Every finding on record at Carrie Elligson Gietner Health Care Center

Based on interview and record review, the facility failed to initiate a Code Purple (protocol for resident who eloped from an off-site location) in accordance with facility policy for one resident (Resident #1) who signed him/herself out for an appointment on 07/14/26 and did not return to the facility. The resident signed him/herself out of the facility on 07/14/26 at 12:58 P.M. with an expected return time of 4:30 P.M., but the resident did not return. Staff were aware the resident did not return as expected and did not communicate this to the subsequent shifts on 07/14/26 and 07/15/26, who failed to initiate the Code Purple. Staff failed to make efforts to locate the resident until 07/16/26, after Department of Health and Senior Services (DHSS) began an onsite visit and Administration became aware the resident was missing. The resident's whereabouts were unknown for 48 hours. During this timeframe, the resident missed seven meals and several doses of anticoagulant, antipsychotic and diabetic medications. The sample was four. The facility census was 93. The administrator was notified on 07/17/26 at 2:28.P.M, of an Immediate Jeopardy (IJ), which began on 07/14/26. The IJ was removed on 07/16/26 as confirmed by surveyor on-site verification. Review of the facility's Resident Outside Pass policy, revised 06/29/23, showed:Purpose:-To ensure that the facility provides education and treatment/medications to the resident/resident's responsible party upon the resident's absence from the facility to ensure continuity of care while the resident is out of the facility, therefore allowing for a successful out of the facility visit without negative effects on the resident.Procedure:-In the event that the resident does not return to the facility at the time given to the facility, the facility will attempt to contact the resident/resident's responsible party to verify the resident's return;-If the facility is not able to contact the resident/resident's responsible party, the facility will then follow the Code Purple procedure. Review of the facility's Concepts of Operation document, no date provided, showed:-It is the responsibility of the facility to provide comprehensive emergency operations planning that meets the needs for identified threats and hazards. The assumption is not that the facility will handle all emergencies internally, but that a whole community approach is taken, drawing outside resources to best protect staff and residents;-This plan is based on the concepts that the emergency functions assigned to the various groups, organizations, agencies and individuals involved in this plan will parallel their normal day-to-day functions as closely as possible. Th same personnel and material resources will be employed as much possible in both normal and emergency functions;-Interdepartmental Facility Codes:--Code Purple-Resident eloped from off-site location (Doctor's office, hospital, family, etc.) Review of the facility's Elopements and Wandering Residents policy, revised 06/12/24, showed the Procedure for Locating Missing Resident:-Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol;--Code [NAME] = Elopement;--Code Purple = Elopement outside the facility (doctor's appointment, etc.);-The designated facility staff will look for the resident;-If the resident is not located in the building or on the grounds, administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office;-Director of Nursing (DON) or designee shall notify the physician and family member of legal representative;-Police will be given a description and information about the resident; including any photos;-All parties will be notified of the outcome once the resident is located;-Appropriate reporting requirements to the State Survey agency shall be conducted;-Procedure Post-Elopement:-A nurse will perform a physical assessment, document, and report findings to physician;-Any new physician orders will be implemented and communicate to the family/authorized representative;-A social service designee will reassess the resident and make any referrals for counseling or psychological/psychiatric consults;-The resident and family/authorized representative will be included in the plan of care;-Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior;-Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. Review of the facility's Incidents and Accidents Policy, revised 05/18/24, showed:Purpose:-It is the policy of this facility for staff to utilize the risk management system to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident;-Definitions:-Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident;-Incident is defined as an occurrence or situation that is not consistent with h routine care of a resident or with the routine operation of the organization. They can involve a visitor, vendor, or staff member.Policy:-Purpose of Incident Reporting:-The purpose of incident reporting can include:--Alert risk management and/or administrator of occurrences that could result in claims or further reporting requirements;--Meeting regulatory requirements for analysis and reporting of incidents and accidents;-Process of Incident Reporting:--Incident/accident reports are part of the facility's performance improvement process and are confidential quality assurance information;--Licensed staff will utilize the risk management system to report incidents/accidents and assist with completion of any investigation information to identify root causes;-The following incidents/accidents require an incident/accident report but are not limited to:--Elopement;-In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risk or harm;-The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events;-The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(etc );-The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital;-The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information;-Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions;-If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the DON and/or Administrator. Review of the facility's midnight census, showed:-07/15/26;-Time: 12:02 A.M.;-Unit: All, Floor: All, Date: 07/14/26;-Resident #1, Bed Status, Confirmed - check mark noted;-Occupied -93;-Actual Physical Head Count - 93;-Physical Count date - 07/15/26;-07/16/26;-Time: 12:14 A.M.;-Unit: All, Floor: All, Date: 07/15/26;-Resident #1, Bed Status, Confirmed- LOA (leave of absence);-Occupied -94;-Actual Physical Head Count - 91;-Physical Count date - 07/16/26. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 06/15/26, showed:-Cognitively intact;-Diagnoses included alcohol abuse, depression, and Chronic Obstructive Pulmonary Disease (COPD, term for progressive, long-term lung diseases that cause inflammation and airway damage, making it difficult to breath);-Use of antipsychotic (psychiatric medication used to treat psychosis) and blood thinning medication. Review of the resident's care plan, in use at the time of survey, showed:-Problem: Moderate risk for suicide;-Problem: At risk for polysubstance abuse related to substance-seeking behavior/safety risk;-Problem: Has the potential for behavior problem related to alcohol abuse;-Problem: Uses psychotropic medication (any prescription or non-prescription substances that affect the central nervous system to alter a person's mind, emotions, thoughts, or behavior) and on anticoagulant therapy (using prescription medications, commonly known as blood thinners, to prevent harmful blood clots forming or getting larger);-No documentation related to the resident's safety when signed out for leaves of absence. Review of the resident's physician order sheet, in use at the time of the investigation, showed: -Apixaban Oral Tablet 5 milligrams (MG), Give 1 tablet by mouth two times a day for blood clots;--Start: 10/16/25;-Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT, 2 puff inhale orally every 4 hours as needed for COPD;--Start: 10/16/25;-Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT, 2 puff inhale orally two times a day for COPD;--Start: 10/16/25;-Flomax Oral Capsule 0.4 MG (Tamsulosin) Give 0.4 MG by mouth one time a day for enlarged prostate;--Start: 03/04/26;-Eplerenone Oral Tablet 25 MG (Eplerenone) Give 1 tablet by mouth one time a day for high blood pressure (HTN)/Heart failure;--Start: 02/15/26. Review of the resident's sign in/sign out log, showed the resident signed out on 07/14/26 at 12:58 P.M. with an expected return time of 4:30 P.M. and destination listed as doctor. Review of the resident's medical record showed no documentation regarding the resident signing out of the facility on 07/14/26, the resident not returning to the facility after signing out LOA, or notifications made to Administration or the resident's physician about the resident not returning to the facility. During an interview on 07/16/26 at 2:19 P.M., Certified Nurse Assistant (CNA) A said he/she worked on 07/14/26 when the resident signed him/herself out. The resident was supposed to return at 4:30 P.M., but did not. CNA A reported this to CNA G, Licensed Practical Nurse (LPN) H, and LPN B, who were coming on for the next shift at 7:00 P.M. On 07/15/26, the resident's family member came to see the resident, but the resident was not there. CNA A checked the sign out sheet and saw the resident was still signed out, as of 07/14/26. CNA A notified LPN B the resident was not there. CNA A was not sure what LPN B did next. During an interview on 07/17/26 at 10:06 A.M., the Assistant Director of Nursing (ADON) said he/she found out the resident was missing on 07/16/26 when it was brought to his/her attention the resident was not in the facility. He/She had the charge nurse (name not given) tell the Administrator on 07/16/26. LPN B told the ADON that he/she told the Administrator on Wednesday (07/15/26) that the resident was gone. The ADON said he/she didn't hear anything about what was being done to locate the resident from the Administrator or anyone else. He/She said LPN B told him/her CNA A was doing rounds and saw the resident wasn't in the building. The resident's family member was looking for him/her, because he/she (family member) said the resident hadn't been answering his/her phone and his/her phone worked with internet connection. The ADON said he/she didn't know anything about the elopement until the investigation was started on 07/16/26. No one attempted to call the resident until yesterday (07/16/26), when the investigation started. He/She called the jails on 07/16/26. The information about the resident was communicated to the Administrator on the 15th, but she didn't do anything that the ADON was aware of. Review of email correspondence from Receptionist F to the Administrator, Director of Nurses (DON), and Regional staff, dated 07/16/26 at 11:41 A.M., showed:-Subject: Resident still out on LOA;-Narrative: Resident is still out on LOA. Informed by 2nd floor staff that during his/her rounds today, he/she noticed the resident was still out LOA, which was not like him/her. His/Her last time signing out was 07/14/26 at 12:55 P.M. Staff reported that his/her family came to visit him/her on 07/15/26 at around 1:00 P.M. and he/she was reported not in the building, and night shift made aware. Steps Receptionist F has taken so far, include notifying the Administrator, who asked if the resident signed out and figured we can just worry about it later, called resident's phone from two different numbers and has not gotten an answer, contacted maintenance, who is looking at the cameras to see if they can figure out when the resident left the building. During an interview on 07/16/26 at 2:00 P.M., the Social Service Designee (SSD) said he/she found out this morning the resident was not at the facility. He/She did not know where the resident was. During an interview on 07/16/26 at 3:43 P.M., the Administrator said the resident's family came to visit yesterday, 07/15/26, and the resident wasn't in the building. She was not aware the resident was missing until it was brought to her attention earlier today. She called the resident's phone number several times, but to no accord. She verified with the hospital the resident attended his/her appointment on 07/14/26 at 2:11 P.M. The hospital staff said the resident left shortly after 3:00 P.M. on 07/14/26. The resident didn't usually do this. He/She always came back from LOA. The facility dropped the ball on the documentation and reporting. They should have been better equipped. Staff should have notified her right away when the resident didn't come back on 07/14/26. During an interview on 07/16/26 at 3:03 P.M., the representative for the resident's physicians, Physician F and Physician G, said neither physician was aware the resident was missing. No one from the facility notified them and neither physician knew where the resident was. During an interview on 07/16/26 at 4:26 P.M., the Administrator said she expected staff to document what happened and to notify her and all other parties necessary of the resident not returning from his/her LOA. She should have reported the incident to DHSS. Review of the facility's investigation timeline, provided to DHSS on 07/17/26, showed: Resident signed out for doctor appointment on 07/14/26 at 12:58 P.M. and didn't return to the facility by 4:30 P.M. as stated on the sign out form. Leadership staff were not made aware until 07/16/26 at 11:00 A.M. On 07/14/26 at 12:51 P.M., the resident is was seen on the camera signing out. The receptionist did not call his/her leaving the facility out on the walkie to inform the rest of the team. The HR Manager walked the resident to the door and entered the code letting the resident out to the front porch. The HR Manager did not see if the resident got into a vehicle or walked to the bus top. There is a jump in the video, so could not see if the resident got into a vehicle or walked to the bus stop. On 07/14/26, the receptionist clocked out at 7:00 P.M. and did not report to the charge nurse on duty or any other staff member that the resident had not returned. The nurse on the 07/14/26 7:00 P.M. to 7:00 A.M. shift documented the resident on LOA. On 07/15/26, the resident's family member came to the facility looking for the resident, as the family member was trying to call the resident and he/she wasn't answering. CNA A told LPN B and LPN B stated he/she told the Administrator. The Administrator stated she was not made aware of the visitor being in the facility looking for the resident. During an interview on 07/17/26 at 2:11 P.M., the ADON said a Code Purple was supposed to be activated when the receptionist told nursing staff the resident didn't come back. Staff would have looked around the facility and outside. The expectation was to alert all staff of the Code Purple. The Administrator was supposed to activate the Code Purple. Code Purple was treated like an elopement because the resident didn't come back. The nurse was to report the issues to the Administrator, but her number wasn't posted anywhere in the facility. During an interview on 07/17/26 at 2:00 P.M., the Administrator said she expected staff to follow the Code Purple and Elopement Policy when the resident didn't come back at the expected time but, definitely, by midnight census. Staff are supposed to see the residents for census accountability. She expected staff to have looked for the resident on each shift until he/she was found and to notify her when they realized he/she (resident) wasn't at the facility. On 07/15/26, when staff said family came to visit the resident, they (staff) should have reported to her then that the resident wasn't in the building. They would have started to look for him/her and notify all parties. She asked staff if the PCP (primary care physician) had been notified prior to 07/16/26, but was told they didn't know. Staff should have documented on 07/14/26 the resident didn't come back and every day after that. All of what was done happened after the state surveyor was on site. She expected there to be documentation in the resident's medical record reflecting LOA starting 07/14/26 until he/she returned and/or was located. Observation on 07/17/26 at approximately 12:55 P.M., showed the ADON walked the resident into the facility. Observation and interview on 07/17/26 at 1:11 P.M., showed the resident was connected to oxygen in the reception area. He/She had on shorts and his/her legs, neck and face appeared bright red. When asked if the resident used oxygen normally, staff said no. Observation showed the resident was out of breath when he/she walked back into the facility. The resident said he/she was doing pretty good, but felt a little tired. Emergency Medical Services (EMS) told the resident it was too hot for anyone to be outside and the sun really beat him/her up. While on leave, he/she took the bus for a last-minute appointment. A friend gave him/her a bus pass, but it didn't work on the way back. He/She then walked from a hospital on a major intersection to an apartment complex approximately 2.8 miles away. He/He received some bad news and drank for approximately three days. He/She had been at a friend's house while on leave. He/She walked from the friend's house/apartment complex to a location approximately 6.4 miles away to get a free meal and a different shirt to wear. During an interview on 07/17/26 at 1:13 P.M, an EMS representative said the resident walked a lot of miles. The resident was sunburned and definitely had a lot of sun exposure. During a telephone interview on 7/17/26 at 3:58 P.M., the Medical Director (MD) said the facility did not notify him when the resident was missing. Nursing staff should have notified him and documented the resident was missing. This laxed behavior could have caused death. When the resident did not return, the charge nurse should have notified the resident's PCP. The nurse should have documented the resident had not returned. Nursing staff should have observed the resident during morning and evening hours. The MD would have expected staff to follow the policy and to notify one of the physicians involved in the resident's care. The resident was lucky to have gotten back. The resident could have had a blood clot. It was important the resident stayed on all his/her medication. During an interview on 07/20/26 at 10:43 A.M., the Administrator said as the investigation was winding down, it was possible both the DON and ADON knew about the resident not coming back. She expected staff to follow the Resident Outside Pass, Code Purple, and Elopement policies. She expected staff to document in the resident's chart that he/she didn't return and what they did (steps taken). Code Purple turned into an elopement if the resident didn't return from an outside appointment within a reasonable time or time expected. Staff was expected to call all parties/entities and proceed from that point. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to identify and address nutritional needs and swallowing difficulties for one resident who was at risk for impaired nutrition and hydration. The resident experienced a significant weight loss of 20.52 % in three months (Resident # 2). The sample size was 20. The census was 97.Review of the facility's Nutritional Management policy, last revised on 5/18/24, showed:-Purpose: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition;-Definitions: Acceptable parameter of nutritional status is inadequate, relative to his/her overall condition and prognosis, such as weight, food and fluid intake, and pertinent lab values; Nutritional status includes both nutritional and hydration status;-Policy:--A systematic approach is used to optimize each resident's nutritional status:---Identifying and assessing each resident's nutritional status and risk factors;---Evaluation and analyzing the assessment information;---Developing and consistently implementing pertinent approaches;---Monitoring the effectiveness of interventions and revising them as necessary;-Identification and assessment: --Nursing staff shall obtain the resident's [NAME] and width upon admission, and subsequently in accordance with facility policy;-Monitoring:--Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis; Examples of monitoring include:--Interview the resident and or resident representative to determine if their personal goals and preferences are being met;--Directly observing the resident;--Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestion for changes if necessary;--Evaluating the care plan to determine if current interventions are being implemented and are effective;--The resident will be monitored for complications associated with interventions;--The care plan will be updated as needed, such as when a resident's condition changes, goals are met per the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition related problems are identified;-The physician will be notified of:--Significant changes in weight, intake, or nutritional status;--Lack of improvement toward goals;--Any complications associated with interventions;--Nutritional recommendations made by the dietician based on the resident's preference, goals, clinical condition or other factors and followed up with the physician or practitioner for orders per facility policy, if indicated;--Dietary orders may be written or modified by the qualified dietician or other clinically qualified nutrition professional if the resident's attending physician or practitioner delegates the task, dependent upon state law or policy;--The resident has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status;--The facility shall discuss the risks and benefits associated with the resident and representative decision and off alternatives, as appropriate;--The comprehensive care plan should describe any interventions offered but declined by the resident or resident's representative. Review of the facility's Weight Monitoring policy, last revised 5/18/24, showed:-Purpose: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight, or desirable body weights range and electrolyte balance, unless the residents' clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Policy:-Monitoring weight:--Weight can be a useful indicator of nutritional status; Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended weight loss over a period of time) may indicated a nutritional problem:--The facility will utilize a systemic approach to optimize a resident's nutritional status; This process includes:---Identifying and assessing each resident's nutritional status and risk factors;---Evaluation and analyzing the assessment information;---Developing and consistently implementing pertinent approaches;---Monitoring the effectiveness of interventions and revising them as necessary;-A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss or gain or compromised nutritional status; Assessments should include the following information:--General appearance (robust, thin, obese or cachectic (extreme weight loss and muscle wasting);--Height;--Weight;--Food and fluid intake; --Fluid loss or retention;--Laboratory or diagnostic testing;-Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences; The care plan should address the following, to the extent possible:--Identified causes of impaired nutritional status;--Reflect the resident's personal goals and preference;--Time frame and parameters for monitoring;--Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new cause of nutritional related problems;--If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate;--Interventions will be identified, implemented, monitored and modified as appropriate consistent with the residents' assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status;-A weight monitoring schedule will be developed upon admission for all residents:--Weights should be recorded at the time obtained;--Residents with weight loss, monitor weekly weight;--If clinically indicated, monitor weight daily;--All others, monitor weight monthly;-Weight analysis:--The newly recorded width should be compared to the previous recorded weight; A significant change in width is defined as:---5% change in weight in one month;---7.5 % change in weight in three months;---10% change in weight in six months;-Documentation:--The physician should be informed of a significant change in weight and may order nutritional interventions;--The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss;--Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed;--If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate the process;--The Registered Dietician (RD) or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutritional progress notes;--Observations pertinent to the resident's weigh status should be recorded in the medical record as appropriate;--The interdisciplinary plan of care communicates care instructions to staff. Review of Resident # 2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/11/26, showed:-Cognitively intact;-No rejection in care;-Required supervision or touch assistance with eating;-Swallowing disorder: none;-Diagnosis includes schizophrenia (a mental condition that distorts reality), infection of intravertebral disc (a part of the back), malnutrition (poor nutrition), and viral hepatitis (inflammation of the liver caused by a virus). Review of the resident's speech therapy evaluation and plan of treatment notes, dated 2/16/26, showed recommendations: thin liquids and upgrade to regular solid food. Review of the residents' weight summary report showed:-On 2/11/26: 143.8 pounds (lbs);-On 3/4/26: 155.0 lbs. Review of the resident's electronic medical record (EMR) showed:-Diagnosis that includes esophageal (a muscular tube that carries food from the mouth to the stomach) obstruction, gastritis (inflammation of the stomach), nausea with vomiting, and alcoholism. -The resident was on therapeutic leave from 3/4 through 3/26/26. Review of the residents' weight summary report showed:-No weight was documented when the resident returned from his/her leave of absence from 3/4 through 3/26/26;-On 4/14/26: 141.0 lbs. Review of the resident's medication administration record (MAR), dated April 2026 and May 2026 showed:-An order, dated 7/12/25, for Boost (liquid nutrition) three times a day (TID); administer 8:00A.M. 11:00 A.M., and 4:00 P.M.;-The order did not provide instructions to document how much of supplement was consumed by the resident. Review of the resident physician progress note, showed on 4/14/26, The resident presents severe abdominal pain in the setting of know peptic ulcer disease (an open sore inside the stomach). The resident reports the pain has been severe for 3 days and persistent enough that the resident was unable to sleep. The resident states that Mylanta (medication to treat indigestion) provided some relief of pain and requested something for sleep. No other acute (short in duration) complaints reported. Vital signs (blood pressure, pulse, respirations and temperature) reviewed in EMR. Weight on 3/4/36: 155 lbs. Height 75 inches (6 foot 3 inches) Treatment: Continue Mylanta as needed for symptom relief. Start hydroxyzine (a medication used to treat anxiety) 25 milligrams (mgs). Encourage avoidance of irritant food and medications. Monitor for worsening symptoms such as bleeding and persistent severe pain. Nursing to report any changes. Preventative: Dietary and ulcer management counseling given. Follow up in four weeks. Review of the resident's RD progress notes, dated 4/29/26 at 4:45 P.M., showed:- Nutritional weight assessment: The resident's weights have been variable. The resident was receiving a regular diet with Boost TID; Weights: February 2026: 143.8 lbs., March 2026: 155 lbs., and April 2026: 141 lbs. Encourage intake of meals and supplements. Will monitor as needed.-The dietician did not make any new recommendations related to the resident's weight loss. Review of the residents' weight summary report showed, on 5/6/26: 128.7 lbs. Review of the resident physician progress notes, dated 5/15/26, showed:-The resident stated he/she was doing well. Denied nausea, vomiting, and diarrhea. Weight: 128.7 lbs. Continue with current care. Follow up in four weeks.-The physician did not address the residents' weight loss. Review of the resident's nursing progress notes, dated 3/1/26 through 5/17/26, showed: -No documentation that the resident's physician was notified about the resident's weight loss on 4/14/26 and 5/6/26.-No documentation of the resident's meal or nutritional supplement consumption as directed by the facility policy. Review of the resident's electronic physician order sheets (e-POS), dated 5/17/26, showed:-An order, dated 7/12/25 for Boost (liquid nutrition supplement) three times a day (TID);-An order, dated 2/17/26, regular diet, regular texture, thin liquids;-An order, dated 4/18/25, weights monthly and record;-An order, dated 9/24/25, dietician consult;-No order for weekly weights as directed by the facility policy. During an observation and interview on 5/17/26 at 10:10 A.M., the resident lay in bed. The resident appeared extremely gaunt (thin) and his/her clothing was extremely loose. The resident's face was sunken in. The resident sat up to the side of the bed and said he/she was weak and used a walker. There were three bottles of Boost on the floor. The resident said the bottles were empty. There were also three clear cups of undigested food and saliva. The resident said he/she was having difficulty swallowing. The resident said he/she had to chew his/her food cut chopped fine for it to go down. The resident said he/she frequently gagged on his/her own salvia and he/she had told everyone in the facility about his/her ongoing swallowing difficulties. The resident said he/she used to have a gastronomy tube (G-tube, a medical device inserted through the abdomen directly into the stomach). The resident raised his/her shirt and exposed his/her stomach, and no G-tube was present. The resident said he/she used to have a softer texture diet and believed he/she needed that type of diet again. The resident did not want another G-tube. The resident said he was aware that he/she lost a lot of weight and was concerned about it. Observation on 5/18/26 at approximately 8:00 A.M., showed the resident lay in bed with multiple cups of saliva and undigested food on the floor next to the resident's bed. Review of the resident's care plan, last updated 5/18/26, showed: -Problem: The resident has unplanned/unexpected weight loss related to esophageal obstruction and gastritis and duodenitis (inflammation of the colon);-Desired outcome: The resident will consume 75% two of three meals a day;-Interventions: Alert dietician if consumption is poor more than 48 hours. Give the resident supplements as ordered and alert the nurse or dietician if not consuming on a routine basis. If weight decline persists, contact the physician and dietician immediately. Labs as ordered. Monitor and evaluate any weight loss. Determine percentage of weight lost and follow facility protocol for weight loss. Monitor and record food intake at each meal; -Problem: The resident is on a mechanical soft diet; -Desired outcome: The resident will maintain a mechanically soft diet with risk for aspiration;-Interventions: Monitor for cough or choking. Staff to educate resident on following his/her diet. Staff to monitor resident for any signs of aspiration (when food or liquids enter the lungs). --Further review showed the care plan was not updated to the upgraded diet order from 2/16/26. Review of the resident's RD progress notes, dated 5/19/26 at 12:52 P.M., showed Nutritional weight assessment: Weights: February 2026: 143.8 lbs, March 2026: 155 lbs., April 2026: 141 lbs., May 2026 128.7. The residents' weights have been variable, but a recent loss of 12.3 lbs. (8.7%) in the past month and weight is now below normal weight range. Recommend adding 2Cal Med Pass (a nutritional supplement), 90 milliliters (mls) four times a day. Encourage intake of meals and supplements. Will monitor and reassess as needed. Observation and interview on 5/19/26 at 5:30 P.M., showed the resident sat at the side of the bed. The resident's meal was regular texture and the resident took small bites of a hamburger with a bun and chewed it multiples times and then spit it into a soda bottle. The resident said he/she could not get the food down. Further observation showed most of the hamburger was chewed up and spit out into the soda bottle and no staff were there to assist the resident Review of the resident's nursing progress notes, dated March 2026 - May 2026, showed staff did not document the residents swallowing difficulties and hypersalivation (excessive saliva). Review of the residents' weight summary report showed:-On 5/20/26: 123.2 lbs;-The resident had a significant weight loss of 20.52 % in three months. During an interview on 5/20/26 at 1:55 P.M., Restorative Therapy (RT) Aide T said he/she was responsible for the monthly and weekly weights. RT Aide T said the resident frequently spit out his /her food and had been having difficulty swallowing. The resident was not on the weekly weight list. RT Aide T placed the weights in the EMR and gave a paper copy of all the weights to the DON and the Charge Nurse. Weekly weights required a physician order. The only weights RT Aide T had on the resident was documented in the EMR. The resident was not weighed when he/she returned from his/her leave in March and probably should have been. During an interview on 5/20/26 at 5:35 P.M., Licensed Practical Nurse (LPN) U said the resident had always had multiple stomach and swallowing issues and it was nothing new. LPN U said the resident always had cups of saliva and undigested food in his/her room. The resident had always looked thin. LPN U was not aware that the resident had a weight loss. The resident normally drank soda, ate candy and other junk food. LPN U didn't think the resident ate much of his/her meals that were served to him/her. He/She said any resident that had weight loss should be weighed weekly, but weekly weights required a physician order. The physician, the RD, and the Director of Nurses (DON) should have been notified of the resident's weight loss. Speech therapy also should have been notified so that they could give some recommendations related to the resident's diet and his/her swallowing difficulties. LPN U was not aware of any special monitoring or diet that the resident was on. During an interview on 5/20/26 at approximately 5:45 P.M., Certified Medicine Technician (CMT) V said the resident had always had swallowing difficulties and a lot of spitting up. CMT V noticed as recently with the last couple of med passes that the resident required his/her medications to be crushed because the resident could not swallow his/her mediations whole. CMT V notified the nurse regarding the resident's swallowing difficulties. During an interview on 5/21/26 at approximately 11:00A.M., Certified Nursing Assistant (CNA) L said the resident used to spit his/her food and saliva onto his/her plate in the dining room, so now the resident had to eat in his/her room. The resident used to have a basin because he/she would spit food and saliva out so often. CNA L said he/she told the nurses about it. The resident had always appeared thin. The resident ate about 25 % of his/her meals. The resident drank a lot of soda and snacks from the vending machine. CNA L was not aware of any special monitoring or diet the resident was on. During an interview on 5/20/26 at approximately 11:00 A.M., the Dietary Manager said she wasn't familiar with the resident since the resident ate in his/her room. She did not know who had weight loss in the building. The RD was responsible for following those concerns. During an interview on 5/20/26 at 12:32 P.M., the RD said she documented the residents' weight loss on 5/19/26 and made recommendations based off of reviewing the resident's medical record. On the RD's 5/19/26 visit to the facility, the RD said she did not interview the resident or any direct staff caring for the resident related to the resident's eating habits or the resident's increased difficulty in swallowing. The RD did not make any observations of the resident eating or having difficulty swallowing. The RD said it was not a requirement for her to meet with the resident on every visit. The RD was not aware that there was no order for weekly weights. She would have expected the facility to follow their policy related to obtaining weights. The residents' weights often fluctuated in the past, so no new recommendations were made with the residents' weight loss on 4/14/26. She would have expected documentation of how much the resident consumed of the supplement. The expectation of the nursing staff was to call the physician first when residents experienced weight loss. During an interview on 5/20/26 at 5:13 P.M., the facility's Medical Director, who was also the resident's physician said he would have expected the nursing staff to notify him of the resident's weight loss. He would expect documentation on the consumption of meals and supplements. The Medical Director would have expected weekly weights per the facility policy. The resident had a history of alcoholism and was likely to have had a lot of muscle wasting. The resident should have been weighed when he/she returned from his/her leave. He would have expected speech therapy to be consulted by the nursing staff since the resident was having difficulty swallowing. The Medical Director would have expected the RD to make new recommendations and accommodate the residents request for a mechanically chopped diet and any food preferences the resident had. During an interview on 5/21/26 at 10:50 A.M., the Director of Rehab (DOR) said the resident was last seen by speech therapy on 2/16/26 and a regular diet and thin liquids were recommended. The speech therapy department was not aware of the residents' ongoing swallowing difficulties and weight loss. The DOR would have expected the nursing staff or the DON to notify the department so that they could complete another swallowing evaluation. Speech therapy normally evaluated residents every three months. The DOR said she usually got a list of residents experiencing weight loss. The DOR reviewed her list for April and May and the resident was not listed as experiencing weight loss. During an interview with on 5/21/26 at 2:22 P.M., the Assistant Director of Nursing (ADON), and DON said the resident had difficulty swallowing and recently had his/her G-Tube removed. The resident was at risk for weight loss. The DON and the ADON said the resident always looked thin but were not aware of the resident's recent significant weight loss. The RT Aide was responsible for reporting weights to the Charge Nurse and the DON. The DON and ADON would have expected the staff to notify physician, the RD and speech therapy about the residents' weight loss and swallowing difficulties. They would expected the RD to go and speak to the residents and observe them during mealtimes. During an interview on 5/21/26 at 2:30 P.M., the Regional Nurse Consultant (RNC) said she would have expected the RD to interview the resident and staff that provided direct care to the resident to get a better perspective on why the resident was losing weight. She would have expected more documentation on the meals and nutritional supplement consumption. She would have expected the staff to notify the RD, the physician and speech therapy regarding the resident's weight loss and swallowing difficulties and document in the resident's EMR. The DON was responsible for reviewing all of the residents' weights in the facility.

