm from the wrist to the elbow, 90 percent of the right forearm covered with purple, red, and black bruising from the wrist to just below the elbow, and the left hand and wrist had two spotted black and red bruised areas. - The administrator said he was concerned about the bruising on the resident. The resident refused to have his/her brief changed and had a right to refuse the care. The staff should have left the resident alone. - Social services responded to LPN A's 9/17/12 request to talk to the resident about refusing care on 9/28/12. In an interview on 10/4/12 at 6:20 P.M., the DON said she was did not know LPN A did not follow supervisors instructions. The DON said LPN A should have followed the Supervisor direction. There was no reason they could not have waited to change the resident. After the incident she talked to all staff involved individually about the incident. MO