Based on interview and record review, the facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known history of substance abuse, including a thorough review of the referral information identifying recent substance use and positive toxicology results. The facility also failed to implement appropriate behavioral health interventions, monitoring, and services during a period in which social services staff were unavailable, resulting in missed opportunities to identify relapse risk, escalating warning signs, and ongoing substance use within the facility (Residents #104, #105, and #101). The resident sample was 20. The census was 97. The administrator was notified on [DATE], of the past non-compliance. The facility educated staff on incidents and accidents, screening resident's belongings, notifying physicians of resident changes in health, residents being in possession of illegal drugs, and the leave of absence policy. The facility also began monitoring and documenting behaviors associated with illegal substance use. The deficiency was corrected on [DATE].Review of the facility's Behavioral Health Service Policy, revised [DATE], showed:-Substance Use Disorder (SUD): Substance use disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home;-Policy: The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma and/or post-traumatic stress disorder (PTSD), as reflected in the facility assessment;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Assessment/Care planning: The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will:--Complete PASRR screening;--Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health;--Monitor the resident closely for expressions or indications of distress;--Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable;--Utilize MDS and care area assessments;--Assess and develop a person-centered care plan for concerns identified in the resident's assessment;--Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis;--Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record;--Ensure appropriate follow-up assessment, if needed;--Discuss potential modifications to the care plan;--Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The resident, and as appropriate the resident's family, are included in the comprehensiveassessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall:--Provide for meaningful activities which promote engagement and positive,meaningful relationships. Residents living with mental health and SUDs may require different activities than other nursing home residents. The facility will ensure thatactivities are provided to meet the needs of these residents;--Address any other individualized needs the resident may have related to the mental disorder or the SUD;--Behavioral contact: If a behavioral contract is used, it will only be used with residents who have the capacity to understand it. A contract will only be used as a method of encouraging the resident to follow their plan of care, and not as a system of reward and punishment. The contract will not conflict with resident rights or other requirements of participation;--Resident refusal to accept, or non-adherence to the terms of a behavioral contract, will not be the sole basis for a denial of admission, transfer or discharge. Review of the facility's Residents- Possession and Use of Illegal Drugs, Marijuana and Alcohol and Drug Screen and Searches policy, revised [DATE], showed:-Purpose: To ensure that the Facility remains free from illegal drugs and substances as well as marijuana and alcohol. To define when and how a resident may be administered a drug screen or have their room searched;-Procedure: Illegal drugs or substances, marijuana and alcohol are not permitted;-The Facility is committed to maintaining a safe environment for every Resident. Part of this commitment is attempting to maintain an environment that is free of illegal drugs, dangerous items and other related contraband;-Use of illegal drugs creates a dangerous environment and may interfere with properly prescribed medications;-Marijuana (while legal) is not allowed in the Facility can interfere with properly prescribed medications.-The use, consumption, possession, transportation, sale or distribution of unlawful or unauthorized drugs (including marijuana), inhalants, alcohol, or the abuse of prescribed drugs or alcohol by any Resident while in the Facility or on Facility property is expressly prohibited and may result in an immediate discharge. Illegal or controlled substances (other than a valid prescription) will be confiscated, and the appropriate law enforcement agency(s) may be notified;-Contraband includes weapons of any kind, any items which could be used as a weapon, illegal or unauthorized drugs (including marijuana), drug paraphernalia, or alcohol. The possession or sale of any contraband while on Facility premises is expressly prohibited;-The Administrator and Director of Nursing shall educate staff and Residents (as appropriate) on the signs and symptoms of illegal drug use;-Process when suspicion of ingestion of illegal substance: If a Resident is suspected of taking an illegal drug or other substance (including marijuana), the Resident shall immediately be placed on one-on-one supervision and the Director of Nursing or charge nurse and Administrator notified;-If the Resident shows any signs of distress or there are other concerns, 911 shall be called immediately;-The nurse shall immediately evaluate the Resident and obtain a complete set of vital signs, including a neurology check and oxygen saturation level;-The Resident's primary care physician shall immediately be contacted for instructions;-If the Resident is not being sent to the hospital, the protocol below for drug screens and searches will apply;-Drug Screen: In the event the Administrator or Director of Nursing has reasonable suspicion that a Resident has ingested illegal or unauthorized drugs, a drug screen may be administered;-Search of Resident's room or property: In the event the Facility's Administrator or Director of Nursing has reasonable suspicion that contraband, illegal drugs or something that poses a safety risk to the Resident or others in the Facility is in a Resident's room, a search of the Resident's room may be considered;-The Facility should not act as an arm of law enforcement and may instead of a search (or if consent is not given for a search), the facility may make a referral will be made to local law enforcement;-If the Resident is his/her own person, the resident must consent to the search. If the Resident refuses the room or property search, the search will not be conducted, and the Management Company Regional Director will be notified;-If suspected illegal drugs are found, the local police and the Department of Health and Human Services will be notified. The Regional Director will also be notified;-Suspected Contraband or Illegal Drugs: If suspected contraband or illegal drugs (including marijuana) are found, those items will be given to the Administrator, Director of Nursing or Charge Nurse for inventory;-All items will be placed in a secure location for all Residents' safety;-Suspected illegal drugs will be turned over to law enforcement personnel for safe disposal;-Increased Oversight: To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility. 1. Review of Resident #104's hospital record, showed:-admitted [DATE]; -Assessment and Plan: Opioid withdrawal: Present on admission;-Sinus tachycardia (heartbeat over 100 beats per minute): Present on admission;-Fentanyl (potent, synthetic opioid drug) use disorder, severe: Present on admission;-Polysubstance use disorder: Present on admission;-Most likely etiology of discomfort at this time was relating to opiate withdrawal given his/her recent initiation of suboxone (used to treat opioid use disorder) and subjective history of mild improvement when using unspecified pill, presumed to be fentanyl (highly potent synthetic opioid) in an outpatient setting although unable to fully rule out component of known rheumatologic conditions;-Plan of care discussion: We reviewed his/her symptoms at the bedside and discussed that based on his/her story and the lab studies he/she performed, at this point that the most likely cause of his/her current pain was opiate withdrawal;-Physician progress note: He/She denied any issues with drug cravings. He/She was worried about managing his/her pain. The Buprenorphine (long-acting partial opioid agonist used to treat opioid use disorder) did not seem to be taking the edge off his/her pain. He/She would like to try methadone (long-acting synthetic opioid used to treat opioid use disorder). We discussed prolonged QT syndrome (a heart rhythm disorder) and strict federal regulations that both prohibit the use of methadone for him/her. He/She confirmed understanding and agreed with the plan to decrease buprenorphine to allow greater efficacy of the breakthrough pain meds;-The resident presented to hospital for chest pain on the initial workup for cardiac and musculoskeletal causes was unremarkable. Suspicion was raised for possible opiate withdrawal caused his/her pain. Review of the resident's face sheet, showed:-admitted [DATE];-Diagnoses of hemiplegia, hemiparesis, and cerebral infarction. Review of the resident's initial psychosocial history, dated [DATE], showed:-Substance Abuse;-Current stressors: blank;-Current diagnosis: blank;-Psychosocial assessment: Change in sleep and increased anxiety;-Past history: Suicidal ideations/attempts;-Self injurious behavior: non-suicidal;-Methods of self-injurious behavior: cutting;-Socialization and support system: Other: staff;-IDT signatures: blank. Review of the resident's care plan, dated 3/23 and revised [DATE], showed:-Problem: The resident was at risk for polysubstance abuse related to substance seeking behavior/safety risk;-Interventions: Administer Narcan per physician's order for signs/symptoms of narcotic overdose;-Monitor for signs of substance abuse/intoxication;-Monitor for signs of withdrawal;-Monitor items brought into the facility;-Offer emotional support during periods of agitation;-Notify physician of refusal or noncompliance;-Offer resident in the room alcoholic anonymous (AA)/ Narcotics anonymous (NA) program;-Problem: The resident is at risk for intentional or unintentional overdose due to history of depression, anxiety, confusion, access to medication substance misuse;-Interventions: Education provided on illegal drug use policy for the facility, Screens and search entering the building, resident possession and use of drug/alcohol policy, Adverse drug event policy, Narcan use policy, residents rights, abuse and neglect policy, and metal wand upon entering the building. Review of the resident's Physician Order Sheet (POS), dated [DATE] through [DATE], showed:-An order, dated [DATE], Hydromorphone (semi-synthetic opioid analgesic used to treat pain) HCl oral tablet 4 mg. Give one tablet by mouth every four hours as needed for pain;-An order, dated [DATE], Hydroxyzine (used to treat anxiety) HCl oral tablet 25 mg. Give 25 mg by mouth every six hours as needed for anxiety. Take one tablet by mouth four times daily as needed for anxiety;-An order, dated [DATE], Methocarbamol (muscle relaxer) Oral tablet 500 mg. Give 500 mg by mouth every six hours as needed for muscle spasms;-An order, dated [DATE], Narcan (lifesaving spray that reserves an opioid overdose) Nasal Liquid 4 mg / 0.1 milliliter (ml). Spray one spray into the nose as needed for overdose;-An order, dated [DATE], hydroxyzine HCl Oral Tablet 25 mg. Give 25 mg by mouth every six hours for anxiety;-An order, dated [DATE], Hydrocodone-Acetaminophen (used to treat pain) Oral Tablet 5-325 mg. Give one tablet by mouth three times a day for pain;-An order, dated [DATE], Trazodone (anti-depressant) HCl Oral Tablet 50 mg. Give one tablet by mouth at bedtime for insomnia;-An order, dated [DATE], hydroxyzine HCl oral tablet. Give 50 mg by mouth two times a day for anxiety;-An order, dated [DATE], hydroxyzine HCl oral tablet. Give 50 mg by mouth two times a day for anxiety until [DATE]. Review of the resident's progress notes, dated [DATE], showed:-Resident continued to exhibit erratic behavior and signs of withdrawal, though he/she denies experiencing any symptoms. Significant safety concerns are noted as the resident repeatedly slides out of his/her wheelchair and engages in self-picking, resulting in a sore on his/her face. Nursing attempted to perform a clinical evaluation and facilitated a telehealth visit with the physician; however, the resident refused both, stating he/she did not wish to speak with the physician again. The physician and Director of Nursing (DON) have been notified of the resident's behavior, his/her refusal of care, and his/her request regarding the physician. Staff will continue to monitor closely for safety and skin integrity.-Further review of the progress notes did not show staff spoke with the physician regarding the resident exhibiting signs of withdrawal of illegal substances. During an interview on [DATE] at 3:48 P.M., Licensed Practical Nurse (LPN) A confirmed he/she wrote the progress note on [DATE]. In his/her opinion, the resident was acting erratic. He/She was offered suboxone, but refused it. It helped with withdrawals. The resident started picking at him/herself and tried to act sane so LPN A would not suspect behaviors. The physician and psychiatrist were contacted. The psychiatrist saw the resident, but there was no way to redirect the resident. LPN A was asked to clarify why withdrawal was documented. LPN A said the resident was withdrawing from street drugs. He/She had an opioid abuse history before he/she was admitted . When the resident was first admitted , he/she was not exhibiting any behaviors, then he/she started to act erratic or self- medicate. Some behaviors included crying hysterically because of pain. They administered pain medication to him/her. One day, LPN A saw a lunch bag in the resident's room, and he/she never let anyone touch it. LPN A did not believe anyone searched his/her bag. Even during room search, an aide needed to search room, but the resident took the bag with him/her and held on to it. The resident was arrested at the facility for illegal substances on [DATE] and the bag was searched. He/She only had one visitor. When LPN A spoke to the physician, he/she mentioned the resident had withdrawals, but did not specify from what. The physician should have known the resident was coming off opioid abuse. [DATE] was the first time LPN A witnessed this behavior from the resident. Before, he/she cried about his/her arthritis. It felt like he/she was drug seeking. The resident would say I want to get out of here and he/she was better off on the streets. He/She was referred to pain management, but he/she did not go. Immediately the resident said he/she would rather go AMA (Against Medical Advice). As far as he/she knew, the resident was prescribed and never refused suboxone. Suboxene was found on him/her during the search. The pill was supposed to sit under the tongue, but LPN A believed the resident was taking it out when staff left the room after administering the medication. The resident took the other pills that were administered in front of staff, but placed the suboxone under the tongue and moved away. During an interview on [DATE] at 3:41 P.M., Certified Nurse Aide (CNA) J said Resident #104 was always in his/her room and he/she had only seen him/her come out about two or three times. He/She was in pain because the resident said he/she was coming off withdrawals from street drugs. CNA J was not sure what drugs, but the resident was on hard drugs. The resident would always sleep. He/She would sleep in his/her wheelchair leaned over the bed. CNA J was not sure if he/she was under the influence. During an interview on [DATE] at 12:19 P.M., the Assistant DON (ADON) said on [DATE], the behavior they were trying to identify was related to pain versus withdrawal. It was believed to be withdrawal because of the resident's substance abuse history. The resident could not identify where the pain was located, whether it was the hip, knee, or if it was arthritic pain. He/She started to get behaviors, and he/she could not identify what was hurting him/her. The resident declined to go to the hospital. They were juggling to see what was wrong. The physician was notified and said he/she would be in to see the resident. The physician would not approve any medication until he/she saw the resident and provided a signature. The resident did not want suboxone. The resident had a face to face with the physician and went against the medication. The ADON recalled he/she refused to take the suboxone. When asked about behaviors related to substance use or bringing illegal substances into the facility, the ADON said the resident only had one visitor. Per facility policy, if they found contraband, they called the authorities. The resident refused treatment. An aide reported at one point seeing the resident on the floor. The resident was abrasive at the time and a plastic bag was seen on the floor. The ADON said the aide no longer worked at the facility. During an interview on [DATE] at 12:56 P.M., Physician P said he/she remembered the resident, and he/she was one of the hard ones. The resident used to ask for narcotics, and they referred him/her to the pain clinic. He/She refused medications at times, even the suboxone. He/She also threw tantrums. Staff reported the resident's refusals, but there was also a psych component as well. On [DATE], he/she was aware of the resident's erratic and odd behaviors in an attempt to get his/her way. Physician P did not hear them say withdrawal. It was not physical, it was more psych. The resident did things to get things. Physician P would have expected to be informed the resident may have been going through withdrawal. If the resident was believed to have withdrawal symptoms, he/she would have sent the resident to the hospital, did a drug screen, and continued to monitor and document. Review of the resident's [DATE] progress notes showed:-On [DATE] at 2:46 P.M., call placed to Physician P for a teledoc/or in-house visit related to patient behaviors, suspected drug use, and possession of illegal substance. The resident refused room sweep which was conducted due to suspected substance abuse. Patient became irate, demanding to sign AMA form. The resident became aggressive, screaming and resistant. Crises prevention intervention (CPI) became in progress by CPI certified staff. The resident screamed that he/she would rather be homeless on the street than in pain and would like the regimen that he/she had while in the hospital. He/She admitted being clean for a few months and had used recently Fentanyl and [NAME] Meth. He/She requested a physician to review pain regime; -On [DATE] at 4:30 P.M., the resident consented to having his/her purse searched by the DON, with Regional Director of Operations (RDO) as witness. During the search there were multiple opened capsules, which appeared to be empty, and multiple capsules which appeared to be intact. There was also a baggie in the resident's purse which contained a crystallized substance which appeared to be clear in color, and white powder in the bottom of the baggie. The resident stated the substances found in his/her purse were Fentanyl and Methamphetamine. The resident was asked if he/she had given any residents any of the narcotics and he/she stated he/she had not. Police Department was notified of the suspected narcotics found on the resident and summoned to the facility. The narcotics were transferred to officers' possession. Officer then conducted another search of the resident's room and found an additional capsule. The Officer interviewed the resident. The resident admitted to the Officer that last evening, he/she sent money to the supplier of the narcotics and asked another resident to sign out and retrieve the narcotics for him/her. The resident stated he/she gave the other resident Fentanyl in exchange for meth he/she had purchased from the supplier. The resident consented to let the Officer look at his/her phone. The police seized the resident's two telephones and stated that forensics would need to be run on them. The responding officer stated they will be applying for warrants on the charge of 2nd degree drug trafficking and took the resident into custody. The resident's medication list was provided to the officer, so they were aware of the legal prescriptions he/she had;-On [DATE] at 7:26 P.M., resident's emergency contact notified of resident being taken into custody by the Police Department pending drug charges;-On [DATE] at 8:00 P.M., immediate discharge served to this resident at hospital at approximately 8:00 P.M. Discharging to the custody of the Police Department. Review of the resident's police report, dated [DATE], showed:-Incident nature: Drugs/Narcotics;-Incident Summary: Trafficking drugs, 2nd degree;-Arrestee arrested;-Original Narrative: Upon our arrival, we were met by employees who stated at approximately 0900 hours, Resident #105 had overdosed in their establishment and went to the hospital. Due to those circumstances, the employees conducted room checks to ensure there was no other narcotics. DON)conducted a search in room where Resident #104 resided and located multiple opened and unopened capsules, a bag containing a crystal-like substance the size of small rocks, and an empty plastic bag containing small traces of a powdery substance. DON removed the narcotics, placed them in a separate container, held the narcotics in the office guarded by employees, and contacted police;-Resident #104 admitted the narcotics were retrieved from his/her black bag inside his/her room. The resident originally stated he/she had the narcotics approximately four months ago before he/she began residing at facility. When officer inquired about Resident #105 overdose, he/she stated the drugs were not received from him/her and he/she never gave them out to anybody else. When officer inquired where the drugs were bought from, the resident stated he/she received them from his/her dealer. When officer inquired about how he/she gets into contact with him/her, the resident used his/her cellphone to provide officer with the cellphone number he/she calls him from along with his/her Chime username and recent transactions. Looking at the transactions officer observed the last payment was on [DATE]. When officer asked the resident about the recent transaction, he/she admitted he/she did buy narcotics from dealer;-When officer asked the resident about his/her relationship with Resident #105 he/she stated he/she knows of him/her, but they did not have a close relationship;-At the time officer was questioning the resident, officers found a capsule inside the resident's purse. Officer #1 located an enclosed capsule and Officer #2 found half of a capsule;-Administrator advised officer after Resident #105 overdose, he/she was approached by witness who told him/her about a weird interaction between Residents #104 and #105;-The following was a synopsis of statements from witness: Witness stated he/she resides in the room right next to Resident #104. At approximately 0300 hours, witness was woken up by Resident #104 and Resident #105 who were speaking loudly. Witness heard Resident #105 directly state [NAME] get that to which Resident #104 declined. Witness entered the room to find out what was going on and Resident #104 told him/her it was nothing and offered him/her money to buy a soda;-It should be noted witness stated Resident #104 and Resident #105 were known to be around each other frequently and appeared to be under the influence;-When officer returned to speak with Resident #104 he/she admitted he/she did spend more time with Resident #105 than he/she originally stated. He/She also stated last night, he/she was not feeling well and had Resident #105 pick up the capsules for him/her and brought them back to him/her;-Narrative: Due to lab results that is attached to the report, Resident #104 was issued with three counts of Possession of a Controlled Substance. Review of the Crime Laboratory Controlled Substance Analysis showed:-Item #1: One red/blue capsule containing white power removed. Lab results showed Fentanyl was the identified substance;-Item #8: One white oblong tablet: Methocarbamol (a muscle relaxant) 500 mg;-Item #13: One round white tablet: Hydroxyzine HCI 25 mg;-Item #16: One round white tablet: Trazodone HCI 50 mg;-Item #17: One oval peach tablet: Buprenorphine HCI 2 mg. Numerous tablets appeared to have been degraded and wet at some point. The tablet pieces and powder were included with the whole tablets based on shape and color;-Item #18: One round off-white tablet with no markings removed. Lab results showed Levorphanol (opioid pain medication) was identified;-Item #21: Numerous loose capsules with residue, debris, a piece of metal, and one knotted disposable glove containing a capsule half with residue;-Item #22: One plastic zipper pouch with residue;-Item #23: One twisted plastic bag containing clear crystals;-Contained a total weight of 3.38 grams. Lab results showed Methamphetamine was identified. Further review of Resident #104's face sheet, showed on [DATE], a diagnosis of opioid abuse was added to the medical record. During an interview on [DATE] at 12:19 P.M., the Administrator and ADON said after another resident's overdose (Resident #105), it initiated a room search. It led to finding drugs on Resident #104. During an interview on [DATE] at 12:19 P.M., the DON said they did a room sweep. Resident #104 got irate and said no to the search and covered his/her bag. He/She wanted to leave and said, let me go. They asked where he/she wanted to go, and the resident said the hospital or the streets. The resident said he/she did not want to be there anymore and did not want to be sick. They told the resident they needed to see what was in the bag. He/She was advised of his/her rights, but he/she was still a resident. They confiscated the bag and saw what was in it. There was a crystalized, hard substance, like crystal meth. There were pills that were popped in the bag. There was a form of suboxone on him/her. It was the kind they were supposed to administer to him/her. The resident admitted he/she received it from an outside source. During an interview on [DATE] at 12:19 P.M., the ADON said on [DATE], the police did a test on what was found, and they arrested the resident. They found enough on the resident to consider it trafficking. The police confirmed Fentanyl was found. There were a lot of capsules, some were already popped. There was a baggie that had a solid crystal piece inside. There was a team of five officers, and it activated more police. It was only found in his/her room. They questioned the resident and asked if he/she gave it to another resident. It could only be assumed because the other resident went to the hospital that day with a lot of issues. The ADON said the officers allowed the resident to smoke and during that time, he/she gave the description of the dealer, phone number, card transaction, and which gas station he/she met the dealer. The resident turned in a second phone. During an interview on [DATE] at 12:19 P.M., the DON said they found out Resident #104 and another resident who ended up overdosing (Resident #105) spent a lot of time together the evening before the resident was arrested. 2. Resident #105's face sheet, showed:-admitted on [DATE];-Diagnoses included other psychoactive substance abuse and homelessness. Review of the resident's POS, dated [DATE] through [DATE], showed an order, dated [DATE], Narcan nasal liquid 4 milligrams (mg), alternating nostrils every six hours as needed for overdosing. Review of the resident's progress notes showed:-On [DATE] at 8:55 A.M., writer called to resident room by CNA due to acute change in condition. Upon arrival, resident found slumped over in wheelchair, unresponsive to verbal and vigorous tactile stimuli. Respirations noted labored and irregular. Code initiated immediately. At 8:59 A.M., 911 activated via cell phone. Assessment completed: Blood glucose: 144 (normal range 70 to 99) saturation: 82% (normal range 95 to 100) on 5 liters (L) oxygen via nasal cannula. The resident was transferred to bed with assistance of multiple staff. Naloxone (Narcan) administered intranasally x 2 per physician order. The resident continued with sporadic, labored respirations and minimal response to continued verbal/tactile stimulation. Cool towel applied and stimulation measures continued in attempt to arouse. Fire department followed by Emergency Medical Service (EMS) arrived and assumed care. At time of transfer to stretcher, resident noted moaning and rubbing chest; however, remained not alert/oriented. Physician notified;-On [DATE] at 9:17 A.M., the patient was his/her own responsible party, physician made aware, EMS on site, Cardiopulmonary Resuscitation (CPR, lifesaving procedures) initiated. Rescue position heart rate 255 (normal range 60 to 100), blood sugar 144, oxygen 82 on 5 L resident with history of diabetes, acute kidney failure, and polysubstance abuse;-On [DATE] at 9:29 A.M., the resident was administered two Narcan for both nares (nostrils), resident remained unresponsive. The resident was transported to the hospital via EMS;-On [DATE] at 12:36 P.M., the resident was at the hospital;-On [DATE] at 5:10 P.M., the patient had low PH (substance or solution is acidic). He/She was stable for now on a Narcan drip. The patient would most likely be admitted for continued treatment evaluation monitoring. Review of the resident's care plan, revised on [DATE], showed:-Problem: Resident had received and has been educated on facility illegal drug policy;-Interventions: Monitor for changes in behavior;-Monitor for increased or unexplained drowsiness, lack of coordination, slurred speech, mood changes, or loss of consciousness;-Offer the resident the in the room Alcoholic's Alcoholics Anonymous (AA) program;-Problem: [DATE], resident had an actual overdose;-Interventions: 911 initiated;-Administer medications per physician orders;-Notify physician;-Psych consult upon return to facility;-Initiate facility emergency protocol;-Room checks per facility policy;-Administered Narcan (life lifesaving medication used to rapidly reverse opioid overdoses) per physician order;-Offer resident in the room AA/Narcotic's Anonymous (NA) program;-Problem: Resident at risk for polysubstance abuse related to substance-seeking behavior/safety risk;-Interventions: Monitor for signs of substance abuse/intoxication;-Monitor for signs of withdrawal;-Monitor items brought into facility;-Offer emotional support during periods of agitation;-Notify physician of refusal or noncompliance;-Offer resident in the room AA/NA program;-Problem: Resident is at risk f[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure food storage, dishwasher sanitizing, and cleaning was in accordance with professional standards of practice, increasing the risk of cross-contamination and food-borne illness. In addition, there was no air gap between the ice machine and drain. This deficient practice had the potential to affect all residents who were served food from the kitchen. The census was 97. Review of dietary cleaning duties list, received 5/21/26, showed:-Morning Crew: Label and tag open food, microwave (inside, outside, under), toaster (inside, out, under after breakfast), freezers (tops, inside shelves, outside), meat slicer (inside, out, under), wipe down all stainless, wipe all mixer surfaces, plate warmer (inside, outside), window sills (kitchen, dining room), clean tables, dry milk cooler, hand washing sink, steam table, spice rack, fill all table condiments, clean and roll all silverware, sweep dining room, mop kitchen and dining room;-Evening Crew: Label and tag open food, microwave (inside, outside, under), toaster (inside, out, under after breakfast), freezers (tops, inside shelves, outside), meat slicer (inside, out, under), wipe down all stainless, wipe all mixer surfaces, plate warmer (inside, outside), window sills (kitchen, dining room), clean tables, dry milk cooler, hand washing sink, steam table, spice rack, fill all table condiments, clean and roll all silverware, sweep dining room, mop kitchen and dining room. Review of the Dietary - Equipment Operations, Infection Control, and Sanitation Policy, revised 2/2/24, showed:-Cleaning schedules: The Dietary Manager shall record all cleaning and sanitation tasks for the Dietary Department;-A cleaning schedule shall be posted with tasks designated to specific positions in the Department;-All tasks shall be addressed as to frequency of cleaning;-The procedures to be used are listed in this Policies and Procedures Manual.-General Daily and Weekly Cleaning schedules may be used or Cleaning Schedules by position may be used;-The Dietary Employee should complete the tasks assigned for the day and shift;-Employees should check off tasks as they are completed. If the employee doesn't accomplish a task, they need to communicate with the Dietary manager and place the task on the list for the following day;-Operation and Sanitation of Equipment: The Dietary Manager assembles and organizes manufacturers' directions for operating and cleaning all dietary equipment;-The U.S. Public Health Service Food Code states the following guidelines for sanitizing solutions:--Use chemical sanitizer in accordance with the manufacturers' use directions included in the labeling:--Serve Safe materials recommended contact times for each for the following sanitizers:---Chlorine: seven seconds at 50 ppm at temperature between 75 degrees Fahrenheit (F) and 115 degrees F;---Iodine: 30 seconds at 12.5 - 25.0 ppm at temperature between 75 degrees F and 120 degrees F;---Quats: 30 seconds at 200 ppm at temperature above 75 degrees F;-All surfaces and equipment shall be washed with a sanitizing solution;-Sanitation buckets must be established with appropriate sanitizing solution generally for bleach, 50-100 parts per million (ppm) or Quaternary (no rinse broad spectrum solution) solution, 200 ppm; however, follow manufacturer's recommended directions;-Sanitizing cloths shall be placed in the sanitizing buckets to be used in sanitizing all work surfaces and equipment;-Dietary shall change these buckets at least every three hours and test with the appropriate litmus strips each time the solution is changed to assure accurate levels of sanitizer;-Dish Machine: Before each use, prepare dish machine for use according to instructions. Allow dish machine to run for 10 minutes in order to bring water temperature up to proper level by sending several empty racks through the machine;-Read temperature gauge on top of machine while racks are in the machine;-Low temperature dish machine: Wash temperature: 120 degrees to 140 degrees F;-Rinse temperature: 120 degrees F to 150 degrees F;-Or follow manufacturer's directions, if different;-Any inaccurate temperatures must be brought to the attention of the Dietary Manager immediately;-The concentration of the sanitary solution during the rinse cycle is 200 ppm with quaternary ammonium. This is used on low temperature dish machines;-A potential of hydrogen (pH) test kit is used daily and may be obtained from the chemical supplier for the low temperature dish machines;-When the chemical sanitizing dispenser is broken or not working correctly on a cold temp machine, appropriate amount of sanitizer, per manufacturer directions, can be manually added to the dish machine at each rinse cycle. Check for correct amount of sanitizer at each rinse cycle with appropriate litmus paper;-Record ppm on low temperature machines three times daily;-Dishwashing procedure: Carefully place dishes in soaking sink as needed;-Air dry dishes by racking or putting on single trays lined with mesh;-Counters: Use a mild detergent and water. Rinse shelves with a clean rag and dry;-Frequency: weekly;-Floors: Dust mop or sweep the area;-Fill one mop bucket 2/3 full of clean warm water;-Add cleaning agent to water according to directions on the label of the container;-Place wet floor signs around the area to be mopped;-Dip the mop into the bucket with the cleaning agent;-Wring out the excess solution from the mop, but do not wring fully dry;-Start the mopping stroke approximately 2 feet straight out from the baseboard;-Make a long mopping stroke close to the baseboard;-Continue mopping in a figure-eight pattern;-After turning the mop over two or three times, dip into the bucket with the cleaning agent;-Mop an area 9 by 12 feet at a time;-Wring the mop out and rinse the floor previously mopped with the cleaning solution;-Allow the floor to dry. Then mop and rinse the other half or other areas that have not been mopped;-Change the cleaning solution water and rinse water as the water color turns brown;-Empty the mop buckets and rinse the buckets with clean warm water;-Rinse the mops in clean warm water and wring out as much water as possible;-Remove mop head and place in designated bucket. 1. Observation of the dining room on 5/17/26 at 8:54 A.M., 5/18/26 at 10:49 A.M., 5/19/26 at 1:55 P.M., and 5/20/26 at 11:47 A.M. and 2:30 P.M., showed a dead cockroach, on its back, and on the floor in the dining room approximately two feet from the door to the stairwell. 2. Observation of the refrigerators and freezer on 5/17/26 at 8:46 A.M., showed: -Sliced cheese open to air in the double refrigerator;-Sliced onions in a container with plastic pulled back in the double refrigerator;-Several large empty boxes in the hallway on the floor in between the kitchen prep and refrigerator area; -An open, uncovered seven-pound container of vanilla pudding; -Wrapped ground beef without date. 3. Observation of the kitchen on 5/18/26 at 10:49 A.M., showed:-Dirt and debris on the floor underneath the window, behind prep countertop;-One dead bug on the floor in front of prep table;-Several salt packets on the floor in the fridge/ freezer area. Observation of the kitchen on 5/19/26 at 1:55 P.M., showed:-Dust, debris and food crumbs under the three-sink sanitizer;-A large empty container of detergent with several dried, dirty rags inside;-Four stacked wet containers on the bottom shelf in the kitchen;-Box of salt and pepper packets in front of an open window during a rainstorm. Several packets inside the box were wet;-Food crumbs, dust and debris behind the prep table on the far end of the kitchen;-Uncovered pack of cheese slices in the refrigerator;-One unopened box of 2% milk with 5/11 written on the box. Manufacturer sticker on the box showed 5/18;-Light bulb in the refrigerator holding boxes of milk, showed water dripping from the bulb onto a box;-Ground beef wrapped and dated 5/15. Ground beef appeared darker in color on one side. Observation of the kitchen on 5/20/26 at 2:30 P.M., showed a bag of frozen, opened cauliflower tied in a knot without a date. 4. Observation of the storage room on 5/17/26 at 8:54 A.M., showed: -Approximately 12 empty boxes on the floor;-12 sugar packets on the floor;-Dust and debris around the perimeter of the floor, including underneath the shelves. Observation of the storage room on 5/18/26 at 10:49 A.M., showed: -Approximately 15 broken down boxes on the shelf between canned goods; -Dented 99 ounce (oz) can of pickle spears; -Plastic glove on the bottom shelf behind large plastic container of pickles; -Three empty boxes on the middle shelf near container of pickles; -Several sugar packets on the floor-Plastic glove on the floor at entrance to storage room-Storage room floor was sticky; -Food crumbs inside the steam table with dust and debris on the bottom shelf;-Five large empty boxes on the floor underneath an electronic box. A sign posted showed, area under fuse panel must stay clear. Observation of the storage room on 5/19/26 at 2:24 P.M., showed:-Approximately six boxes on the floor underneath an electronic box. A sign posted showed, area under fuse panel must stay clear; -Sticky floors;-A large can of six pound cheese dented at the top of the can;-A large three pound can of mushroom soup dented at the top of the can;-A large can of pickle spears dented on the side of the can;-A 25-pound bag of seasoned fish breading not completely closed, open to air;-Approximately ten packets of sugar and salt on the floor. Observation of the storage room on 5/20/26 at 2:36 P.M., showed:-Approximately six empty boxes on floor below fuse box on wall, with sign that reads do not place anything below this fuse box;-A three pound can of mushroom soup dented at the top of the can;-A dented, six pound can of diced peaches;-A 25-pound bag of seasoned fish breading not completely closed, open to air;-Three salt and sugar packets on the floor;-Two visibly soiled towels with dark substance which were in an unused steam table with approximately 11 bags of unopened tortilla chips. 5. Observation and interview on 5/21/26 at 2:19 P.M., showed Dietary Aide F at the dish machine. There were several dishes in the dish machine sink that soaked in brown water. Dietary Aide F said he/she did not know how to test the dish machine. He/She made sure there was bleach and soap in the sink first and then he/she ran them through the dish machine. 6. During an observation and interview on 5/21/2026 at 2:23 P.M., Dietary Aide G said the three-sink sanitizer was tested daily. He/She was initially unable to find strips. At 2:25 P.M., Dietary Aide G found strips to test the sanitizer. He/She ran water and sanitizer into the sink and placed a testing strip inside the water. The strip did not change color. He/She matched the testing strip against the container that showed parts per minute (ppm) results with matching colors. Dietary Aide G said the strip appeared light purple; however, the strip did not change to light purple, which was 10 ppm on the container. He/She checked the sanitizer to ensure it was working properly. He/She used a new test strip and placed it inside the water. He/She was unsure of the color and confirmed the strip appeared darker due to it getting wet. Dietary Aide G said the sanitizer was installed earlier this year and they came by to check it but did not test it. The three-sink sanitizer was tested on ce a week. It was last tested this past weekend. 7. Observation on 5/17/26 through 5/21/26, on all days of survey, showed no air gap behind the ice machine in the kitchen. 8. During an interview on 5/21/26 at 2:36 P.M., the Dietary Manager said the three-sink sanitizer had soap, rinse, and sanitizer. They did not have a test book right now, but it was recently fixed. Dietary Manager was unable to say the amount of PPM the test strip needed but would find out. It was recently fixed on 4/4/26. They were unable to smell sanitizer and there were problems getting the solution to come out. The dish machine was tested with a strip to check the amount of sanitizer in the machine. It was both hot water and sanitizing dish machine. There was no test log and had not been used since she started March 2026. If cups and spoons needed to be soaked, they were placed in a prewash of sanitizer liquid and dish soap. It was the same liquid sanitizer used in the green and red buckets. Staff were in-serviced, and they talked about different procedures such as checking the hot water and if utensils came out spotty. Their spoons appeared spotty at one point. Staff was expected to test the dish machine and the three sanitizing sink every day. She would expect staff to report if sanitizer was not coming out. The dietary aides were responsible for cleaning the floors in the dining room, kitchen, and storage room. They did have cleaning duties that were listed for morning and evening. The cleaning list also included the storage room. Staff was expected to notify her if any cans were delivered dented. She would expect boxes to be broken down. Sometimes staff go too fast and grab things instead of taking their time. They did not take out of the boxes and did not have time to break them down. The Dietary Manager was not aware of the air gap, only to keep the area clean. The Dietary Manager and cooks were responsible for checking expiration dates on food. The Dietary Manager was not aware of a box of milk cartoons that had a best buy date of 5/18 written on it. She was not aware of milk thrown out. She would expect containers to be air dried completely before stacking on the shelf. At 2:56 P.M., the Dietary Manager confirmed there were no testing strips for the dish machine. She confirmed the sanitizing liquid used with dish soap to soak dishes was bleach. The Dietary Manager raised a container of brand name cleaner with bleach. The Dietary Manager said it was used for utensils but was not sure about dishes. They used the same cleaner to clean the table. 9. During an interview on 5/21/26 at 3:09 P.M., the Administrator said she would expect the dish machine and three sanitizer sink to be tested regularly. It was not appropriate to use brand bleach on dishes. They recently had the dish machine serviced. Corporate and maintenance would assist in the process. She would have expected the storage room to be cleaned, with non-food items off the shelves.

Based on observation, interview, and record review, the facility failed to ensure resident rooms (Resident #2), resident common area meeting spaces, and resident belongings were kept in a clean, safe, and homelike manner. Concerns were noted with shower rooms on the 300, 500 and 100 hall, resident phone rooms, and with the sunrooms at the ends of resident halls. The sample size was 20. The census was 97.Review of the facility's Safe and Homelike Environment policy, revised 6/5/24, showed:-In accordance with the residence rights, the facility will provide a safe, clean, comfortable, and home like environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk;-A homelike environment is one that D emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a home like environment. A determination of homelike should include the residence opinion of the living environment;-The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting;-Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment;-The facility will provide and maintain bed and bath linens that are clean and in good condition. Review of the facility's Housekeeping - Deep Cleaning Policy, revised 6/29/23-All areas should be monitored on a daily basis and all resident living areas and non living areas should be clean and odor free;-Daily cleaning: Pick up all trash and put into trash can and empty, dust mop or sweep floor, and clean shower rooms inside the shower, around the shower, and the baseboards in the room;-Bathroom floors will be swept and mopped and any dirt, grime, or stains will be hand scrubbed with stiff brush or other equipment suitable for removing surface dirt from entire floor. If the stain is not removable then housekeeper will notify maintenance department with a maintenance request form. 1. Review of Resident # 2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/11/26, showed:-Cognitively intact;-No rejection in care;-Requires partial to moderate assistance with personal hygiene and bathing;-Diagnosis include, schizophrenia (a mental condition that distorts reality), infection of intravertebral disc ( a part of the back), malnutrition (poor nutrition), and viral hepatitis (inflammation of the liver caused by a virus). Observation on 5/17/26 at 10:10 A.M., 5/18/26 at 9:05 A.M., and 5/19/26 at 8:45 A.M., showed the resident lay in bed. The white fitted bed sheet had stains and dark discoloration. Multiple bottles of empty soda bottles, crumbs of food, food wrappers, and cups of undigested food in clear cups were on the resident's floor next to his/her bed. Multiple personal items were in the residents' room and closet. During an interview on 5/18/26 at 9:05 A.M., the resident said he/she wasn't sure if his/her room was cleaned every day. The resident said he/she was messy and tried to pick things up him/herself but really couldn't, due to pain. The resident said he/she was having difficulty swallowing and that was why he/she spit food and saliva in the cups 2. Observation on 5/17/26 at 8:43 A.M. of the 300 hall Tub Washroom, showed two large industrial trash cans filled with waste lined up next to the tub. Broken baseboard pieces and broken tiles were observed behind the washroom's toilet. Observation on 5/17/26 at 9:07 A.M. of the shower room on the 500 hall, showed three large industrial trash cans blocking access to the sink and cabinets. A soiled blue sock was observed in the bathtub. Observation on 5/18/26 at 9:27 A.M. of the shower room on the 500 hall, showed three large industrial trash cans blocking access to the sink and cabinets. A soiled blue sock was observed in the bathtub. Observation of the 100 hallway shower room, showed:-On Observation on 5/19/26 at 9:02 A.M., the room had a mildew-like smell. Dirty towels were on the ground under the bench and on top of the shower bench. A wet towel was on the ground. Hair was on the ground and on the shower wall. A used white washcloth was on the ground in the right corner of the room; -On 5/20/26 at 6:59 A.M., the room had a mildew-like smell. Hair was on the floor and the shower wall. A used washcloth was on ground in the right corner of room; -On 5/21/26 at 6:43 A.M., wet towels were on the ground in front of the shower bench. Hair was on the ground and on the shower bench. A used white washcloth was on the floor in the right corner of the room. During an interview on 5/17/26 at 10:10 A.M., Resident #2 said he/she didn't take showers because the shower room was so filthy. The facility did not provide any type of shoes to wear in the shower, and he/she did not want to put his/her bare feet directly on the shower floor. 3. Observation 5/17/26 9:28 A.M. of the 300 hall resident Phone Room, showed a small room with a sitting table and chairs with a phone available for residents to use. The room's floor had a dark, sticky stain in the center of the room and pieces of plastic trash were observed in the corner of the room near the doorway.Observation 5/18/26 9:16 A.M. of the 300 hall resident Phone Room, showed a small room with a sitting table and chairs with a phone available for residents to use. The room's floor had a dark, sticky stain in the center of the room and pieces of plastic trash were observed in the corner of the room near the doorway. 4. Observation on 5/17/26 at 8:42 A.M. of the sunroom at the end of the 300 East resident's hall, showed an empty wood pallet propped up against the [NAME] wall of the sunroom. Observation on 5/19/26 at 9:00 A.M., of the 100 hallway sun room, showed:-A large dead cockroach was on ground in the corner of the room;-Trash debris was on ground in various areas;-Grey cigarette ash was on the ground behind the desk;-Food wrappers were on the desk. The desk was visibly dusty. Observation on 5/21/26 at 6:45 A.M., showed:-Food wrappers were on the desk. The desk was visibly dusty. 5. During an interview on 5/17/26 at approximately 9:00 A.M., Housekeeper H said the hall shower rooms, common areas, and resident rooms were cleaned daily and as needed. During an interview on 5/21/26 at 11:20 A.M., Certified Nursing Assistant (CNA) L said the nursing staff changed sheets daily and as needed and the housekeeping staff cleaned the resident rooms and swept the floors once daily. During an interview on 5/21/26 at 8:54 A.M., Licensed Practical Nurse (LPN) A said Certified Nursing Assistants (CNA) were responsible for ensuring dirty linen was taken out of the shower rooms. He/She said housekeeping was responsible for cleaning the shower rooms. He/She said the shower rooms were cleaned once a day and as needed. During an interview on 5/21/26 at approximately 10:00A.M., the Housekeeping Supervisor said resident rooms and the shower rooms on resident halls were expected to be cleaned daily and as needed. During an interview on 5/21/26 at 2:22P.M., the Administrator, Director of Nursing, Assistant Director of Nursing, and Regional Nurse Consultant said she would expect all shower rooms and resident rooms to be cleaned daily and as needed. The Administrator said she would expect facility staff to complete the inventory list on admission and when new items were brought in for a resident. She would expect all rooms to be cleaned daily and sheets to be changed when visibly soiled.

Based on interview and record review the facility failed to send a copy of the transfer and discharge notices to a representative of the Office of the State Long-Term Care Ombudsman (resident advocate) for January, February, March, and April 2026. The census was 97. Review of the facility's Resident Transfer, Discharge, Immediate Discharge, and Therapeutic Leave policy, last revised 4/28/25, showed:-Purpose: Establish policy and procedure regarding the transfer/discharge of residents; To ensure no inappropriate discharges are made and that no discharges are made in an unsafe manor;-Notice of discharge or transfer: -Who must receive notice; -Notifying the representative for the Office of the State Long-Term Ombudsman; -A copy of the discharge transfer notice shall be sent to the Ombudsman at least 30 days in advance of the discharge or as soon as possible; -In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman; This notice shall be sent when practicable and a monthly list is acceptable and should include if the resident's return is expected. Review of the facility's admission and Discharge Report, dated 6/27/24 through 5/17/26, showed:-January 2026: Eight residents discharged ;-February 2026: Six residents discharged ;-March 2026: Eight residents discharged ;-April 2026 : Eight residents discharged . During an interview on 5/14/26 at 8:04 A.M., the Ombudsman said their office has not received the transfer discharge notifications consistently from the facility starting from January 2026. During an interview on 5/18/26 at 2:50 P.M., the Social Service Director (SSD) said he had only been at the facility for two weeks and has not sent any documentation of the facility's transfers and discharges to the Ombudsman's office and is unsure what the previous SSD sent. During an interview on 5/21/26 at 2:22 P.M., the Administrator said she expected the SSD to send the required documentation for discharges and transfers to the Ombudsman's office. The facility has not been sending the transfer discharge documentation timely and consistently to the Ombudsman's office. The facility has not had a dependable SSD in the facility for several months.

Based on observation, interview and record review, the facility failed to ensure residents received appropriate activities of daily living (ADL, daily care) care to meet the needs of residents by not assisting three residents with their showers (Resident # 35, Resident #25 and Resident #2) and provide foot care for one resident (Resident #25). The facility also failed to assist one resident during mealtimes (Resident #55). The sample size was 20. The census was 97. Review of the facility's ADL policy, dated 5/18/24, showed:-Purpose: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-Cares and services will be provided for the following ADLs;-Bathing, dressing, grooming and oral care;-Transfer and ambulation;-Toileting;-Eating to include meals and snacks; and systems;-Policy: The facility will provide a maintenance and restorative program to assist the residents in achieving and maintaining the highest practicable outcome base on the comprehensive assessment.-A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's Podiatry Services policy, last revised on 5/14/24, showed:-Purpose: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health;-Policy:-Foot care that is provided in the facility, such as toenail clipping for residents without complicating disease processes, should be provided by staff who have received education and training to provide this service;-Residents requiring foot care who have complicating disease processes will be referred to qualified professionals such as a podiatrist (foot doctor). 1. Review of Resident #35's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 2/10/26, showed:-Diagnoses included cerebrovascular accident (CVA, stroke), paraplegia, malnutrition, depression, schizophrenia, and asthma;-Cognitively intact;-Impairment on both sides to upper and lower extremity;-Uses wheelchair;-Substantial/maximal assistance for eating;-Dependent with oral hygiene, toileting, shower/bathe self, upper and lower body dressing, and personal hygiene. Review of the resident's care plan, in use during survey, showed:-Problem: Resident has an Activity of Daily Living (ADL) self-care performance and mobility deficit related to spinal injury paraplegia, poor coordination, obesity, weakness, and neurological impairment requiring maximum assistance with ADLs;-Interventions:--Monitor for fatigue and poor coordination;--Provide max assist with ADLs, transfers, mobility, and hygiene;--Two staff members for ADL care;--Bathing/showering: Resident is totally dependent on 1-2 staff to complete this task;--Bed mobility: The resident is totally dependent on staff for repositioning and turning in bed;--Personal hygiene/oral care: The resident is totally dependent on one staff for personal hygiene and oral care;--Encourage the resident to discuss feelings about self-care deficit;--Encourage the resident to use bell to call for assistance;--Monitor/document/report as needed (PRN) any changes, any potential for improvement, reasons for self-care, deficit, expected course, decline in function; -Problem: Resident's family member came into facility to discuss resident's care;-Interventions:--Staff will offer daily get ups to resident;--Showers will continue to be offered 2x a week. Review of the resident's shower sheets, May 2026, showed:-On 5/2/26, a bed bath and signed by Certified Nursing Aide (CNA) and charge nurse;-On 5/6/26, a shower was documented and signed by CNA and charge nurse;-On 5/9/26, a bed bath or shower was not documented. It was signed by CNA and charge nurse;-On 5/13/26, a bed bath or shower was not documented. It was signed by the charge nurse;-On 5/16/26, no staff signature or other written documentation. During an observation and interview on 5/20/26 at 2:38 P.M., the resident said showers were not frequent, it was whenever staff wanted to take him/her there. Cleanliness was a part of nursing too. He/She asked for a shower in the past and was told no due to reasons such as staffing or broken or no shower bed. Staff changed his/her brief, but that is it. When he/she received a bed bath, it was not sufficient because they used wipes on his/her back. He/She asked staff not to do that. They called it a bed bath, but it was only a wet wipe without any water. If he/she received a shower, staff did not moisturize his/her skin. His/her shower days were Wednesday and Saturday and confirmed today was his/her shower day. His/Her scalp was very itchy, and his/her hair had not been washed. He/She did not remember the last shower, but it was the end of last month. His/her scratched his/her scalp a lot. The resident never refused a shower. Staff documented he/she refused, but no one talked to him/her about refusal. The resident said when he/she was at a former facility, he/she signed the shower sheet if they refused. The resident believed staff should do the same here. The resident's hair appeared matted, covered with a large amount of dandruff, presenting as whitish flakes throughout his/her hair. During an interview on 5/20/26 at 3:38 P.M., Licensed Practical Nurse (LPN) I said sometimes the resident refused to get out of bed. For example, he/she told staff he/she would not get out of bed if certain people were out there or in the hall. He/She was not known to refuse showers. During an interview on 5/20/26 at 3:41 P.M., CNA J said the resident did not have any refusals for showers or getting out of bed. Sometimes, in a sarcastic way, he/she would say, I did not know I could get out of bed. During an interview on 5/21/26 at 9:52 A.M., the Administrator said the resident had not received a shower since 5/6/26. She was uncertain if the resident wanted it and did not hinder the shower. She would inform nursing so the resident could receive a shower. During an interview on 5/21/26 at 10:30 A.M., CNA K said he/she used two gray buckets for bed baths. One bucket has hot water and the other was for the soap. They used soap and wash cloths, depending on the part of the body. If a resident requested wipes, he/she would use them. Otherwise, he/she used a washcloth. 2. Review of Resident #25's, quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No rejection of care;-Uses a walker and wheelchair;-Partial to moderate assistance with personal hygiene, bathing, toilet hygiene, putting on and taking off footwear;-Requires supervision or touching assistance from staff for lower body dressing;-Diagnosis includes chronic (long term) lung disease, high blood pressure, heart failure, morbid obesity and difficulty walking. Review of the resident's care plan, in use during the time of the investigation, did not address the resident's ADL needs. Review of the resident's shower sheets, dated 4/1, 4/6, 4/9, 4/13, 4/20, 4/23, 4/24, 4/30, 5/4, 5/7, 5/11, 5/14, 5/16, and 5/18/26 showed:-Signed by the CNA and Charge Nurse;-No description of type of bathing or showering;-No skin issues listed;-Does the resident need his or her toenails cut? Blank. Review of the podiatrist list provided by the facility, dated 4/9/26, showed the resident was not listed.During an observation and interview on 5/17/ 26 at 8:47 A.M. and 5/19/26 at 8:55 A.M., the resident sat in his/her wheelchair. The resident exposed his/her lower legs and feet by lifting his/her pant legs. The resident's legs and feet were extremely dry with a dark skin discoloration to the calf area of the legs. The resident's hair was oily. The resident said he/she required assistance getting in the shower room because there was a lip when you entered the shower and he/she was afraid he/she was going to trip and fall because of it. The resident said he took a bird bath and washed his/her hair at the sink located in his/her room. He/She had not received assistance from staff for his/her showers. The resident's toenails were approximately one half an inch long and were jagged. The resident said no staff member had ever provided any type of toenail trimming or foot care since he/she had been admitted . Observation on 5/17/26 at 10:00 A.M., 5/18/26 at 9:00 A.M., and 5/19/26 at 1:05 P.M., showed the shower room had an uneven bump located directly before the shower stall. During an interview on 5/21/26 at 10:50 A.M., CNA L said the resident required assistance with his/her showers and he used his/her walker to get into the showers. The facility nail clippers were so flimsy that they were not useful in cutting the resident toenails. If staff could not cut resident's toenails, then the resident should be referred to the podiatrist. If a resident required a bed bath, then it should be written on the shower sheet as a bed bath. Foot care should be provided on their shower days and as needed. All skin issues including dry skin should be on the resident's shower sheets. 3. Review of Resident # 2's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No rejection in care;-Requires partial to moderate assistance with personal hygiene and bathing;-Requires supervision or touch assist putting on and takin off footwear;-Diagnoses included, schizophrenia (a mental condition that distorts reality), infection of intravertebral disc (a part of the back), malnutrition (poor nutrition), and viral hepatitis (inflammation of the liver caused by a virus). Review of the resident's care plan, in use at the time of survey, showed:-Problem: The resident is at risk for ADL self-care performance deficit due to deconditioning;-Interventions: Encourage the resident to participate to the fullest extent with each interaction. Monitor and document any changes, any potential for improvement, reason for self-care deficit, expected course or declines in function. Praise all efforts of self-care. Review of the resident's shower sheets, dated 4/2, 4/9, 4/13, 4/16, 4/20, 4/24, 4/27, 4/30,5/4, 5/7, 5/11, 5/14, and 5/18/26 showed:-Signed by the CNA and Charge Nurse;-No description of type of bathing or showering. Observation on 5/17/ 26 at 10:10 A.M., 5/18/26 at 9:05 A.M. and 5/19/26 at 8:45 A.M., showed the resident lay in bed. The white fitted bed sheet had stains and dark discoloration. The resident wore white socks and the bottom of the socks were stained black. The resident's hair was messy and had white particles in it. During an interview on 5/17/26 at 10:10 A.M., the resident said he/she didn't take showers any longer because the shower room on the 200 hall was so filthy. The facility did not provide any type of shoes to wear in the shower, and he/she did not want to put his/her bare feet directly on the shower floor. The resident said he required assistance with his/her showers because he/she was unsteady on his/her feet. The resident could not remember the last shower he/she took at the facility. Observation on 5/17/26 at 10:00 A.M., 5/18/26 at 9:00 A.M., and 5/19/26 at 1:05 P.M., showed the shower room on 200 hall had multiple used wet towels and had a moldy odor. There was mold on the tile grout on the wall of the shower. During an interview on 5/21/26 at 10:50 A.M., CNA L said the resident refused his/her showers and always had an excuse. The CNAs should document refusals of resident showers on the shower sheets. The facility did not supply any type of shower shoes. The resident should be encouraged to change his/her soiled socks, but the resident had a tendency to refuse care. 4. During an interview on 5/21/26 at 2:22 P.M., the Regional Nurse Consultant (RNC) and the Director of Nursing (DON) said the residents were expected to get showers two to three times a week. They would expect staff to complete accurate documentation of the showers to include what type of bathing activity occurred and any skin or foot issues. Foot care could be provided by staff and included toenail trimming and moisturization of the feet. It was expected that staff helped the residents with showers when the resident's needed assistance. The facility did not provide any type of shower shoes for the residents to wear. 5. Review of Resident #55's quarterly MDS, dated [DATE], showed:-Diagnoses included hypertension (high blood pressure), depression and anxiety;-Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed:-Problem: Resident has an activities of daily living(ADL) self-care performance deficit;-Desired outcome: Resident will maintain current level of function by the review date;-Interventions: Eating: Resident requires supervision or touching assistance from staff to perform this task. Review on 5/17/26 at 11:14 A.M., of the resident's POS, dated 5/2026, showed an order, dated 9/30/24 for regular diet, regular food texture, thin/regular drink consistency. Observation on 5/20/26, of the resident in the main dining room, showed:-At 7:59 A.M., the resident was in the dining room for breakfast. The resident had a carton of milk, bowl of cereal, plate of scrambled eggs, a piece of toast, and a sausage patty;-At 8:02 A.M., the resident was struggling to open the milk carton. The resident, who was seated at the table with him/her, opened the milk carton for him/her. CNA B was in the dining room speaking with other residents;-At 8:16 A.M., the resident started to eat the hot breakfast portion. He/She struggled to use his/her fork with his/her hand visably shaking. He/She started to shovel the scrambled eggs onto the fork with his/her hands;-At 8:17 A.M., the resident pushed the remainder of the scrambled eggs onto the piece to toast. The resident brought his/her head down to the piece of toast to take a bite and appeared to struggle with lifting the piece of toast all the way to his/her mouth. During an interview on 5/20/26 at 12:24 P.M., the Registered Dietician (RD) said she was unaware the resident was not on hospice and must have been documented that in error. She said she came to the facility on 5/19/26 but did not actually lay eyes on the resident. She said she was unaware the resident was struggled to open his/her milk carton and with lifting silverware up to his/her mouth. She would have expected staff oversight in the dining room. She would expect staff to assist the resident and refer the resident to occupational therapy if they had concerns. During an interview on 5/21/26 at 6:47 A.M., the resident said he/she struggled to open juice cartons and milk cartons. He/She said the residents who sat at his/her table in the dining room helped him/her. He/She said he/she did have weight loss but tried to eat as much as possible. Observation on 5/21/26 at 7:45 A.M., showed the resident in the main dining room for breakfast. The resident held his/her milk carton and attempted to open it. A resident from the table next to his/her got up and opened the milk carton for the resident. CNA B was in the dining room talking with dietary staff. During an interview on 5/21/26 at 9:46 A.M., CNA B said the resident required one staff touch assistance and supervision during meals. He/She said the resident should be eating finger food because he/she ate with his/her hands. He/She said he/she did not help the resident because the resident wanted to be independent. During an interview on 5/21/26 at 2:46 P.M., the Administrator and DON said staff should assist residents during meals with opening packages. If any staff saw residents struggling to feed themselves, they should have reported this to the resident's nurse. Nursing staff should have assist the residents and if they were having a hard time eating, staff should have notified therapy for possible occupational therapy evaluations. 1611324 2784565

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program that supports resident's interests and their choices of activities for three residents (Residents #7, Resident #25, and Resident #8). In addition, the facility failed to provide one to one (1:1) activities to one resident who was identified as having the potential to benefit from them (Residents #35). The sample size was 20. The census was 97. Review of the facility's Activities policy, last revised on 7/19/23, showed:Purpose: The purpose of this policy is to ensure that all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being;-Procedure:--The Life Enhancement Director coordinates from the comprehensive assessment and ensures that activities are designed to promote and enhance emotional health, self-esteem, pleasure, comfort, education, creativity, success and independence for all residents based on interview and assessing the resident's likes and dislikes;--If the resident requires more intensive interventions for activities, programming that is relevant to the resident' specific needs, interests, culture, and history/background, than an individualized activities plan of care will be developed to enhance their psychosocial well-being;--The activities calendar will be posted on each unit and will include activities that are appropriate for general therapeutic social setting of the population that meets the specific needs, cognitive impairments, interests and supports the quality of life while enhancing self-esteem and dignity. Review of the facility's activity calendar, dated 5/17 through 5/27/26, showed:-On 5/18/26 at 10:00A.M., dancing; 10:30 A.M., coffee and conversation; 2:00 P.M., bingo;-On 5/19/26 at 10:00 A.M., chair exercises; 10:30 A.M., What song is this?; 2:00 P.M., Men's club; 3:30 P.M., Narcotics Anonymous meeting;-On 5/20/26 at 10:00 A.M., dancing; 10:30 A.M., washers and cornhole; 2:00 P.M., arts and crafts;-On 5/21/26 at 10:00 A.M., dancing; 10:30 A.M., sharing jokes; 2:00 P.M., women's club;-On 5/22/26 at 10:00 A.M., dancing; 10:30 A.M., washers and cornhole; 2:00 P.M., bingo;-On 5/23/26 at 10: 00 A.M., chair exercises, 10:30 A.M., cards and games; 2:00 P.M., music sensory.-On 5/27/26 at 10:00 A.M., prayers in the chapel, 10:45 A.M., washers and cornholes; 2:00P.M., Fun facts and trivia;-The facility did not offer any activity in the evening hours. 1. Review of Resident #7's quarterly Activities Assessment, dated 1/14/2026, showed:-Describe the resident's favorite activities: being with friends. No additional comments;-Described the resident's activity preferences and attendance levels: the resident attends quite a few activities but notes she feels it's hard to attend sometimes. No additional comments;-Describe changes to activity focuses (strengths, problems, preferences): none;-Progress towards activity goals marked as met by the resident;-Summary note: The resident attends quite a few activities but notes she feels it's hard to attend sometimes. The resident likes being with friends. Review of the resident's quarterly MDS (Minimum Data Set, a federally mandated resident assessment tool completed by facility staff), dated 2/3/26, showed:-The resident is cognitively intact;-Medical diagnoses including hypertension, obstructive uropathy (a chronic condition in which urine is blocked in the urinary tract due to intrinsic issues in the tract or processes pressing on the ureters), Type II Diabetes, depression, and schizophrenia (a chronic and severe brain disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness, often leading to hallucinations, delusions, and disorganized thinking). Review of the resident's care plan, in use during the time of the survey, did not address the resident's current dissatisfaction with the lack of activities. During an observation and interview on 5/17/26 at 9:04 A.M., the resident sat pleasantly near the nurse's station on the 500 hall and watched television. The resident said he/she often sat there as it was one of the best ways to pass the time. During an observation and interview on 5/19/26 at 1:31 P.M., the resident sat pleasantly at the nurse's station on the 500 hall. When asked about activities in the facility the resident said there were no activities after dinner and indicated the only activity in the afternoons and evenings were the smoke times for residents who smoked. The resident did not smoke and would have liked to have something to do in the afternoons or evenings throughout the week. The resident said he/she liked dogs and would have enjoyed any kind of visit from a dog. During an interview on 5/21/26 at 10:11, A.M. Certified Nursing Assistant (CNA) M said activities in the afternoons and evenings included coffee socials or residents would go outside in the yard to do activities. CNA M had never saw Resident #7 attend an activity and had never seen anyone attempt to encourage him/her to attend any activities. 2. Review of Resident # 25's, quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-No rejection of care;-Uses a walker and wheelchair;-Diagnosis includes chronic (long term) lung disease, high blood pressure, heart failure, morbid obesity and difficulty walking. Review of the resident's care plan in use at the time of survey showed:-Problem: The resident has little to no involvement with activities;-Interventions: Explain to the resident the importance of social interaction, and leisure time; Encourage the resident's participation by: blank; Remind the resident that he/she can leave the activity at any time. Review of the residents Engagement Insights, dated 4/1/26 through 5/1/26 showed the resident participated in one program, bingo for 120 minutes. During an interview on 5/19/26 at 8:55 A.M., the resident said he/she would really enjoy some evening activities. If you did not smoke, there was nothing to do. The resident would have enjoyed a non-alcoholic Happy Hour. None of the activities really interested the resident and the same activities were repeated so much. 3. Review of Resident #8's annual MDS, dated [DATE], showed:-Diagnosis included schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder), anxiety, and depression;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed:-Problem: The resident has a potential for decline in activity participation;-Desired outcome: The resident will remain active in participating in activities of choice through next review;-Interventions: Activities will provide 1:1 activities on request. Activities will remind/escort the resident as needed to activities of choice. Encourage socialization with others as tolerated. The resident enjoys music and TV in his/her room. He/She joins group smoking and some activities in the main dining room. During an interview on 5/17/26 at 8:36 A.M., the resident said there were not enough activities provided. He/She would have liked to see more activities of different varieties. He/She said he/she attended activities he/she was interested in but other than that sat around and waited for smoke breaks. Observation on 5/19/26 at 8:56 A.M., showed the resident in the hallway waiting for the smoke break at 9:30 A.M. No morning activities were provided on the 100 hallway. During an interview on 5/21/26 at 12:33 P.M., the Activity Director said the resident participated in activities such as bingo and music. She said the resident would benefit from more activities. 4. Review of Resident #35's annual MDS, dated [DATE], showed:-Diagnoses included cerebrovascular accident (CVA, stroke), paraplegia, malnutrition, depression, schizophrenia, and asthma;-Cognitively intact;-Impairment on both sides to upper and lower extremity;-Uses wheelchair;-Activity preferences: Somewhat important to do your favorite activities, go outside to get fresh air when the weather is good, participate in religious services and practices, do favorite activities, to be around animals such as pets, and listen to music. Review of the resident's care plan, in use during survey, showed:-Problem: Discharge plan: Resident admitted to facility for long term care;-Interventions: Encourage resident to become engaged in facility life through group activities, meals in dining room, and therapeutic groups if applicable to needs;-Problem: Resident refused care from staff;-Interventions: Staff to offer daily if patient would like to get up;-If resident refuses, multiple attempts will be made by aid then nurse. Document if indicated;-Resident's right to refuse will be respected; -Resident will be educated on the benefits of services offered, such as increased quality of life, dignity, and increased socialization; -Resident will be educated on the increased risk of not receiving the services he/she is offered such as immunity, impaired skin integrity, psychosocial mood disturbance. Review of the resident's quarterly activities assessment, dated 3/23/26, showed:-Attendance and participation summary: Does not really come to activities, but says he/she would like to do more things;-Describe resident's favorite activities: Live music, going outside to get fresh air;-Activity plan review: Activity related focus remains appropriate/current as per current care plan;-Describe changes to activity focuses: He/She wants therapy equipment he/she can use and books to read;-Describe changes to goals: He/She wants to do more when it comes to activities. During an interview on 5/20/26 at 2:38 P.M., the resident said he/she did not get out of bed. He/She was not asked daily if he/she wanted to get out of bed and staff would refuse. They gave excuses such as staffing or would tell him/her there were emergencies. They would also ask, are you sure. The resident liked getting fresh air. The residents who smoked or were able to walk were able to go outside. He/She was out of bed last week, but it was only for four hours. The resident preferred longer, but the aide was leaving and did not know who would relieve them. Activities did not go to resident rooms or walk around. The resident said the only interaction was when mail was delivered. It would be helpful to go outside. He/She felt isolated, and it was depressing. During an interview on 5/20/26 at 3:38 P.M., Licensed Practical Nurse (LPN) I said sometimes the resident refused to get out of bed. For example, he/she told staff he/she would not get out of bed if certain people were out there or in the hall. During an interview on 5/20/26 at 3:41 P.M., Certified Nurse Aide (CNA) J said the resident did not have any refusals regarding getting out of bed. Sometimes, in a sarcastic way, he/she would say, I did not know I could get out of bed. During an interview on 5/21/26 at 12:22 P.M., the Activity Director said the resident preferred to keep to him/herself. He/She tried to engage with the resident when he/she delivered the mail. The resident was not talkative or willing to engage. He/She asked if there were books or crossword puzzles, he/she wanted. The Activity Director was not sure if the resident had a rapport with other residents, but if he/she did, they would have to go to his/her room. 5. Observation on 5/19/26 at 10:05 A.M., showed music played in the main dining room. Five residents sat in the main dining room and no residents were exercising. Activities Assistant (AA) N sat at a dining room table and spoke with another staff member. 6. Observation on 5/20/26 at 2:10 P.M., showed three residents worked on a paper craft. Activities Aide (AA) N stood in the main dining room and did not assist or engage with the residents who participated in the arts and crafts activity. 7. During the resident council meeting on 5/20/26 at 2:00 P.M. nine residents said there was a lack of variation in activities, specifically activities that happened in the evening. Residents indicated they had a desire for various activities and said the Activity's Director told them to suggest activities that they would like to do, but residents had trouble remembering activity ideas to relay to the Activities Director. Recently a washer's board and two corn-hole boards were purchased, but residents were unable to use them in the dining room or indoors. Very few activities were held in the afternoons after 2:30 P.M., and one of them was the monthly Resident Council Meeting. Activities were often held on the second-floor dining room, the largest space in the facility, but the room could not be used in the afternoons because dietary staff needed to turn it over for dinner service. 8. During an interview on 5/19/26 at 1:30 P.M., AA N said the Activities Department was responsible for all the smoke breaks. There were no evening activities except smoking. 9. During an interview on 5/21/26 at 8:54 A.M., LPN A said the facility needed more activities. He/She said the activity department was short staffed. He/She said a lot of the time residents just sat around doing nothing. 10. During an interview on 5/21/26 at 12:21 P.M., the Activities Director (AD) said her current calendar of events was based off what the previous AD did before. She tried to provide interesting activities by looking online and collecting input from the residents. She had a budget to maintain, and it didn't cover all the costs of the activities. The AD paid for some of the supplies for the activities out of her own pocket. The Activities Department was responsible for all the smoke breaks and that sometimes cut into the activity times. She would have expected staff to engage with the residents while providing the activities and encourage resident to come out of their rooms to participate. The AD did not have a 1:1 list. She would normally go into the resident rooms that did not come out for activities and speak with them for about five minutes. The AD did not consider five minutes of speaking with the resident a 1:1 activity. There were no evening activities because of lack of staff, family conflicts and being unable to work evenings. She would have liked the nursing staff to have provided some evening activities. 11. During an interview on 5/21/26 at 2:22 P.M. the Administrator expected all departments to take turns providing smoke breaks for the residents. It should not have just been the Activities Department doing the smoke breaks. The Administrator would have expected a variety of activities that interested the residents. She would have expected evening activities and staff to engage with the residents during the activity. She did not consider Narcotics Anonymous and Resident Council meetings an activity. The Administrator would have expected the AD to have had a 1:1 list and provided activities to those residents as well. 2784565

Based on observation, interview, and record review, the facility failed to ensure smoking assessments were completed for three residents (Residents #91, #2, and #31) and failed to ensure lighters and cigarettes were not taken in two residents' rooms (Residents #91 and #2). The sample was 20. The census was 97. Review of the facility's Smoking Safety Regulations Policy, dated 6/29/23, showed: -The facility will provide direct supervision for smoking by patients classified as not responsible; -The policy did not address the frequency of smoking assessments; -The policy did not address the storage locations of smoking materials. 1. Review of Resident # 91's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/28/26, showed: -Diagnoses included cancer, chronic (long term) lung disease, seizures, and stroke; -Moderately impaired cognition; -admission date 10/31/25. Review of the resident's care plan, in use at the time of the survey, showed: -The care plan did not address that the resident smoked. Review of the resident's smoking and safety evaluation, dated 10/31/25, showed: -Uses tobacco; -Smoking safety evaluation: Blank; -Care planning: Blank; -Smoking cessations care planning: Blank; -Clinical suggestions: Blank. -No further smoking assessments were available for review. Observation on 5/19/26 at 1:30 P.M., showed the resident walked out to the smoking area using a rollator (a type of walker). Activities Assistant (AA) N gave the resident one cigarette and a lighter. The resident sat on his/her rollator and lit the cigarette and began to smoke. Once the resident finished smoking his/her cigarette, the resident extinguished and disposed of the cigarette on the ground. At 2:00 P.M., the resident walked into the building passing Certified Nursing Assistant (CNA) O and AA N that were holding the door open for the resident. The resident kept the lighter in his/her hand as he/she propelled the rollator into the building. The resident got into the elevator and took it to the 200 hall. The resident got off the elevator with the cigarette lighter in his/her hand and walked to his/her room and set the lighter on the bedside table. CNA O and AA N did not remove the cigarette lighter from the resident before he/she entered the building. 2. Review of Resident # 2's quarterly MDS, dated [DATE], showed: -Diagnoses included schizophrenia (a mental condition that distorts reality), infection of intravertebral disc (a part of the back), malnutrition (poor nutrition), and viral hepatitis (inflammation of the liver caused by a virus); -Cognitively intact; -Uses a walker; -admission date 4/18/25. Review of the resident's care plan in use at the time of survey, showed: -Problem: The resident is smoker; -Interventions: Instruct resident about smoking risks, smoking hazards, and smoking cessation aids that are available; -Instruct resident about the facility smoking policy on smoking : Locations, times, safety concerns; -Notify charge nurse immediately if it is suspected the resident has violated facility smoking policy. Review of the resident's smoking and safety evaluation, dated 4/18/25, showed: -Uses tobacco; -Balance problems sitting or standing. -Care planning: Blank; -Smoking cessations care planning: Blank; -Clinical suggestions: Blank. Review of the resident's smoking and safety evaluation, dated 1/8/26, showed: -Uses tobacco: -Follows the facility's policy on location and time of smoking; -Care planning: Blank; -Smoking cessations care planning: Blank; -Clinical suggestions: Blank. Review of the resident's record showed no further smoking and safety evaluations available for review. Observation and interview on 5/17/26 at 10:10 A.M., showed the resident lay in bed. Next to the resident on the bed was half of a smoked cigarette and a lighter. The resident said he/she just came back in from smoking. 3. During an interview 5/19/26 at 1:40 P.M., CNA O and AA N said the residents are not to have cigarettes in their room. Residents are allowed to light their own cigarettes with the lighters that are provided to them. All lighters are then taken back before the resident goes back into the building. During an interview on 5/21/26 at 11:20 A.M., CNA L said that no residents should have lighters or cigarettes in their room. Staff should immediately remove the cigarettes and lighter when found. During an interview on 5/21/26 at 12:21 P.M., the Activities Director said she would expect staff to ensure that the residents do not go into the building with cigarettes or lighters in their possession after smoking. 4. Review of Resident #31's quarterly MDS, dated [DATE], showed: -Diagnosis included chronic obstructive pulmonary disease (COPD, lung disease), diabetes, and mild intellectual disabilities; -Moderately impaired cognition; -admission date 10/24/22. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident is a smoker; -Desired outcome: Resident will not smoke without supervision through the review date; -Interventions: Instruct resident about smoking risks and hazards and about smoking. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated smoking policy. Review of the resident's smoking and safety evaluation, dated 7/11/25, showed: -Uses tobacco; -Smoking and safety: Blank; -Care planning: Blank; -Smoking cessations care planning: Blank; -Clinical suggestions: Blank. Observation on 5/20/26 at 9:39 A.M., showed the resident walking back into the building from the 100 hallway smoking patio after smoking. Staff supervised the smoke break. 5. During an interview on 5/21/26 at 8:54 A.M., Licensed Practical Nurse (LPN) A said upon admission to the facility, the nurse was responsible for completing the initial smoking assessment. The smoking assessments should be completed upon admission and quarterly. The smoking assessments should be completely filled out. The care plan should indicate if the resident is a smoker. 6. During an interview on 5/21/26 at 2:22 P.M., the Administrator and the Regional Nurse Consultant (RNC) said the residents are not allowed to have cigarettes or lighters in the room. The staff are expected to remove the items when discovered. The RNC said she would expect the staff to light the residents cigarettes and not give them the lighter to ensure the resident do not have them in their possession. They would expect the resident's tobacco use to be addressed on the care plan. They would expect the smoking assessments to be accurate and fully completed on admission and quarterly.

Based on interview and record review, the facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with State guidelines for nine of 10 sampled employees. The census was 97. Review of the facility's tuberculosis (TB) testing policy, dated 6/29/23, showed:-Purpose: To ensure each resident and employee of the facility is tested for TB after entering the facility to prevent the spread of infection;-Procedure: Upon hire a new employee will receive a two step purified protein derivative (PPD) skin test. Each employee will also have an annual one step TB test to ensure that any possible infections can be triggered proactively to prevent further spread. 1. Review of Employee AA's personnel file, showed:-Hire date of 5/28/25;-No documentation of first step TB test being administered;-No documentation of second step TB test being administered. 2. Review of Employee BB's personnel file, showed:-Hire date of 5/4/26;-A first step TB test administered on 4/27/26 and read on 4/29/26 with a negative result;-No documentation of second step TB test being administered. 3. Review of Employee CC's personnel file, showed:-Hire date of 5/4/26;-A first step TB test administered on 4/28/26 and read on 4/30/26 with a negative result;-No documentation of second step TB test being administered. 4. Review of Employee DD's personnel file, showed:-Hire date of 5/4/26;-A first step TB test administered on 4/28/26. No documentation of results;-No documentation of second step TB test being administered. 5. Review of Employee EE's personnel file, showed:-Hire date of 4/24/26;-A first step TB test administered on 4/17/26 and read on 4/19/26 with a negative result;-No documentation of second step TB test being administered. 6. Review of Employee FF's personnel file, showed:-A first step TB test administered on 4/27/26 and read on 4/29/26 with a negative result;-No documentation of second step TB test being administered. 7. Review of Employee GG's personnel file, showed:-Hire date of 6/11/25;-No documentation of first step TB test being administered;-No documentation of a second step TB test being administered. 8. Review of Employee HH's personnel file, showed:-Hire date of 7/30/25;-No documentation of first step TB test being administered; -No documentation of second step TB test being administered. 9. Review of Employee II's personnel file, showed:-Hire date of 4/24/26;-No documentation of step one TB test being administered;-No documentation of second step TB test being administered. During an interview on 5/21/26 at 2:59 P.M., the Regional Nurse Consultant and Administrator said employees should receive their first step TB test prior to their first day on site at the facility. They would expect staff to also receive a second step TB test within the required timeline. Nursing staff was responsible for administering the TB test to the newly hired employees.

Based on observation and interview, the facility failed to ensure expired medications and biologicals were removed from medication carts and medication rooms in the facility. Concerns were noted with two of two medication rooms and one of four medication carts reviewed for the survey. The resident sample was 20. The census was 97.Review of the facility's Medication Storage Policy revised 5/18/24, showed:-All drugs and biologicals will be stored in locked compartments under proper temperature controls;-Only authorized personnel will have access to the keys to locked compartments;-The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the medication destruction policy. 1.Observation on 5/18/26 at 12:31 P.M. of the fifth-floor medication storage room showed a bottle of MedLine Drug Buster (a chemical agent that uses activated charcoal to quickly neutralize the active ingredients in pills, liquids, controlled substances and transdermal patches), expired as of 3/31/25. Observation on 5/18/26 at 12:41 of the fourth-floor medication room showed: -Seven bottles of Nutren 1.5 (a calorically dense, complete liquid nutrition formula designed for tube feeding or oral supplementation) 250mL (milliliters), expired as of 2/13/26; -One bottle of Geri-Care Bisacodyl Laxative, expired as of 12/2025; -One bottle of Nature's Blend Vitamin C 250mg (milligram) tablets, expired as of 1/2026; -One bottle of Acamprosate (an FDA-approved prescription medication used alongside counseling and social support to help people with alcohol use disorder ([NAME]) maintain abstinence) 333mg, expired as of 5/15/26; -One bottle of Atorvastatin (a prescription statin medication used to lower bad cholesterol (LDL) and triglycerides in the blood) 40mg, expired as of January 2026. Observation on 5/18/26 of the third-floor treatment cart, showed:-One bottle of Geri-Care Daily Multivitamins, expired as of April 2026; -One box of Mucinex-DM (an over-the-counter medication that combines an expectorant and a cough suppressant to relieve chest congestion and quiet both wet and dry coughs) 12 Hour Relief, expired January 2026. 2. During an interview on 5/19/26 at 9:21 A.M., Certified Medication Technician (CMT) E said no one member of the nursing staff or administration was responsible for auditing carts and rooms, but nursing staff took it as a collective responsibility. CMT E noted not all staff accept this responsibility, often causing CMTs or nurses passing medications to travel multiple floors to retrieve stocked medications that were not replaced on the cart. CMT E would expect all expired medications to be removed from the facility medication rooms and carts. 3. During an interview on 5/21/26 at 9:48 AM, Licensed Practical Nurse (LPN) D said he/she was not sure how often the pharmacy partner came in to remove expired medications or perform necessary medication wasting services. Not one individual on the nursing staff or administration was responsible for the auditing of medication rooms and medication carts, but nursing staff took it as a collective responsibility to restock medication carts or remove expired medications when noted. LPN D would expect all expired medications to be removed from treatment carts or medication rooms in the facility. 4. During an interview on 5/21/26 at 2:41 PM, the facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Nurse Consultant said they would expect all expired medications and biologicals to be removed from medication rooms and carts within the facility. No current process placed sole responsibility on any member of the nursing administration to review or audit medication rooms for expired medications. The facility pharmacy partner came once per month to audit and remove expired medications identified by the facility. The Administrator, DON, ADON, and Regional Nurse Consultant would expect all medications in medication rooms or on medication carts to be within the date of expiration and should be removed by staff when noted as expired.

Based on interview and record review, the facility failed to provide necessary care and services for two residents (Resident #101 and #104) by failing to assess, monitor, and respond to signs and symptoms associated with substance use and overdose. The facility failed to ensure ongoing medical monitoring following an overdose that required Narcan (life-saving medication used to rapidly reverse opioid overdoses) administration (Resident #101). The facility failed to assess, evaluate, and implement interventions following observed behavioral changes and signs consistent with substance use or withdrawal, resulting in missed opportunities to identify and address ongoing substance related risks (Resident #104). The sample size was 20. The census was 97. Review of the facility's Residents- Possession and Use of Illegal Drugs, Marijuana and Alcohol and Drug Screen and Searches policy, revised 4/30/24, showed:-Purpose: To ensure that the Facility remains free from illegal drugs and substances as well as marijuana and alcohol. To define when and how a resident may be administered a drug screen or have their room searched;-Procedure: Illegal drugs or substances, marijuana and alcohol are not permitted;-The Facility is committed to maintaining a safe environment for every Resident. Part of this commitment is attempting to maintain an environment that is free of illegal drugs, dangerous items and other related contraband;-Use of illegal drugs creates a dangerous environment and may interfere with properly prescribed medications;-Marijuana (while legal) is not allowed in the Facility and can interfere with properly prescribed medications;-The use, consumption, possession, transportation, sale or distribution of unlawful or unauthorized drugs (including marijuana), inhalants, alcohol, or the abuse of prescribed drugs or alcohol by any Resident while in the Facility or on Facility property is expressly prohibited and may result in an immediate discharge. Illegal or controlled substances (other than a valid prescription) will be confiscated and the appropriate law enforcement agency(s) may be notified;-Contraband includes weapons of any kind, any items which could be used as a weapon, illegal or unauthorized drugs (including marijuana), drug paraphernalia, or alcohol. The possession or sale of any contraband while on Facility premises is expressly prohibited;-The Administrator and Director of Nursing (DON) shall educate staff and Residents (as appropriate) on the signs and symptoms of illegal drug use;-Process when suspicion of ingestion of illegal substance: If a Resident is suspected of taking an illegal drug or other substance (including marijuana), the Resident shall immediately be placed on one-on-one supervision and the Director of Nursing or charge nurse and Administrator notified;-If the Resident shows any signs of distress or there are other concerns, 911 shall be called immediately;-The nurse shall immediately evaluate the Resident and obtain a complete set of vital signs, including a neurology check and oxygen saturation level;-The Resident's primary care physician shall immediately be contacted for instructions;-If the Resident is not being sent to the hospital, the protocol below for drug screens and searches will apply;-Drug Screen: In the event the Administrator or DON has reasonable suspicion that a Resident has ingested illegal or unauthorized drugs, a drug screen may be administered;-Search of Resident's room or property: In the event the Facility's Administrator or DON has reasonable suspicion that contraband, illegal drugs or something that poses a safety risk to the Resident or others in the Facility is in a Resident's room, a search of the Resident's room may be considered;-The Facility should not act as an arm of law enforcement and may instead of a search (or if consent is not given for a search), the facility may make a referral will be made to local law enforcement;-If the Resident is his/her own person, the resident must consent to the search. If the Resident refuses the room or property search, the search will not be conducted and the Management Company Regional Director will be notified;-If suspected illegal drugs are found, the local police and the Department of Health and Human Services will be notified. The RCMC Regional Director will also be notified;-Suspected Contraband or illegal Drugs: If suspected contraband or illegal drugs (including marijuana) are found, those items will be given to the Administrator, Director of Nursing or Charge Nurse for inventory;-All items will be placed in a secure location for all Residents' safety;-Suspected illegal drugs will be turned over to law enforcement personnel for safe disposal;-Increased Oversight: To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility. Review of the facility's Intensive Monitoring policy, revised 4/30/24, showed:-Residents who require more intensive monitoring due to crisis, behavioral/psychiatric symptoms will be monitored by the facility staff;-Intensive Monitoring is defined as periodic (hourly, every two hours, or every shift) check by a facility staff member;-One to One monitoring a designated employee assigned by a Facility Supervisor. Residents who require intensive monitoring of one to one will have a dedicated staff member within eyesight;-Intensive Monitoring: Intensive monitoring is provided as periodic (e.g. hourly, every two hours, or every shift) check by a facility staff member;-Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues. The level of Intensive Monitoring shall be identified by the specific situation or resident assessment;-Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;-Based on the assessment of the resident at the discretion of the administrative staff of Facility Supervisor, either intensive monitoring, one to one or two to one;-Residents who require intensive monitoring of one to one will have an assigned employee within eyesight until resident has stabilized or returned to prior level of function. Educated on the reasoning for the intensive monitoring, including triggers and interventions for that specific resident. The employee will interact with the resident throughout to receive therapeutic interventions;-The facility's Interdisciplinary Team will address the residents' behavioral concerns and ensure interventions are in place to address the residents' needs (psychiatry follow up, counseling, medical needs, etc.);-Once the resident has stabilized and/or returned to prior level of function, the facility's Interdisciplinary Team will meet to discuss determination of discontinuation of Intensive Monitoring;-The facility staff will document the intensive monitoring in the residents' Electric Medical Record;-Documentation: Documentation of intensive monitoring will be done in the electronic medical record under the task. 1. Review of Resident #101's care plan, dated 3/26/26, showed:-Problem: Resident is at risk for polysubstance abuse r/t substance-seeking behavior/safety risk/opioid abuse;-Desired outcome: Resident will verbalize risks associated with substance abuse;-Interventions: Monitor for signs of substance abuse/intoxication Monitor for signs of withdrawal. Monitor items brought into facility. Offer emotional support during periods of agitation Notify physician of refusal or noncompliance. Offer resident in the room alcohol anonymous (AA)/narcotics anonymous (NA) program. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 4/1/26, showed:-Diagnosis included opioid abuse, acute kidney failure, and chronic obstructive pulmonary disease (COPD, lung disease);-Cognitively intact. Review of the resident's physician's orders summary (POS), dated 4/20/26, showed an order, dated 4/20/26, for a urine analysis (UA) for drug screening. Review on 5/21/26 at 11:50 A.M., of the resident's UA results, showed:-The resident's urine was collected on 4/21/26 at 3:15 P.M.;-The resident's urine tested positive for methamphetamine (meth, a highly addictive synthetic stimulant). Review on 5/21/26 at 11:50 A.M., of the resident's progress notes, showed:-A note, dated 4/28/26 at 9:01 P.M., Resident left the facility to go the store. Upon return, he/she took his/her night medication and then went to his/her room. The Certified Medication Technician (CMT) heard a loud gasp outside his/her room. The CMT called this writer to his/her room. Writer observed resident sitting upright in his/her wheelchair snoring loudly. After approximately two minutes of sternum rub, the resident was transferred to the bed. Narcan was given and he/she let out numerous gasps. Writer observed the resident's chest rise and fall. Writer left room to inform administration and the doctor. The resident is back in his/her wheelchair eating a sandwich. The resident was counseled about the dangers of using street drugs;-A note, dated 4/28/26, Order received for UA and Urine drug screen. Spoke with resident about receiving counseling. He/She agreed to do so;-A note, dated 4/29/26 written by the Administrator, the resident came to the Administrator as he/she was doing rounds. The resident freely admitted he/she had taken something while out on 4/28/26 and the results had scared him/her. He/She spoke of his/her life being more important than what he/she had done and we discussed the possibility of mixing unknow substances with his/her prescribed medication. He/She advised he/she was willing to start and continue a program. I offered open door for any follow up or if he/she wished to talk at any given time. He/She does not want to leave the facility and will follow appropriate guidelines;-No documentation on 4/29/26 of monitoring after the resident's overdose. During an interview on 5/20/26 at 6:37 A.M., Certified Nursing Assistant (CNA) Q said no interventions were put in place prior to the resident's drug overdose other than checking the resident's room. After the resident's overdose, no further monitoring was put in place. During an interview on 5/20/26 at 11:37 A.M., the DON and Assistant Director of Nursing (ADON) said on 4/28/26 the resident was administered Narcan when the resident was observed to being having symptoms of a drug overdose. They said the resident was not sent to the hospital because he/she was in the early stages of a drug overdose and was not in respiratory distress. They said the resident's physician was notified and gave an order for the resident to be monitored and for a UA to be obtained. During an interview on 5/20/26 at 12:56 P.M., Physician P said the facility contacted him/her on 4/28/26 and reported that the resident had a drug overdose. He/She ordered monitoring of the resident, a UA, and a consultation for psychiatric services. He/She said he/she told the facility not to send the resident to the hospital to avoid unnecessary emergency room visits. He/She would have expected the facility to conduct neurological (a brief physical examination to evaluate brain and nervous system functions) checks on the resident for 24 hours and obtain the resident's vitals. He/She would have expected the facility to document their monitoring in the resident's medical record. He/She said documenting that the resident is in his/her wheelchair eating a sandwich was not appropriate monitoring. During an interview on 5/20/26 at 1:05 P.M., Licensed Practical Nurse (LPN) A said he/she was aware of the resident's overdose. He/She said if a resident had a drug overdose, staff was supposed to call emergency services and inform the DON and ADON of the overdose. He/She said she would have called 911 regardless of what the physician said if a resident had symptoms of an overdose and narcan was administered. He/She said documenting the resident was eating a sandwich was not appropriate monitoring. He/She would have expected proper monitoring to be conducted. During an interview on 5/21/26 at 3:06 P.M., the Administrator, DON, and Regional Nurse Consultant said the physician's order was given after the resident overdosed to monitor for change of condition, obtain a drug screen, and consult with psychiatric services to see the resident. They said the physician never mentioned neurological checks. They said they did not know if the resident actually had a drug overdose. They said monitoring of the resident should have been documented in the resident's medical record. They said they should have documented vitals and the resident's cognitive status. 2. Review of Resident 104's hospital record, showed:-admitted [DATE]; -Assessment and Plan: Opioid withdrawal: Present on admission-Sinus tachycardia (heartbeat over 100 beats per minute): Present on admission; -Fentanyl (potent, synthetic opioid drug) use disorder, severe: Present on admission; -Polysubstance use disorder: Present on admission;-Most likely etiology of discomfort at this time is relating to opiate withdrawal given his /her recent initiation of suboxone (used to treat opioid use disorder) and subjective history of mild improvement when using unspecified pill, presumed to be fentanyl in an outpatient setting although unable to fully rule out component of known rheumatologic conditions;-Plan of care discussion: We reviewed his/her symptoms at the bedside and discussed that based on his/ her story and the lab studies he/she performed at this point that the most likely cause of his/her current pains was opiate withdrawal;-Physician progress note: He/She denies any issues with drug cravings. He/She is worried about managing his/her pain. The Buprenorphine (long-acting partial opioid agonist used to treat opioid use disorder) does not seem to be taking the edge off his/her pain. He/She would like to try methadone (long-acting synthetic opioid used to treat opioid use disorder). We discussed prolonged QT syndrome (a heart rhythm disorder) and strict federal regulations that both prohibit the use of methadone for him/her. He/She confirmed understanding and agreed with the plan to decrease buprenorphine to allow greater efficacy of the breakthrough pain meds;-Resident presented to hospital for chest pain on the initial workup for cardiac and musculoskeletal causes was unremarkable. Suspicion was raised for possible opiate withdrawal cause his/her pain. Review of the resident's hospital discharge record, showed:-admitted [DATE];-discharged [DATE];-Discharge diagnosis: Opioid withdrawal. Review of the resident's initial psychosocial history, dated 3/23/26, showed:-Substance Abuse;-Current stressors: blank;-Current diagnosis: blank;-Psychosocial assessment: Change in sleep and increased anxiety;-Past history: Suicidal ideations/ attempts;-Self injurious behavior: non-suicidal;-Methods of self injurious behavior: cutting;-Socialization and support system: Other: staff;-Interdisciplinary Team (IDT) signatures: blank. Review of the resident's care plan, dated 3/23/26 and revised 4/21/26, showed:-Problem: Resident is at risk for polysubstance abuse related to substance seeking behavior/safety risk;-Interventions: Administer Narcan per physician's order for signs/symptoms of narcotic overdose. Monitor for signs of substance abuse/intoxication. Monitor for signs of withdrawal, monitor items brought into the facility. Offer emotional support during periods of agitation. Notify physician of refusal or non-compliance. Offer resident in the room Alcohol Anonymous/Narcotics Anonymous (AA)/ NA) program;-Problem: The resident is at risk for intentional or unintentional overdose due to history of depression anxiety confusion access to medication substance misuse;-Interventions: Education provided on illegal drug use policy for the facility, screens and search entering the building, resident possession and use of drug/alcohol policy, adverse drug event policy, Narcan use policy, resident's rights, abuse and neglect policy, and metal wand upon entering the building. Review of the resident's admission MDS, dated [DATE], showed:-Diagnoses include cerebrovascular accident (CVA, stroke), hemiplegia or hemiparesis,-Cognitively intact;-Feeling down, depressed, or hopeless: No response;-No verbal or physical behaviors;-Impairment on one side to upper and lower extremity;-Uses a walker;-No presence of pain the last five days;-Administered antipsychotic and antidepressant in the past seven days. Review of the resident's POS, dated 3/23/26 through 4/20/26, showed:-An order, dated 3/23/26, Hydromorphone (semi-synthetic opioid analgesic used to treat pain) HCl oral tablet 4 milligrams (mg). Give one tablet by mouth every four hours as needed for pain;-An order, dated 3/23/26, Hydralazine (used to treat high blood pressure) HCI (hydrochloride) 25 mg. Give 1 tablet by mouth every six hours as needed (PRN) for anxiety;-An order, dated 3/23/26, Hydroxyzine (used to treat anxiety) HCl oral tablet 25 mg. Give 25 mg by mouth every six hours as needed for anxiety. Take one tablet by mouth four times daily as needed for anxiety;-An order, dated 3/23/26, Methocarbamol (muscle relaxer) Oral tablet 500 mg. Give 500 mg by mouth every six hours as needed for muscle spasms;-An order, dated 3/23/26, Narcan Nasal Liquid 4 mg / 0.1 milliliter (ml). Spray one spray into the nose as needed for overdose;-An order, dated 3/23/26, Sennosides (laxative) Oral Tablet 8.6 mg. Give 8.6 tablet by mouth one time a day for constipation;-An order, dated 3/23/26, Melatonin (sleep supplement) oral tablet 3 mg. Give 3 mg by mouth at bedtime for sleep.-An order, dated 3/23/26, Acetaminophen Oral tablet 325 mg. Give two tablets by mouth every six hours PRN for pain;-An order, dated 3/23/26, Aspirin oral capsule 81 mg. Give 81 mg by mouth one time a day to prevent heart attacks;-An order, dated 3/23/26, Butalbital-ASA-Caffeine Oral Capsule 50-325-40 mg (Butalbital-Aspirin-Caffeine, combination medication used to treat headaches), give one capsule by mouth every four hours PRN for headaches or migraine;-An order, dated 3/29/26, Butalbital-ASA-Caffeine Oral Capsule 50-325-40 mg, give one capsule by mouth as needed for headaches or migraine;-An order, dated 3/30/26, Excedrin Extra Strength Oral Tablet 250-250-65 mg (Aspirin-Acetaminophen-Caffeine), [NAME] (dispense as written). Give two tablets by mouth every six hours PRN for migraine;-An order, dated 3/26/26, hydroxyzine HCl Oral Tablet 25 mg. Give 25 mg by mouth every six hours for anxiety.;-An order, dated 3/27/26, Fioricet Oral Capsule 50-300-40 MG (Butalbital- Acetaminophen-Caffeine, pain reliever). Give one tablet by mouth every 24 hours as needed for headaches or migraine;-An order, dated 3/30/26, Hydrocodone-Acetaminophen (used to treat pain) Oral Tablet 5-325 mg. Give one tablet by mouth three times a day for pain;-An order, dated 4/2/26, Trazodone (anti-depressant) HCl Oral Tablet 50 mg. Give one tablet by mouth at bedtime for insomnia;-An order, dated 4/2/26, hydroxyzine HCl oral tablet. Give 50 mg by mouth two times a day for anxiety;-An order, dated 4/10/26, hydroxyzine HCl oral tablet. Give 50 mg by mouth two times a day for anxiety until 4/16/26;-An order, dated 4/11/26, Furosemide (used to treat fluid retention) oral tablet 20 mg. Give 20 mg by mouth one time a day for excessive fluid retention;-An order, dated 4/12/26, Cephalexin Oral Capsule (used to treat bacterial infections) 500 mg. Give 500 mg by mouth two times a day for leg infection for seven days. Review of the resident's progress notes, dated 4/12/26, showed resident continue to exhibit erratic behavior and signs of withdrawal, though he/she denies experiencing any symptoms. Significant safety concerns are noted as the resident repeatedly slides out of his/her wheelchair and engages in self-picking, resulting in a sore on his/her face. Nursing attempted to perform a clinical evaluation and facilitated a telehealth visit with the physician; however, the resident refused both, stating he/she does not wish to speak with the physician again. The physician and DON have been notified of the resident's behavior, his/her refusal of care, and his/her request regarding the physician. Staff will continue to monitor closely for safety and skin integrity. During an interview on 5/19/26 at 12:19 P.M., the Administrator said the resident went through a confession that he/she was clean and wanted to stay clean. He/She had a Brief Interview Mental Status (BIMS) of 15 (cognitively intact). When he/she first arrived, he/she did not leave a lot. He/She was isolated in his/her room but came out in the evening. They went over the drug policies and the resident reassured staff it was not the life he/she wanted. The resident received treatment and got clean. He/She was in the hospital for two months working on his/her sobriety. During an interview on 5/19/26 at 12:19 P.M., the ADON said on 4/12/26, the behavior they were trying to identify was related to pain versus withdrawal. It was believed to be withdrawal because of the resident's substance abuse history. The resident could not identify where the pain was located, whether it was the hip, knee, or if it was arthritic pain. He/She started to get behaviors, and he/she could not identify what was hurting him/her. The resident declined to go to the hospital. They were 'juggling to see what was wrong. The physician was notified and said he/she would be in to see the resident. He/She would not approve any medication until he/she saw him/her and provided a signature. While the resident was at the facility, he/she had issues with medications. There were several combinations of medications he/she wanted to put together. Physician did not see evidence that would suffice for those medications. He/She tried Norco for seven days, then Butram (synthetic opioid used to manage pain) order would be approved. He/She did not want to prescribe Suboxone medication. The resident had a face to face with the physician and went against the medication. The ADON recalled he/she refused to take the medication. The resident only had one visitor. Per facility policy, if they found contraband, they called the authorities. An aide reported seeing the resident on the floor. The resident was abrasive at the time and only a plastic bag was seen on the floor. The ADON said the aid no longer worked at the facility. During an interview on 5/20/26 at 3:48 P.M., LPN A confirmed he/she wrote the progress note on 4/12/26. In his/her opinion, the resident was acting erratic. He/She was offered the suboxone but refused it. It helped with withdrawals. The resident picked at him/herself and tried to act sane so LPN A would not suspect behaviors. He/She was off for two days, but there were sores that appeared on the resident. He/She had not interacted with anyone else, so it was self-induced picking. The resident was brought out in the hall and did the same thing. The physician and psychiatrist were contacted. Psych saw the resident, but there was no way to redirect the resident. LPN A was asked to clarify why withdrawal was documented. LPN A said the resident was withdrawing from street drugs. He/She had an opioid abuse history before he/she was admitted . When he/she was first admitted he/she was not doing any of the behaviors, then he/she started to do it or self- medicate. Some behaviors included crying hysterically because of pain. They administered pain medication to him/her. LPN A saw a lunch bag in the resident's room, and he/she would never let anyone touch it. LPN A did not believe anyone searched his/her bag. Even during room search, an aide needed to search room, but the resident took the bag with him/her and held on to it. On the day the resident was arrested, the bag was searched. He/She only had one visitor. When LPN A spoke to the physician, he/she mentioned the resident had withdrawals, but did not specify from what. The physician knew the resident was coming off opioid abuse. On 4/12/26 was the first time LPN A witnessed this behavior from the resident. Before, he/she cried about his/her arthritis. It felt like he/she was drug seeking. The resident would say I want to get out of here and he/she was better off on the streets. He/She was referred to pain management, but he/she did not go. Immediately he/she said he/she would rather have gone AMA (Against Medical Advice). The resident never refused Suboxone. It was found on him/her during the search. The pill was supposed to sit under the tongue, but LPN A believed the resident was taking it out. The resident took the other pills that were administered in front of staff but placed the Suboxone under the tongue and moved away.Review of the resident's progress notes, showed no further assessment or documentation regarding the residents' withdrawal symptoms. During an interview on 5/20/26 at 12:56 P.M., Physician P said he/she remembered the resident, and he/she was one of the hard ones. The resident used to ask for narcotics, and they referred him/her to the pain clinic. He/she refused medications at times, even the Suboxone. He/She also threw tantrums. Staff reported the resident's refusals, but there was also a psych component as well. On 4/12, he/she was aware of the resident's erratic things, odd behaviors in attempt to get his/her way. Physician P did not hear them say withdrawal. It was not physical; it was more psychological. The resident did things to get things. Physician P would expect to be informed. If the resident was believed to have withdrawal symptoms, he/she would have sent the resident to the hospital, did a drug screen, and continued to monitor and document. During an interview on 5/20/26 at 3:41 P.M., CNA J said Resident #104 was always in his/her room and only had seen him/her come out about two or three times. He/She was in pain because the resident said he/she was coming off withdrawals from street drugs. CNA J was not sure what drug, but the resident was on hard drugs. The resident always slept. He/She slept in his/her wheelchair but leaned over the bed. The resident said he/she was comfortable. CNA J was not sure if he/she was under the influence. Review of the resident's progress notes, showed:-On 4/20/26 at 2:46 P.M., call placed to Physician P for a teledoc / or in-house visit related to patient behaviors, suspected drug use, and possession of illegal substance. Resident refused room sweep which was conducted due to suspected substance abuse. Patient became irate, demanding to sign AMA form. Resident became aggressive, screaming and resistant, and crises prevention intervention (CPI) became in progress by CPI certified staff. Patient screamed that he/she would have rather been homeless on the street than in pain and would have liked the regimen that he/she had while in the hospital. He/She admitted being clean for a few months and has used recently Fentanyl and [NAME] Meth. He/She is requesting physician to review pain regime; -On 4/20/26 at 4:30 P.M., resident consented to having his/her purse searched by the DON, with RDO as witness. During the search there were multiple opened capsules, which appeared to be empty, and multiple capsules which appeared to be intact. There was also a baggie in the resident's purse which contained a crystallized substance which appeared to be clear in color, and white powder in the bottom of the baggie. The resident stated the substances found in his/her purse were Fentanyl and Methamphetamine. The resident was asked if he/she had given any residents any of the narcotics and he/she stated he/she had not. Police Department was notified of the suspected narcotics found on the resident and summoned to the facility. The narcotics were transferred to officers' possession. Officer then conducts another search of the resident's room and found an additional capsule. Officer interviewed the resident. The resident admitted to the officer that last evening, he/she sent money to the supplier of the narcotics and asked another resident to sign out and retrieve the narcotics for him/her. Resident states he/she gave the other resident Fentanyl in exchange for meth he/she had purchased from the supplier. The resident consented to let officer look at his/her phone. The police seized the resident's two telephones and stated that forensics would need to be run on them. The responding officer stated they will be applying for warrants on the charge of 2nd degree drug trafficking and took the resident into custody. The resident's medication list was provided to the officer, so they were aware of the legal prescriptions he/she has;-On 4/20/26 at 7:26 P.M., resident's emergency contact notified of resident being taken into custody by the Police Department pending drug charges;-On 4/20/26 at 8:00 P.M., immediate discharge served to this resident at hospital at approximately 8:00 P.M. Discharging to the custody of the Police Department. Review of the resident's police report, dated 4/20/26, showed:-Incident nature: Drugs/Narcotics;-Incident Summary: Trafficking drugs, 2nd degree;-Arrestee arrested;-Original Narrative: Upon our arrival, we were met by employees who stated at approximately 0900 hours, Resident #105 had overdosed in their establishment and conveyed to the hospital. Due to those circumstances, the employees conducted room checks to ensure there was no other narcotics. DON conducted a search in room where offender Resident #104 resided and located multiple opened and unopened capsules, a bag containing a crystal-like substance the size of small rocks, and an empty plastic bag containing small traces of a powdery substance. DON removed the narcotics, placed them in a separate container, held the narcotics in the office guarded by employees, and contacted police;-Resident #104 admitted the narcotics were retrieved from his/her black bag inside his/her room. The resident originally stated he/ she had the narcotics approximately four months ago before he/she began residing at facility. When I inquired about Resident #105 overdose, he/she stated the drugs were not received from him/her and he/she never gave them out to anybody else. When I inquired where the drugs were bought from, the resident stated he/she received them from his/her dealer. When I inquired about how he/she gets into contact with him/her, the resident used his/her cellphone to provide me with the cellphone number he/she calls him from along with his Chime username and recent transactions. Looking at the transactions I observed the last payment was on April 19, 2026. When I asked the resident about the recent transaction, he/she admitted she did buy narcotics from dealer;-When I asked the resident about his/her relationship with Resident #105 he/she stated he/she knows of him/her, but they did not have a close relationship;-At the time I was questioning the resident, officers found a capsule inside the resident's purse. Officer #1 located was an enclosed capsule and Officer #2 found half of a capsule;-Administrator advised me after Resident #105 overdose, he/she was approached by witness who told him/her about a weird interaction between Residents #104 and #105;-The following is a synopsis of statements from witness: Witness stated he/she resides in the room right next to Resident #104. At approximately 0300 hours, witness was woken up by Resident #104 and Resident #105 who were speaking loudly. Witness heard Resident #105 directly state [NAME] get that to which Resident #104 declined. Witness entered the room to find out what was going on and Resident #104 told him/her it was nothing and offered him/her money to buy a soda;-It should be noted witness stated Resident #104 and Resident #105 were known to be around each other frequently and appeared to be under the influence;-When I returned to speak with Resident #104 he/she admitted he/she did spend more time with Resident #105 than he/she originally stated. He/She also stated last night, he/she was not feeling well and had Resident #105 pick up the capsules for him/her and brought them back to him/her;-Narrative: Due to lab results that is attached to the report, Resident #104 was issued with th

Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was given to three of three sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #9, #21, and #75). The census was 97. Review of the facility's Advanced Beneficiary Notice policy, dated 11/5/24, showed:-Purpose: To ensure the facility provides timely notices regarding Medicare eligibility and coverage;-Policy: A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their quality improvement organization (QIO).-To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while the resident/representative is under duress or in an emergency situation;-The Social Service Director or designee, is responsible for issuing such notices. 1. Review of Resident #9's medical record, showed: -Medicare Part A skilled services start date of 4/23/26 and end date of 4/29/26;-Stayed in facility;-No NOMNC form given to resident. 2. Review of Resident #21's medical record, showed:-Medicare Part A skilled services start date of 3/4/26 and end date of 3/10/26;-Stayed in facility;-No NOMNC form given to resident. 3. Review of Resident #75's medical record, showed:-Medicare Part A skilled services start date of 11/6/25 and end date of 12/18/25;-Stayed in facility;-No NOMNC form given to resident. During an interview on 5/21/26 at 3:05 P.M., the Administrator said NOMNCs should have been given to the residents at least two days before Medicare covered services ended. She said the Social Service Director was responsible for this, but the facility was without a social worker for at least four months.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) seven days a week. This had the potential to affect all residents of the facility. The sample was five. The census was 86. Review of the facility's Sufficient Staffing Policy, dated February 2023, showed the following:-Purpose: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.-Policy: -The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week;- Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's daily staffing sheets showed the following:-8/20 through 8/22/25, no RN scheduled;-8/25 through 8/31/25, no RN scheduled;-9/1 through 9/5/25, no RN scheduled. During an interview on 9/8/25 at 12:42 P.M., the Director of Nursing (DON) said the facility currently only has two RNs in the building. The DON said he/she has been working as an RN on the floor but did not know he/she could not be the DON and the RN on the floor at the same time. The Administrator was present at the time and agreed with the DON. 16113302606159

Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals for one of one observed mealtime preparation. The census was 86.Observation on 9/22/25 at 11:05 A.M. of the kitchen, showed [NAME] D took one breaded chicken breast, placed it in a blender and added approximately one tablespoon of water and blended for approximately 45 seconds. Observation after blending, the breaded chicken breast appeared to be of ground meat consistency and not smooth. [NAME] D portioned the mixture into tin pans and placed it on the steamtable. Review of the facility's Pureed Breaded Chicken Breast recipe, dated 2025, showed the following:-One Serving: One breaded chicken breast, four tablespoons and two teaspoons of water and one fourth teaspoon of chicken base;-Combine chicken base and water to make chicken broth. Place prepared breaded chicken breasts in a sanitized food processor. Add broth and blend until smooth. During an interview on 9/22/25 at 11:15 A.M., [NAME] D said he/she should have followed the recipe for the pureed breaded chicken breast. [NAME] D said he/she looked at the recipe and thought he/she was following the recipe. Observation on 9/22/25 at 11:17 A.M., showed [NAME] D took one and one half four-ounce (oz) scoop of mixed vegetables and placed in a blender and blended for approximately 45 seconds. Observation after blending, showed the mixed vegetables were smooth with small lumps of vegetables. During an interview on 9/22/25 at 2:04 P.M., the Dietary Manager (DM) said he/she did not have a recipe for pureed mixed vegetables. They are just pureed until smooth. They never had a recipe for mixed vegetables. The DM expected the cooks to follow the recipes as written to ensure the proper nutrition for the food. The DM did not know why the cooks did not follow the recipes. The Administrator was present and said he/she agreed with the DM. 2619550

Based on observation, interview and record review, the facility failed to keep the kitchen walls clean and floors free of grease, dirt and grime for one of one day of observation. The census was 86.Review of the facility's Dietary Cleaning Duties, undated, showed the following:-Morning Crew: Wipe down all stainless surfaces, clean ovens and stove top, mop kitchen and dining room;-Evening Crew: Wipe down all stainless surfaces, clean ovens and stove top, mop kitchen and dining room;All employees must clock out with work completed at designated time. The cook on duty is responsible for checking that above duties are completed before they clock out. Manager is to assure this process is carried out. Observation on 9/22/25 of the kitchen, showed the following:-9:00 A.M., the floor under the refrigerator and along the back wall had dirt built up and grime;-9:02 A.M., the floor under the stove and fryer had built up grease and grime and the walls next to the fryer had built up grease and grime;-9:04 A.M., the floor under the coffee station had built up dirt and grime;-11:04 A.M., the walls behind and alongside the three sinks had built up grease and grime. During an interview on 9/22/25 at 2:15 P.M., the Dietary Manager (DM) said the cooks and the servers should deep clean the kitchen each day. The DM said the dietary staff are not allowed to have overtime, so the kitchen has not been cleaned properly. The DM said his department did not have labor hours for deep cleaning. During an interview on 9/22/25 at 2:20 P.M., the Administrator said she was aware of the concerns with the cleanliness of the kitchen. 2606159

Based on interview and record review, the facility failed to meet professional standards when staff failed to make an appointment and follow up with a urologist (specializes in the urinary and reproductive systems) as requested by the urologist for one resident. (Resident #4). The sample was five. The census was 86. Review of the facility's Transcription of Orders/Following Physician's Orders Policy, dated 5/18/24, showed the following:-Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Procedure:-A. Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section; -B. Clarification of Physician's Orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the Physician's Orders. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/25, showed the following:-Moderate cognitive impairment;-Required partial to moderate assistance with activities of daily living;-Diagnoses of high blood pressure, anxiety and depression. Review of the resident's nurse's note, dated 7/28/25 at 5:06 P.M., showed the nurse received a call from the urologist. He/She said the resident has diagnosis of prostate cancer (abnormal, uncontrollable growth of cells in the prostate gland, a part of the male reproductive system) and needs treatment. He/She said the resident has a follow up appointment in September but wants the resident to have an urgent appointment this week. The doctor has two offices, one for Tuesday appointment before noon. And a second for Friday appointment in morning. A transportation sheet made out. One copy was placed under social services door and a copy placed in transportation book. Review of the resident's medical record, showed no documentation regarding scheduling an appointment or the resident going to an appointment. During an interview on 9/22/25 at 12:47 P.M., Certified Nurse Aide (CNA) A said he/she escorted the resident to a doctor's appointment on 8/1/25. CNA A said they arrived at the doctor's office, they were turned away for not having an actual appointment on that day. CNA A said he/she and the resident came back to the facility and he/she made the charge nurse (unknown person) aware the resident returned without being seen. CNA A said he/she did not know if there was any follow up at that time. During an interview on 9/25/25 at 9:21 A.M., Licensed Practical Nurse (LPN) B said the resident came back to the facility and went to the previous Administrator's office. LPN B was told the DON and Administrator would handle the situation. LPN B said he/she did not know if another appointment was made for the resident. During an interview on 9/8/25 at 1:40 P.M., the resident said he/she had prostate surgery about six months ago. The resident said he/she did not know if he/she had an appointment with a urologist. He/She did not remember going to an appointment. The resident said he/she would probably find out from the Administrator. Review of the resident's medical record, showed no documentation of a scheduled appointment for the resident to see the urologist. During an interview on 9/22/25 at 10:23 A.M., Nurse C said he/she works with the urologist. When the urologist called the facility and made the recommendation for the resident to be seen immediately, the facility should have called and scheduled an appointment for the resident to be seen as soon as possible. Nurse C said without an appointment, the resident will not be seen. The resident was seen on 9/12/25. During an interview on 9/8/25 at 2:30 P.M., the DON said he/she expected the facility's policy to be followed. The Charge Nurse is to make the appointment and chart the date and time in the resident's medical record. The Charge Nurse should notify Social Services to set up the transportation. The Administrator was present at that time and agreed with the DON. 2609855

Based on interview and record review, the facility failed to provide protective oversight for one resident, (Resident #1), when the facility failed to follow their weather advisory procedures regarding going outdoors in extreme heat. The failure put this resident, who was prescribed two medications that could affect the body's ability to regulate temperature, at an increased safety risk due to the extreme heat. The resident was outside of the facility, without supervision, from 9:00 A.M. until approximately 4:00 P.M., during a heat advisory. The resident reported to facility administration that after purchasing cigarettes, he/she became overheated and lost consciousness in someone's backyard for an unknown length of time. The resident was admitted to the hospital on [DATE] at 4:28 P.M. and transferred to another hospital on 7/25/25, with nasal abrasions, fractures, and heat exposure The sample was six. The census was 83.The Administrator was notified on 07/31/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 07/24/25. Upon notification, the facility administration immediately in-serviced all staff on the facility's policy and procedures for inclement weather/severe heat, leave of absence, and guardianship, and completed chart audits for guardianship verification. The IJ was corrected on 07/25/25. Review of the Inclement Weather/Severe Heat Precautions policy, dated 8/23/22, showed:-Purpose: The purpose of this policy is to identify potentially harmful weather or outside temperatures that may pose harm to the residents;-Policy: The facility will identify the following environmental risks that may cause harm to the resident: Excessive heat greater than 98 degrees Fahrenheit (F) (deemed by the Medical Director) and heat advisory;-The Administrator, Director of Nursing (DON) or designee will determine the weather status before residents exit the facility on walks, Outside Pass (OSP) time, or out of the facility smoke time. If any of the environmental risks are present that may cause harm to the resident, the Administrator/DON/Designee will assess the resident's best interest whether residents should leave facility for OSP time;-In the event that the resident becomes noncompliant with following the inclement/excessive weather guidelines, the legal guardian/designee will be notified. If the resident is their own responsible party, the facility administration/designee will educate the resident on the risks of exiting the facility, and document education in the resident's record and ensure that the plan of care reflects the resident's noncompliance in following facility policy along with interventions and education. Review Resident #1's medical record showed:-A Pre-admission Screening and Resident Review (PASARR), dated 9/16/21, showed the resident wandered, needed supervision for safety, 24/7 supervision, monitor for elopements, fifteen minute checks and maximum monitoring; -Resident admitted to the facility on [DATE].-Diagnoses included: high blood pressure, end-stage renal disease (a severe medical condition where the kidneys have permanently lost most or all of their function), diabetes, anxiety, depression, bipolar (mood disorder that can cause intense mood swings) and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of the Missouri casenet website showed the resident was appointed a guardian on 2/4/22. Review the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/2/25, showed:-Cognitively intact;-No behaviors. Review of the resident's medical record showed court documents, dated 6/4/25, confirmed the resident's guardianship remained in place. Review of the resident's care plan, in use at the time of the investigation, showed prior to 7/24/25, nothing noted in the care plan about the resident's ability or inability to go out independently on leave of absence (LOA), and nothing noted about the presence of a guardian or the resident's ability or inability to make decisions on his/her own. Review of the resident's Physician's Orders Summary (POS), dated 7/31/25, showed:-An order, dated 9/30/24, Haloperidol (antipsychotic medication used to treat mental illness) Oral Tablet 5 milligrams (mg);-An order, dated 9/30/24, Propranolol HCl (heart medication) Oral Tablet 20 mg. Review of the Center for Disease Control and Prevention (CDC) website showed the use of Haloperidol and Propanolol HCl can affect the body's ability to regulate temperature. Review on 7/31/25, of the resident's LOA sign out sheet showed, on 7/24/25 the resident signed out at 9:00 A.M. No destination was obtained. No length of stay was obtained. No signature from the resident was obtained. Review of the National Weather Service website showed on 7/24/25, the St. Louis area was under a heat advisory, and the high temperature for the day was 96 degrees F with a heat index of 107 degrees F. Review of the facility's investigation, dated 7/24/25, showed at 9:00 A.M. on 7/24/25, the resident approached the Activity Director to see if he/she could go to the gas station. The Activity Director escorted the resident to the DON's office and asked the DON if the resident could go. The DON said the resident could go to the store if he/she signed out. The resident was last seen by the Dietary Manager walking on the sidewalk, down Broadway (same street as the location of the facility) wearing a white t-shirt and tan pants around 9:15 A.M. When the resident did not return to the facility, a search was conducted where the resident said he/she was heading. Staff notified the family and the physician of the resident's unknown whereabouts at around 5:00 P.M. After being called by the family, the police arrived the facility around 5:10 P.M. to see about the resident. Staff contacted hospitals and learned the resident was in the emergency room of a local area hospital waiting to be seen, brought in around 4:28 P.M. The Administrator and the Social Service Director went to the hospital to check on the resident in the waiting room. The resident was admitted into the hospital for further evaluation. Review of the resident's initial hospital medical record, showed: The resident was brought to the emergency department on 7/24/25 at 4:28 P.M. The resident had heat exposure and facial abrasions around the nose area. Possible left nasal bone fractures were noted. Review of the resident's hospital records from the second hospital, showed:-The resident admitted to the current hospital after being transferred from a previous hospital on 7/25/25 at 10:34 A.M.;-The resident admitted with facial abrasions around the nose area and left nasal bone fractures were confirmed. During interviews on 7/29/25 at 11:04 A.M. and on 7/31/25 at 7:44 A.M., the Administrator said the DON gave the resident permission to sign himself/herself out to go to the gas station to purchase cigarettes without asking the Administrator. The Administrator had told the resident he/she could not leave the building due to a heat advisory. The Administrator did not inform any other staff the resident had requested to go outdoors during the severe heat advisory and had advised him/her against going outdoors. The Social Worker started a building search around 1:00 P.M., and the Human Resources (HR) director and the Administrator started an outdoor search. After the resident had not come back to the facility by 3:00 P.M., the Administrator and the HR director left the facility and conducted an additional outside search looking for the resident at places he/she was known to frequent. Staff did not start a search right away, because it was not out of the ordinary for the resident to go to the park or other places. They did not get a detailed list of where the resident was going to go that day. The DON reported to the family the resident had not returned to the facility, and that is when the family alerted the facility to the fact the resident had a guardian. The Administrator called the hospital at approximately 4:30 P.M. and found out the resident was in the emergency room (ER) and was informed the resident had been found outside, collapsed at an address a half a mile from the facility. The Administrator and the Social Worker went to the hospital at approximately 5:00 P.M. to check on the resident. The Administrator was not previously aware the resident had a guardian. The Administrator was made aware of the guardianship by the resident's daughter. Per the policy, the guardian should have been made aware the resident had gone outdoors during a heat advisory after the administrator advised him/her not to go. During an interview on 7/30/25 at 7:31 A.M., the Activities Director said she was approached by the resident on 7/24/25. The resident asked her if he/she could leave the building to go to the store mentioning that he/she had already been told no by the Administrator due to the weather. The Activities Director approached the DON, who was in the main office, and asked her if the resident could leave the building. The DON gave the resident permission to leave the building. During an interview on 7/30/25 at 8:36 A.M., the DON (who is no longer with the facility) said on 7/24/25 at 9:00 A.M., the Activities Director asked her if the resident could sign himself/herself out to go to the gas station. The DON gave the resident permission to sign himself/herself out. Around 3:00 P.M., when the resident still had not returned to the facility, she contacted the regional staff while the Administrator and HR Director started to search for the resident. The regional staff told her not to call 911 since the resident signed himself/herself out, it was not considered an elopement. The DON was not aware the resident had a guardian that should have been notified when the resident left the facility, against the administrator's advice, during a severe heat advisory. During interviews on 7/30/25 at 9:50 A.M. and on 7/31/25 at 7:23 A.M., the Dietary Manager (DM) said on 7/24/25, he was driving to work and saw the resident walking down the street in the direction of the facility around 9:03 A.M. to 9:05 A.M. The DM said he was not concerned, because this was normal for him to see the resident walking. The alarm bells were raised when the resident was not back by lunch. The resident never misses a meal. The DM mentioned it to an unidentified Certified Nurse's Aide (CNA) in the dining room. The CNA said they were already aware the resident was not back yet. The DM said he saw the resident walking/going places all the time. The resident has a usual gas station he/she walks to and provided the name (the gas station is .07 miles from the location where the resident was found). During an interview on 7/30/25 at 7:37 A.M., the guardian said she was not informed the resident had been signing him/herself out of the facility. The guardian said he/she did not want the resident signing him/herself out, because the resident needed supervision. The guardian was informed on 7/24/25 the resident left the building, fell, and was transferred to the hospital. Since the facility staff were not aware the resident had a guardian, the guardian had not been kept informed of the resident choosing to exit the building during a severe heat advisory, against advice. During interviews on 7/30/25 at 11:33 A.M. and on 7/31/25 at 10:30 A.M., the resident's physician said he was aware the resident had a guardian. The resident would be safe to go out on his/her own, but the facility should have educated the resident and monitored to make sure the resident was not out for prolonged periods of time in the heat. During an interview on 7/30/25 at 12:20 P.M., the Administrator and Regional Nurse Consultant said their process for determining if a resident can sign themselves out is to complete an elopement evaluation, review the guardian paperwork, and to look at the resident's PASRR. These steps were not completed for this resident. If a resident wanted to go out during excessive heat, staff should educate the resident on the risks. If they still want to leave, staff should inform the guardian. They have a waiver for residents to sign if they want to go out of the building against the advice of staff. The resident did not sign one of the waivers. 257250925724902572447

Based on observation, interview and record review, the facility failed to ensure medications on the 200 hallway, were stored properly for multiple residents, including two sampled (Residents #1 and #2), which had the potential to cause harm to all residents. The sample was five. The census was 87.Review of the facility's medication storage policy, dated 5/18/24, showed:-Policy: All drugs and biologicals will be stored in locked compartments, cabinets, drawers, refrigerators, under proper temperature control. Narcotics and controlled substance medications are stored under double lock and key;-Any discrepancies which cannot be resolved must be reported immediately as follows: Notify the Director of Nursing (DON), charge nurse, and the pharmacy. Complete an incident report detailing the discrepancy, steps taken to resolve it, and names of all licensed staff working when the discrepancy was noted. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. 1. Observation on 7/3/25, at 7:25 A.M., of the nurse's station on the second floor, showed:-The nurse's station was located in an open room with no doors. The nurse's station was open and accessible for anyone to walk behind it;-An open box, positioned on the ground behind the nurse's station, in front of a medication cart. The box contained 45 cards of medication;-A trash bag on the ground behind the nurse's station contained finished medication cards that needed to be disposed of, along with one of the medication cards still containing medications;-An open box, on the ground contained finished medication cards that needed to be disposed of;-An open box, positioned under the desk behind the nurse's station. The box contained over 45 cards of medication;-A open box, positioned under the desk behind the nurse's station next to the previous box. The box contained over 45 cards of medication. Observation on 7/3/25 at 8:43 A.M. and 10:48 A.M., of the nurse's station on the second floor, showed:-An open box, positioned on the ground behind the nurse's station, under the desk. The box contained 45 cards of medication;-A trash bag on the ground behind the nurse's station contained finished medication cards that needed to be disposed of. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff.dated 4/9/25, showed:-Moderate cognitive impairment;-Diagnoses included acute kidney failure, heart failure, and schizophrenia (mental illness that affects the way a person thinks, feels and behaves). Observation on 7/3/25 at 7:27 A.M., of the nurse's station on the second floor showed the following under the desk:-A medication card labeled with the resident's name. The medication card contained 28 hydrochlorothiazide (high blood pressure medication) 12.5 milligram (mg) capsules;-A medication card labeled with the resident's name. The medication card contained 14 Farxiga (diabetic medication) 10 mg tablets;-A medication card labeled with the resident's name. The medication card contained 28 Amlodipine (high blood pressure medication) tablets. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included chronic kidney disease and heart failure. Observation on 7/3/25 at 7:28 A.M., of the nurse's station on the second floor showed the following under the desk:-A medication card labeled with the resident's name. The medication card contained 28 hydroxyzine (antihistamine) 10 mg tablets. 4. During an interview on 7/3/25 at 7:20 A.M., Certified Medication Technician (CMT) A said the pharmacy comes around once a month to deliver medication to the facility. The medication is delivered in boxes and then placed behind the nurse's stations for staff to put the medications away in storage. The medication is not stored in a timely manner and normally sits behind the nurse's station where anyone has access to it. The facility policy should store medication as soon as it is delivered. 5. During an interview on 7/3/25 at 9:08 A.M., CMT B said CMTs and nurses are responsible for putting away medications in the proper storage areas when it is delivered. If medication cannot be put away right away, it should be locked in the storage room. Medication should never be left unattended because residents could get into it. 6. During an interview on 7/3/25 at 11:51 A.M., the Regional Nurse Advisor said he would expect boxes of medication to be put away in the proper storage locations. Nurses are responsible for checking in medication and putting them away. The medication boxes observed behind the nurse's station desk were delivered on 6/28/25 and should have been stored properly on the day it was delivered. Residents should never be behind the nurse's station for safety purposes. 7. During an interview at 12:45 P.M., the Administrator and DON said they would expect nursing staff to follow the medication storage policy. They would expect medication to be put away as soon as it is delivered or stored in the locked medication storage room until it can be placed on the medication carts.MO00256390

Based on interview and record review, the facility failed to conduct a background screening for one hired employee (Administrator A). The facility failed to screen Administrator A to rule out the presence of a Federal Indicator, failed to conduct a Criminal Background Check (CBC), and Employee Disqualification List (EDL) check. The facility also failed to maintain records of the employment application, experience and education, references, license verification, and results of the background checks required by section 660.317 of Revised MO Statues. Administrator A was employed at the facility for approximately four months. This had the potential to affect all residents. The census was 86. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -This Facility will not employ individuals who have been convicted of abusing, neglecting or mistreating individuals. Potential employees are screened for a history of abuse, neglect or mistreating of residents; -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Review of the facility's Background Screening policy, dated 12/27/24, showed: -The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied. For example, if an employee applies for a job position that requires driving, an investigation of the employee's driving record will be conducted; -For all applicants applying for a position as a Certified Nurse Aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing; -Persons applying for employment and current employees will be informed of this policy. The company will not conduct a background investigation without an applicant's or employee's advance consent. Applicants or employees who do not consent to a background investigation will, however, not be considered for positions that the company has determined to require the completion of a background investigation; -If the background investigation(s) disclose any material misrepresentation or omissions by the applicant or employee on the application form or reveal information indicating that the individual may not be appropriate for hire, the company will investigate the matter further. Upon completion of such investigation, if the company determines that the applicant's or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, or, if already employed, will be terminated; -The facility will not employ individuals who: -Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; -Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property; -Have a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation or resident property; -All inquiries regarding background investigations should be directed toward the Director of Human Resources or Administrator. Review of Administrator A's Missouri Department of Health and Senior Services (DHSS) facility history, showed: -Administrator at Facility D on 10/14/24 through 11/5/24; -Administrator at Facility E on 11/7/24 through 3/19/25. Review of Administrator's A file, received 4/2/25, showed: -No hire date; -No application or resume of employment; -No CBC or EDL checks; -No federal indicator check; -No Administrator license documentation; -Several copies of unsigned facility policies and procedures; -A copy of Administrator A's driver's license and social security card. During an interview on 4/3/25 at 12:45 P.M., Regional Human Resources (HR) C said Administrator A was already employed when he/she returned to the company and Administrator A came from Facility D, a sister home in another city, so he/she had no idea who completed Administrator A's on-boarding and background check when he/she was hired. He/She was at the facility the week of February 3, 2025. HR C had concerns because Administrator A did not have a background check. They were supposed to get the information from Facility D and have it with him/her in the facility, but it slipped his/her mind. HR C thought the Business Office Manager (BOM) took care of it. The BOM handles HR and resident trust account. He/She asked the BOM if he/she had a file for Administrator A and he/she said no, and they would have to see if they could get the information from Facility D. Administrator A was at the facility at the time and HR C spoke to him/her. Administrator A said, they never sent my stuff over. Administrator A said he/she got in touch with someone and they were sending it over. HR C later spoke to Administrator A and asked him/her about the background check. He/She asked Administrator A if he/she received it and Administrator A said, yes. HR C thought it was given to the BOM to file. During an interview on 4/3/25 at 12:52 P.M., the BOM said HR C was at the facility in January or February 2025. He/She checked the employee files. Administrator A did not have a file. Without having the file, the BOM did not remember what was missing. He/She could not recall if there was a conversation regarding specific information that was missing or needed. During an interview on 4/3/25 at 1:17 P.M., Administrator B said he/she had been the Administrator since 3/27/25. The facility has HR, but they are responsible for background checks of the floor staff. Corporate HR ran his/her background check and other salaried management staff. Administrator B said Administrator A came from a different facility. On a corporate level, Administrator B was not privy to conversations that were had, however, the facility's BOM and HR check licenses on all facility staff. MO00251596

Based on observation, interview, and record review, the facility failed to consistently assess pain or provide treatment in a timely manner for one resident (Resident #10) who fell and fractured his/her arm on 9/13/24. The resident missed a surgery date on on 10/23/24 after staff fed the resident, which resulted in the surgery being canceled. The facility failed to ensure the resident was seen by his/her orthopedic physician despite several attempts by the office to set up appointments since the postponed surgery or set up a new date for the surgery. The facility also failed to complete a new pain assessment after the resident's arm was fractured. These failures resulted in pain and a loss of mobility for the resident. The sample was three. The facility census was 77. Review of the facility's Pain Management policy revised on 6/26/24, showed: -Purpose: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan and the resident's goals and preferences; -Policy: The facility will utilize a systematic approach for recognition, assessment and monitoring of pain; -Recognition of pain: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: --Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; --Evaluate the resident for pain and the cause(s) upon admission, during ongoing assessments and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain); --Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences; -Facility staff will observed for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: --Loss of function or inability to perform activities of daily living (ADLs) e.g. rubbing a specific location of the body, or guarding a limb or other body parts; --Behaviors such as: Resisting care, irritability, depressed mood or decreased participation in usual physical and/or social activities; --Skin conditions; -Pain assessment: The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g. nurses, practitioner, pharmacists and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident; --History of pain and its treatment (including non-pharmacological, pharmacological and alternative medicine treatment and whether or not each treatment has been effective; --Asking the resident to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident; --Reviewing the resident's current medical conditions; --Identifying key characteristics of the pain: --Duration of pain; --Frequency; --Location; --Timing; --Pattern (consistent or intermittent); --Radiation of pain; -Obtaining descriptors of the pain; -Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain; -Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood); -Current prescribed pain medications, dosage and frequency; -The resident's goals for pain management and his/her satisfaction with the current level of pain control; -Physical and psychosocial issues that might be causing or exacerbating the pain; -Pain management and treatment: -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -Factors influencing the choice of treatments include: -The cause, location and severity of resident's pain; -The resident's current medical condition; -The resident's current medications; -The resident's desired level of relief and tolerance for adverse consequences; -Potential benefits, risks and adverse consequences of medications; -Available treatment options; -Non-pharmacological interventions will include but are not limited to: -Environmental comfort measures; -Loosening any constrictive bandage, clothing or device; -Applying splinting (e.g. pillow or folded blanket); -Physical modalities (e.g. cold compress, warm shower/bath, massage, turning or repositioning); -Cognitive/behavioral interventions (e.g. music, relaxation techniques, activities, diversions, teaching the resident coping techniques and education about pain); -Pharmological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain; -Monitoring, reassessment and care plan revision: -Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences such as: -Tolerance; -Physical dependence; -Increased sensitivity to pain; -Constipation; -Sleepiness, dizziness and/or confusion; -Depression; -If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/24, showed: -Cognitively intact; -No behaviors or rejection of care; -Functional Limitation in Range of Motion: No Independent with all ADLs; -No pain; -No falls since admission or prior assessment. Review of the resident's progress notes, showed on 9/13/24 at 7:30 A.M., the resident told staff he/she fell and was able to pick him/herself up off the floor. Upon assessment the resident's right arm was painful to the touch and swollen. Staff placed a call to the resident's physician. An order was received to send the resident to the emergency room (ER) for evaluation and treatment. The resident able to move all other extremities without difficulty. At 7:40 A.M., staff called 911. At 8:10 A.M., emergency transfer staff in facility to transfer resident. At 12:40 P.M., the resident returned from the ER with a appointment to see the ortho (orthopedic physician) and with splint to be worn when up until appointment with ortho. At 12:45 P.M., staff called the resident's physician to inform him of his/her return. Review of the resident's hospital records, dated 9/13/24, showed: -Fall unclear mechanism. Right upper extremity injury. Facial involvement; -Final diagnosis: Closed right (RT) humeral fracture (a break in the upper arm bone), spiral (bone broken in a twisting motion) displaced (a displaced fracture means the pieces of the bone moved so much a gap formed around the fracture); -Relevant imaging results show RT humeral fracture and contusion (bruise) without fracture to nasal bone; -Patient sent back to nursing home with sling and follow up with ortho, ENT (ear, nose and throat specialist) and physician. Further review of the resident's progress notes showed: -On 9/14/24, no time noted, the resident remained on incident follow-up (IFU) related to his/her fall. He/She was in no apparent distress. Staff would continue to monitor. His/Her call light was in his/her reach and bed was in the lowest position. At 7:00 P.M., the resident's family were in the facility to visit. The resident's arm remained in the sling. Staff administered acetaminophen (pain reliever) three times on the shift. It was effective within an hour. There was bruising and swelling to the right arm. Staff provided assistance with the resident's activities of daily living. -On 9/15/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU. He/She did not complain of pain or distress at the time. At 7:00 P.M., the resident remained on observation, seated in his/her wheelchair. The staff administered acetaminophen three times during the shift. It was effective within an hour. Staff noted no signs of acute distress. The resident did have bruising on the bridge of his/her nose and the right arm. Staff provided assistance with all ADLs; -On 9/16/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU/fall with injury. He/She had significant bruising to the entire right arm related to the fracture and a sling in place. At 4:30 P.M., the resident was up in his/her wheelchair propelling him/herself. No complaints of pain or discomfort at the time. His/Her arm was discolored and edematous (abnormally swollen with fluid); -On 9/17/24, no time noted, the resident's arm was extremely swollen and staff noted discoloration from shoulder to hand. His/Her hand was warm to the touch and his/her radial (pulse felt in the wrist) pulse was weak. Staff notified the resident's physician and sent the resident to the ER for evaluation; -On 9/18/24 at 12:20 A.M., the resident returned to the facility and no issues were found with his/her venous Doppler (a non-invasive ultrasound test that uses high frequency sound waves to examine circulations in a person's veins). There were no changes on the x-ray of his/her right hand since the initial x-ray. The resident denied pain. At 6:15 A.M., staff checked on the resident who voiced no pain. At 7:10 A.M., the resident would not get up to use the restroom or attempt to use his/her call light. -On 9/19/24, no time noted, the resident continued to wear an arm sleeve. Staff encouraged him/her to elevate his/her arm. No complaints of pain at the time. Review of the resident's electronic Medication Administration Record (eMAR) dated 9/1/24 through 9/30/24, showed: -An order dated 9/6/24 for diclofenac sodium (used to reduce pain, swelling and joint stiffness) tablet delay release 75 milligrams (mg). Give one tablet two times a day with food. Documented as administered 9/6 through 9/30/24; -An order dated 6/20/24 for acetaminophen oral tablet 325 mg. Give two tablets every four hours as needed for pain. Two tablets administered on 9/18/24 at 10:00 A.M., 9/28/24 at 9:00 A.M. and 1:00 P.M. and 9/19/24 at 5:00 A.M. and 7:00 P.M. -No documentation of administration for the rest of the month. Review of the orthopedic physician's office visit notes dated 9/19/24, showed: -The resident had been having right upper extremity pain for nine days; -The resident had an injury to the shoulder after a fall; -The resident complained of pain during the day and night and had sleep disturbances; -The resident complained of loss of strength and loss of motion; -At this point they had tried treatment options including activity modification, anti inflammatory medications, acetaminophen and bracing; -The symptoms were not improving with conservative measures; -PROMIS (Patient reported outcomes measurement information system measures health status from the patient's perspective) upper extremity score: 15 (severe dysfunction); -PROMIS pain score 76 (severe); -No current facility administered medication on file prior to visit; -Physical exam: Splint removed; -Skin: Diffuse healing ecchymosis (a widespread bruise, where the discoloration from leaked blood under the skin is spread out over a large area, rather than localized in one spot); -Right upper extremity: Tenderness along the arm. Mobile fracture fragments (pieces of broken bone); -X-ray showed a comminuted shaft fracture (the bone breaks into several pieces) with a long spiral fragment (the bone twists in a corkscrew shape); -Displaced comminuted right proximal humerus fracture (a severe break in the upper part of the arm where the bone shatters into multiple pieces and has shifted out of its normal position); -Plan: Therapy as tolerated to improve range of motion of wrist and hand. Another x-ray in a week to see if better alignment. Review of the resident's monthly physician's notes, dated 9/19/24, showed: -The chief complaint was a right humerus fracture; -The resident had new or worsening medical problems over the last month; -The resident was feeling tired or poorly; -The resident had a fall in the shower and complained of right arm pain. Sent to the hospital and found to have a right humerus fracture. Ortho consulted and to follow up as outpatient. The resident returned to the nursing home within hours. He/She was going to follow up with ortho today for surgery. His/Her right arm was ace wrapped and his/her hand was swollen; -Resident reported pain and feeling tired or poorly; -He/She reported muscle weakness; -He/She reported lower back pain, left hip joint pain, joint pain in both knees, muscle aches, muscle stiffness and stiffness localized to one or more joints; -He/She reported memory lapses or loss; -He/She reported skin symptoms; -Mild disorientation was observed and judgement was impaired. Review of the resident's progress notes, showed: -On 9/23/24 between 7:00 A.M. and 7:00 P.M., staff notified the resident's physician regarding swelling, redness and warmth in the right arm. A new order was received for doxycycline (used to treat and prevent infections) 100 mg, twice a day by mouth for ten days and lasix (used to treat water retention and swelling) 40 mg one time a day by mouth for ten days. The resident's sling remained intact and staff encouraged him/her to sleep on his/her left side; -On 9/24/24 between 7:00 A.M. and 7:00 P.M., the resident's sling remained in place. His/Her arm and fingers remained edematous; -On 9/29/24 at 8:30 P.M., resident seated in bed watching television, showing no signs and symptoms of pain or distress. Review of the physician's appointment records for the resident on 12/18/24, showed on 9/26/24, the resident's orthopedic appointment with the physician was canceled. Review of the resident's progress notes, showed no documentation of a missed appointment on 9/26/24. Review of the resident's eMAR dated 10/1/24 through 10/31/24, showed: Acetaminophen 325 mg. -No documentation of administration 10/1 through 10/31/24. Review of the resident's electronic Treatment Administration Record (eTAR), dated 10/1/24 through 10/31/24 showed: -An order dated 10/2/24 to assess for pain every shift; --On 10/2 through 10/31/24, all areas were left blank for both shifts for pain level. -No documentation of pain level assessed 10/1 through 10/30/24; -An order for diclofenac sodium 75 mg. Give one tablet two times a day for pain. -No documentation of medication administered 10/1 through 10/31/24. Review of the physician's appointment records for the resident on 12/18/24, showed on 10/3/24, the resident did not show up for his/her orthopedic appointment. Review of the resident's progress notes, showed no documentation of missed appointment on 10/3/24. Review of orthopedic physician office visit notes dated 10/10/24, showed: -Chief complaint: Right upper extremity pain; -The resident was unable to follow up since last visit and they had been unable to successfully get medical clearance for surgery until then; -Physical exam: -Right upper extremity: Tenderness along the arm. Mobile fracture fragments. Shoulder and elbow range of motion not attempted due to pain. There was swelling over the elbow forearm and hand and weak elbow flexion and extension (motion of bending and straitening the elbow); -Plan: Resident agreed to proceed with surgery in the form of right humerus, open reduction and internal fixation (surgical procedure to repair broken humerus bone in upper arm. The surgeon makes an incision to realign the bone and uses hardware like screws, plates, rods or pins to hold the bone together); -The surgery would not be scheduled until there was medical clearance. Review of the resident's progress notes, showed on 10/14/24 at 2:50 P.M., the resident's surgeon's office called related to his/her 10/23/24 surgery. They needed surgery clearance. Staff called the resident's physician who stated they would fax the letter on 10/15/24. Review of the resident's physician's appointment records, showed on 10/23/24, the resident was scheduled for surgery. Review of the resident's progress notes, showed: -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork; -No documentation if surgery occurred or why it did not; -No documentation of notifications to physician or family representative; -No documentation of rescheduling of surgery. Review of the resident's eMAR dated 11/1/24 through 11/30/24, showed: Acetaminophen 325 mg. -No documentation of administration 11/1 through 11/30/24. Review of the resident's eTAR dated 11/1/24 through 11/30/24 showed: -Diclofenac Sodium 75 mg. No documentation of administration 11/1/24 through 11/30/24; -No assessment for pain documented 11/1 through 11/30/24. Review of the resident's monthly physician visit notes dated 11/1/24, showed: -Resident feeling tired or poorly; -Has chronic pain. Seen for follow up. Complained of left hip pain as well; -Seen in wheelchair, wearing a sling on upper right extremity. Fell in September suffering a right proximal comminuted fracture and saw ortho. Surgery was canceled and rescheduled. Labs done as pre-operative (pre-op) and they cleared him/her. Review of the physician's appointment records for the resident on 12/18/24, showed on 12/5/24, the resident did not show up for his/her orthopedic appointment. Review of the resident's progress notes showed no documentation of an appointment on 12/5/24 or why it was missed. Review of the resident's eMAR dated 12/1/24 through 12/31/24, showed: Acetaminophen 325 mg. -No documentation of administration 12/1 through 12/18/24. Further review of the resident's eTAR dated 12/1/24 through 12/18/24, showed: -Diclofenac Sodium 75 mg. No documentation of administration 12/1/24 through 12/18/24; -No assessment for pain documented 12/1 through 12/18/24. Review of the resident's monthly physician visit notes dated 12/16/24, showed: -Resident feeling tired or poorly; -Has increased edema right upper extremity and both lower extremities. Was in sling, not using much. Will increase Lasix to two times a day and get labs; -Resident reported lower back pain, left hip joint pain, joint pain in both knees, muscle stiffness and stillness localized to one or more joints; -Not well appearing; -Comminuted right proximal humerus fracture. Now in sling. Cleared for surgery if needed. Review of an email sent by the resident's orthopedic physician's office on 12/18/24, showed the office staff tried to make the appointment with the nursing facility but had not seen the resident since 10/10/24, and no one would call them back. Observation and interview on 12/18/24 at 2:00 P.M., showed the resident sat in a wheelchair in the hallway with a sling on his/her right arm. His/Her head was slumped down, and he/she appeared to be tired. He/She said he/she was not in pain at the moment but had pain when he/she slept and/or moved his/her arm the wrong way. He/She bruised his/her arm in a fall but could not remember the date he/she fell. He/She could report the pain to staff when he/she had it, but it would not do any good. They only gave him/her over the counter medication when he/she complained, and it did not always help. The resident cried out in pain when a staff member attempted to pull his/her right sleeve down to observe the bruising. The brusing was dark purple, greenish and yellowish in color. It started at his/her wrist and extended to his/her shoulder. His/Her arm and hand appeared to be very swollen and red. During an interview on 12/18/24 at 2:10 P.M., Certified Nurse's Aide (CNA) F said the resident expressed pain whenever they had to move his/her arm to assess it. He/She noticed the increased bruising to the resident's right arm that morning when giving the resident a shower and reported it to the nurse. The resident's hands were also extremely swollen. The nurse told him/her it was probably older brusing from the original fall and to just keep an eye on it. The resident did not have this much bruising the week before when he/she gave him/her a shower. The resident complained of pain whenever he/she was transferred or needed help with dressing. If he/she was sitting still in his/her wheelchair, the resident would not complain of pain. During an interview on 12/26/24 at 12:30 P.M., Licensed Practical Nurse (LPN) C said he/she assesses pain by asking the resident if they are in pain and administering pain medications if they are in pain. He/She did not know anything about recording a pain level in the new eMAR. It is a new system, and he/she is still learning how to use it. He/She administered all medications as ordered. He/She did not know the system was not documenting the medication as not administered. He/She does not do formal pain assessments on residents and was not sure who did them or if one was done at all. During an interview on 12/18/24 at 3:00 P.M., the resident's physician office representative said they were aware the resident was scheduled for surgery and missed it on 10/23/24. The physician cleared the resident for surgery and the physician thought the facility was rescheduling it. The physician saw the resident several times after the fall, and he/she did not complain of pain to him those times. That is why he did not order more pain medications. The facility should have been doing pain assessments as soon as the resident returned from the hospital. The facility did not notify the office the resident missed more appointments or the resident continued to have pain. The facility should have notified the physician's office about this. Review of the resident's progress notes, showed on 12/18/24 at 1:30 P.M., staff contacted the hospital to find out the orthopedic surgeon's name. The staff member left a message with the surgeon's scheduler to get surgery rescheduled. At 1:40 P.M., staff contacted the resident's physician to inform him they were trying to reschedule the surgery, however they wanted another X-ray to ensure no additional injury occurred. At 2:20 P.M., the person who set up the schedule from the physician's office called back and indicated he/she would have to contact the orthopedic surgeon to see there was anything else on file. They would reschedule once he/she spoke to the physician and would get back with them no later than 12/21/24. The staff member explained they were requesting an x-ray and would forward it to the physician's office when the results were back. At 2:55 P.M., staff were notified by another resident, the resident had a bruise on his/her right arm. The nurse assessed the arm and noted bruising to the arm, forearm and elbow. The resident had slight swelling to the arm. The resident wore a sling related to his/her shoulder fracture. Staff notified therapy to evaluate the resident for a sling and right arm to ensure the sling was properly positioned as concerns were noted due to swelling and abnormal bruising. The bruising was most likely related to fracture, sling and acute issues involving the right arm. The X-ray company was notified and aware of STAT (immediate) order. Staff were waiting for the X-ray company to arrive. Review of the resident's electronic medical records on 12/18/24, showed no documentation of pain assessments conducted 8/24 through 12/18/24. During an interview on 12/26/24 at 11:15 A.M., Licensed Practical Nurse M said they changed from paper charts to electronic in September 2024. If there is an assessment for pain, LPN M asks the resident if they are in pain and enters in yes or no. Some of the electronic records do not allow him/her to enter a level. If a resident told the LPN he/she was in pain, then he/she would administer as needed medications or notify the physician if the resident did not have an order for pain medication. LPN M would document all of this in the resident's electronic medical record. LPN M does not do the actual pain assessment and did not know who was responsible for this. He/She gave the resident all of his/her ordered medications and did not know why the eMAR was not reflecting this. Review of an email sent by the facility Administrator on 12/26/24, showed the MDS coordinator was responsible for updating the MDSs and care plans. The expectation for updating these records was to obtain any records they could locate. No pain assessments were done between 9/24 and 12/18/24. During an interview on 12/30/24 at 12:15 P.M. the MDS Coordinator said she was responsible for performing pain assessments on residents quarterly or with a change in condion. This involved reviewing the resident's medication administration records and/or asking the residents their current pain levels. She had not been able to review the medication administration records for a couple of months, but she asked the staff about the resident's pain medication administration and they reported he/she was not having increased pain. She assessed the resident at his/her quarterly MDS update in August and then again on 11/18/24. She did not know why the updated MDS was not showing up in the system. She probably assessed him/her after he/she came back from the hospital with a fractured arm, but he/she was not sure and could not find the documentation. The resident should have been assessed for pain within 14 days after his/her arm was fractured. During an interview on 12/30/24 at 12:30 P.M., the Interim Director of Nursing (DON) said if a resident said they were in pain, staff should ask what level of pain they were experiencing from 1 to 10 and then document that on the eMAR. If the resident had pain medication ordered, it could be administered or if not, the staff member or nurse would notify the resident's physician to get something for the resident's pain. Then the staff would go back an hour later to see if the resident was still in pain and if so, would need to seek out a higher level of pain control. All of this needed to be documented so they could care plan potential pain issues. If pain levels and times were not being documented, then the staff would not know when to administer as needed medications. It would be harder to assess a resident for increased pain without the documentation. Pain assessments were supposed to be done every three months. They would be automatically done if a resident had chronic pain and updated if a resident expressed new pain. The DON could not find a pain assessment in Resident #10's medical file. There should have been one done when the resident came back from the hospital after he/she fractured his/her arm. During an interview on 12/18/24 at 3:15 P.M. and on 12/30/24 at 1:00 P.M., the Administrator said the resident should have been assessed for pain after he/she came back from the hospital with the fractured arm. He/She was not working at the facility when this occurred and did not know the resident was not assessed. If the resident was having pain when staff were providing care, this should have been documented and the physician notified. MO00246748

Based on interview and record review, the facility failed to ensure a resident (Resident #10) kept all appointments with the orthopedic surgeon after an unwitnessed fall resulting in a fracture of his/her right arm on 9/13/24. Delay of treatment has caused pain and a decrease in his/her ability to perform activities of daily living (ADLs). The sample was three. The census was 77. Review of the facility's Resident Appointment policy, updated on 8/24, showed: -Purpose: To ensure all appointments and follow-up appointments (as needed) are scheduled. Residents will be taken to all scheduled appointments (barring emergency circumstances that require rescheduling). The facility is responsible in assisting with appointment management and scheduling/coordination of transportation (if requested/needed); -Procedure: -Nursing staff to assist with scheduling appointments and follow-up if needed; -Nursing staff to communicate transportation to social services director (SSD) and SSD will set up transportation for the scheduled appointment; -The SSD or designee is responsible for scheduling any needed follow-up appointments; -Communication, appointments, follow ups, concerns, etc. will be documented appropriately. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/24, showed: -Cognitively intact; -Independent with ADLs; -No history of pain; -No history of falls since admission or prior assessment; -Diagnoses included other specified disorders of bone density and structure, and muscle weakness. Review of the resident's progress notes, showed the following: -On 9/13/24 at 7:30 A.M., the resident said he/she had a fall and was able to pick him/herself up off the floor. Upon assessment, the resident's right arm was painful to the touch and swollen. Staff placed a call to the resident's physician. An order was received to send the resident to the emergency room (ER) for evaluation and treatment. The resident able to move all other extremities without difficulty. At 7:40 A.M., staff called 911. At 8:10 A.M., emergency transfer staff were in facility to transfer resident. At 12:40 P.M., the resident returned from the ER with an appointment to see ortho (orthopedic doctor specializes in the management of pain related to the musculoskeletal system) and with a splint to be worn when up, until appointment with ortho. At 12:45 P.M., staff called the resident's physician to inform him of the resident's return. Review of the resident's hospital records, dated 9/13/24, showed: -Fall, unclear mechanism. Right upper extremity injury. Facial involvement; -Final diagnosis: Closed right (RT) humeral fracture (a break in the upper arm bone), spiral (bone broken in a twisting motion)displaced (a displaced fracture means the pieces of the bone moved so much, a gap formed around the fracture); -Relevant imaging results show RT humeral fracture and contusion (bruise) without fracture to nasal bone; -Patient sent back to nursing home with sling and follow up with ortho, ENT (ear, nose and throat specialist) and physician. -No documentation in hospital notes to indicate when surgery or follow up appointments were made. Review of the resident's progress notes, on 9/14/24, no time noted, showed the resident remained on IFU (incident follow up) related to his/her fall. The resident's arm remained in the sling. Staff administered pain medication three times during the shift. It was effective within an hour. There was bruising and swelling to the right arm. Staff provided assistance with the resident's activities of daily living. -On 9/15/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU. The staff administered pain medication three times during the shift. It was effective within an hour. The resident did have bruising on the bridge of his/her nose and the right arm. Staff provided assistance with all ADLs; -On 9/16/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU/fall with injury. He/She had significant bruising to the entire right arm related to the fracture and has a sling in place. His/Her arm was discolored and edematous (swelling); -On 9/17/24, no time noted, the resident's arm was extremely swollen and staff noted discoloration from shoulder to hand. His/Her hand was warm to the touch and his/her radial (wrist) pulse was weak. Staff notified the resident's physician and sent the resident to the ER for evaluation; -On 9/18/24 at 12:20 A.M., the resident returned to the facility and no issues were found with his/her venous Doppler (ultrasound test that uses sound waves to examine the circulation of blood in veins). There were no changes on the x-ray of his/her right hand since the initial x-ray. The resident denied pain. Review of the orthopedic physician's office visit notes dated 9/19/24, showed: -The resident had been having right upper extremity pain for nine days; -The resident had an injury to the shoulder after a fall; -The resident complained of pain during the day and night and had sleep disturbances; -The resident complained of loss of strength and loss of motion; -At this point, they had tried treatment options including activity modification, anti inflammatory medications, Tylenol and bracing; -The symptoms were not improving with conservative measures; -PROMIS (Patient reported outcomes measurement information system measures health status from the patient's perspective) upper extremity score: 15 (severe dysfunction); -PROMIS pain score 76 (severe); -No current facility administered medication on file prior to visit; -Physical exam: Splint removed; -Skin: Diffuse healing ecchymosis (a widespread bruise, where the discoloration from leaked blood under the skin is spread out over a large area, rather than localized in one spot); -Right upper extremity: Tenderness along the arm. Mobile fracture fragments (pieces of broken bone); -X-ray showed a comminuted shaft fracture (the bone breaks into several pieces) with a long spiral fragment; -Displaced comminuted right proximal humerus fracture (a severe break in the upper part of the arm where the bone shatters into multiple pieces and has shifted out of the normal position); -Plan: Therapy as tolerated to improve range of motion of wrist and hand. Another x-ray in a week to see if better alignment. Review of the resident's monthly physician's notes, dated 9/19/24, showed: -The chief complaint was a right humerus fracture; -The resident had new or worsening medical problems over the last month; -The resident was feeling tired or poorly; -The resident had a fall in the shower and complained of right arm pain. Sent to the hospital on 9/18/24 and found to have a right humerus fracture. Ortho consulted and to follow up as outpatient. The resident returned to the nursing home within hours. He/She was going to follow up with ortho today for surgery. His/Her right arm was ace wrapped and his/her hand was swollen; -Resident reported pain and feeling tired or poorly; Review of the resident's care plan updated 9/13/24, showed: -Problem: Potential for self care deficit related to, ambulates with wheelchair; -Goals: Resident will maintain current level of function and be clean and well groomed through next review; -Interventions: Resident ambulates around the facility with wheelchair. Gait usually abnormal. Positions independently. Transfers without assistance. Dresses independently. Feeds self. Monitor consumption report. Toilets self. Continent. Urinary dribbles, wears bladder pads. Personal care done independently. Showers independently. Bedtime routine completed independently. On 9/13/24, resident had a fall in his/her room. Complained of pain in right arm and sent to ER to evaluate and treat. Returned with right arm and nose fractures; -Problem: Potential for falling. On 9/13/24, the resident reported he/she had fallen and complained of right arm pain. Staff informed physician. New order received to send to emergency room to evaluate and treat; -Interventions: Monitor for gait and balance. Keep area free of clutter. Encourage rest periods. Assist with transfers as needed. Physical therapy/occupational therapy per physician's orders; -Problem: Potential for pain; -Interventions: Educate resident on signs and symptoms of lethargy due to administration of pain medications. Administer routine pain medications per physician's orders. Monitor for effectiveness of pain management and alert physician as needed. Monitor for verbal/nonverbal indicators of pain. Pain management consultation as needed. Pain assessment quarterly. See assessment in chart. Review of the resident's progress notes, showed: -On 9/23/24 between 7:00 A.M. and 7:00 P.M., staff notified the resident's physician regarding swelling, redness and warmth in the right arm. A new order was received for doxycycline (used to treat infection) 100 milligrams (mg), twice a day by mouth for ten days and lasix (used to help reduce excess fluid in the body) 40 mg, one time a day by mouth for ten days. The resident's sling remained intact and staff encouraged him/her to sleep on his/her left side. No signs of acute distress noted. -On 9/24/24 between 7:00 A.M. and 7:00 P.M., the resident's sling remained in place. His/Her arm and fingers remained edematous (swollen); -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork. The resident was scheduled for surgery; -No documentation if surgery occurred or why it did not; -No documentation of notifications to physician or family representative; -No documentation of rescheduling of surgery. Review of the resident's monthly physician visit notes dated 11/1/24, showed: -Resident feeling tired or poorly; -Has chronic pain. Seen for follow up. Complained of left hip pain as well; -Seen in wheelchair, wearing a sling on upper right extremity. fell in September suffering a right proximal comminuted fracture and saw ortho. Surgery was canceled and rescheduled. Labs done as pre-operation (pre-op) and they cleared him/her. Review of the orthopedic physician's appointment records for the resident on 12/18/24, showed on 9/26/24, the resident's orthopedic appointment with the physician was canceled. Review of the resident's progress notes, showed no documentation of missed appointment on 9/26/24. Review of the orthopedic physician's appointment records for the resident on 12/18/24, showed on 10/3/24, the resident did not show up for his/her appointment. (There is nothing in the progress notes to show the surgery was rescheduled.) Review of orthopedic physician office visit notes dated 10/10/24, showed: -Chief complaint: Right upper extremity pain; -The resident was unable to follow up since last visit and they had been unable to successfully get medical clearance for surgery until then; -Physical exam: -Right upper extremity: Tenderness along the arm. Mobile fracture fragments. Shoulder and elbow range of motion not attempted due to pain. There was swelling over the elbow forearm and hand and weak elbow flexion and extension (motion of bending and straightening the elbow); -Plan: Resident agreed to proceed with surgery in the form of right humerus, open reduction and internal fixation (surgical procedure to repair broken humerus bone in upper arm. The surgeon makes an incision to realign the bone and uses hardware like screws, plates, rods or pins to hold the bone together); -The surgery would not be scheduled until there was medical clearance. Review of the resident's progress notes, showed: -On 10/14/24 at 2:50 P.M., the resident's surgeon's office called related to his/her 10/23/24 surgery. They needed surgery clearance. Staff called the resident's physician who stated they would fax the letter on 10/15/24; -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork; -No further documentation of why surgery was canceled and/or rescheduled. Review of the resident's physician's appointment records, showed: -On 10/23/24, the resident was scheduled for surgery; -On 11/8/24, the resident's follow up appointment was canceled because the surgery did not occur; -On 12/12/24, the resident was a no show for his/her appointment. Review of a transportation note dated 12/12/24, provided by the facility on 9/18/24, showed the resident's 12/12/24, appointment with the orthopedic physician was canceled because transportation failed to show. During interviews on 12/18/24 at 12:45 P.M. and at 2:20 P.M., Licensed Practical Nurse L said he/she was working on 12/12/24, and the transportation company did show up but left because the resident was not downstairs ready to go. He/She did not remember getting a call from the physician's office or rescheduling an appointment for him/her. The resident needed more help now with transferring, showering and dressing. He/She used to use a walker before the fall and now needed to use a wheelchair. During an interview on 12/18/24 at 1:10 P.M., the SSD said she sat up the transportation for resident appointments. The resident was supposed to go to the hospital for some appointments, but the SSD did not know the resident missed them. The SSD only had documentation for the 10/10/24 appointment that the resident made, the 10/23/24 surgery date that was missed and the 12/12/24 appointment that was missed. The SSD did not know about the other appointments and did not remember setting up transportation for them. The nurse would have made those appointments, and the SSD did not know why she was not given the information. The nurse was no longer working at the facility. Review of the resident's monthly physician visit notes dated 12/16/24, showed: -Resident feeling tired or poorly; -Has increased edema right upper extremity and both lower extremities. Was in sling, not using much. Will increase Lasix to two times a day and get labs; -Resident reported lower back pain, left hip joint pain, joint pain in both knees, muscle stiffness and stillness localized to one or more joints; -Not well appearing; -Comminuted right proximal humerus fracture. Now in sling. Cleared for surgery if needed. During an interview on 12/18/24 at 2:00 P.M., the resident said he/she had been in pain for several months. It did not hurt all of the time, mostly when he/she had to move the arm or turned the wrong way. It was usually at a level 3 out of 5. He/She was not able to do the things he/she used to do and it made him/her sad. He/She just wanted to have the surgery and get the arm fixed so he/she could take care of him/herself again. He/She was supposed to get surgery but when he/she got down to the lobby, the transportation people had left. This happened a lot. He/She tried to get there as soon as possible, but it took a while to get on the elevator and get downstairs. It was very frustrating because he/she just wanted to feel good again. During an interview on 12/19/24 at 12:15 P.M., the facility's physical therapy manager said the resident was referred to them in October and was still on their caseload. They were working to teach him/he how to function with one arm. The resident needed staff assistance with transferring, toileting, dressing and showering. They were not working with his/her right arm because it was still fractured and in a sling. Review of a note sent by the resident's orthopedic physician's office on 12/18/24, showed the office tried to make the appointment with the nursing facility but had not seen the resident since 10/10/24, and no one would call them back. During an interview on 12/18/24 at 2:10 P.M., Certified Nurse's Aide (CNA) F said he/she noticed brusing on the resident that morning during his/her shower. He/She did not notice it earlier since the resident was wearing long sleeves. The bruising was not there the prior week when he/she gave him/her a shower. The resident fell a few months ago and had some bruising and pain since them. He/She cannot move his/her arm very well. The CNA had to help the resident transfer out of bed into his/her wheelchair, shower, dress and toilet. The resident could not do these things by him/herself since the fall. During an interview on 12/18/24 at 2:00 P.M., the resident said he/she had a bruise on his/her arm from falling a couple of weeks ago. He/She did not remember the actual fall in 9/24. He/She is getting very confused and cannot remember things as well anymore. During an interview on 12/18/24 at 2:15 P.M., the orthopedic physician's nurse, said the resident was originally scheduled to have surgery on 10/10/24, and the resident did not have the approval from the physician's office to do it. They rescheduled the surgery for 10/23/24 and then could not do it because the resident had eaten that morning. They attempted to call the facility several times to set up an appointment to have the resident come into the outpatient clinic, but no one would help them set up the appointment. They finally got one set up for 12/12/24, and the resident did not show up. No one called the clinic to let them know the resident was not coming. They had been trying to set up another appointment, but no one would return their calls. During an interview on 12/18/24 at 3:00 P.M., the resident's physician office representative said they were aware the resident was scheduled for surgery and missed it on 10/23/24. The physician cleared the resident for surgery, and the physician thought the facility was rescheduling it. The facility did not notify the office the resident missed more appointments or the resident continued to have pain. They should have notified them about this. They rescheduled another x-ray for the resident because the facility reported he/she was having pain and swelling. The facility did not notify them about the new brusing on his/her right arm. They did not think the resident fell because he/she would not have been able to get him/herself up off the floor. It was probably due to complications with the fracture and should have been noticed prior to 12/18/24 if it was older brusing and reported to them. During an interview on 12/19/24 at 11:50 A.M., the resident's orthopedic surgeon said the resident's arm was broken and could not heal on its own. The resident had lost mobility in his/her upper extremities because he/she could not use his/her arm. Their office tried to set up an appointment with the resident several times. He was concerned because the resident was expressed being in a lot of pain when he saw him/her and might not be expressing this pain to the staff. The x-ray they took did not indicate a new break but the old fracture could be moving or he/she might have damaged it again and it was causing the swelling and bruising. The resident might never regain his/her mobility back. That is why it is so important to get the surgery done before any more damage occurs. No one from the facility notified his office that the resident continued to have bruising and swelling in his/her arm and hands. The arm would not get better unless the resident had the surgery, and he/she would continue to have pain. They had referred him/her to physical therapy to increase the strength in the arm, but it would not help if he/she could not move his/her arm. During an interview on 12/18/24 at 1:00 P.M., the corporate nurse said they had been having problems with the transportation company. They would come late or not show up at all. The charge nurse is responsible to set up appointment and once this is done, he/she will give the information to the SSD who will set up transportation. If the resident misses an appointment, the charge nurse should reach out to the physician's office to reschedule it. All of this information should be documented in the resident's medical record. She was not aware of why the resident missed his/her surgery date or that he/she missed several follow up appointments. Review of the resident's hospital records, dated 12/18/24, showed: -The patient presented with complaint of right arm pain; -The patient fell and developed right humeral fracture on 9/13/24; -Patient scheduled to be seen by ortho as outpatient, but his/her appointments were not kept by the nursing home; -Since fall, he/she could not follow up with orthopedic surgery; -As patient has difficulty moving right arm for a couple of months and has not seen the orthopedic doctor recently, he/she decided to come to the emergency room and be seen by ortho; -Patient was admitted for further evaluation and management. Review of the resident's X-ray results dated 12/19/24, showed a comminuted displaced multipart fracture of the proximal humerus is noted with significant displacement of fracture fragments with foreshortening (due to the positioning of the bone on the x-ray, the bone appears shorter than it actually is on the image, indicating the fracture fragments might be telescoped (one [NAME] is sliding partially inside another bone) into each other). During an interview on 12/27/24 at 1:00 P.M., the former Director of Nursing (DON) said he/she knew the resident was scheduled for surgery in October and it had to be rescheduled because the resident ate that morning. Staff should not have fed him/her. The charge nurse was responsible for rescheduling the surgery and letting the SSD know so she could set up transportation. No one ever told the DON the resident was still missing appointments. The staff should have reported the missed appointments so the DON could find out what happened and follow up. During interviews on 12/18/24 at 2:40 P.M. and at 4:00 P.M., the Administrator said she just started working at the facility a couple of months ago. She was not here when the resident fractured his/her arm and did not know he/she had missed the surgery. The resident should have gotten his/her surgery by now. When the first surgery was missed, they should have immediately rescheduled another one and made sure transportation was available. She knew the resident missed his/her transportation on 12/12/24 but thought it was just a regular appointment. She would have expected staff to document when appointments were made and/or missed and for them to follow up setting up a new appointment. The nurses were responsible for setting the appointments and then once the appointment was made, they would notify the SSD who would set up transportation. The staff should have had the resident ready to go when transpiration arrived. MO00246748

Based on interview and record review, the facility failed to ensure a resident (Resident #10) kept all appointments with the orthopedic surgeon after an unwitnessed fall resulting in a fracture of his/her right arm on 9/13/24. Delay of treatment has caused pain and a decrease in his/her ability to perform activities of daily living (ADLs). The sample was three. The census was 77. Review of the facility's Resident Appointment policy, updated on 8/24, showed: -Purpose: To ensure all appointments and follow-up appointments (as needed) are scheduled. Residents will be taken to all scheduled appointments (barring emergency circumstances that require rescheduling). The facility is responsible in assisting with appointment management and scheduling/coordination of transportation (if requested/needed); -Procedure: -Nursing staff to assist with scheduling appointments and follow-up if needed; -Nursing staff to communicate transportation to social services director (SSD) and SSD will set up transportation for the scheduled appointment; -The SSD or designee is responsible for scheduling any needed follow-up appointments; -Communication, appointments, follow ups, concerns, etc. will be documented appropriately. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/24, showed: -Cognitively intact; -Independent with ADLs; -No history of pain; -No history of falls since admission or prior assessment; -Diagnoses included other specified disorders of bone density and structure, and muscle weakness. Review of the resident's progress notes, showed the following: -On 9/13/24 at 7:30 A.M., the resident said he/she had a fall and was able to pick him/herself up off the floor. Upon assessment, the resident's right arm was painful to the touch and swollen. Staff placed a call to the resident's physician. An order was received to send the resident to the emergency room (ER) for evaluation and treatment. The resident able to move all other extremities without difficulty. At 7:40 A.M., staff called 911. At 8:10 A.M., emergency transfer staff were in facility to transfer resident. At 12:40 P.M., the resident returned from the ER with an appointment to see ortho (orthopedic doctor specializes in the management of pain related to the musculoskeletal system) and with a splint to be worn when up, until appointment with ortho. At 12:45 P.M., staff called the resident's physician to inform him of the resident's return. Review of the resident's hospital records, dated 9/13/24, showed: -Fall, unclear mechanism. Right upper extremity injury. Facial involvement; -Final diagnosis: Closed right (RT) humeral fracture (a break in the upper arm bone), spiral (bone broken in a twisting motion)displaced (a displaced fracture means the pieces of the bone moved so much, a gap formed around the fracture); -Relevant imaging results show RT humeral fracture and contusion (bruise) without fracture to nasal bone; -Patient sent back to nursing home with sling and follow up with ortho, ENT (ear, nose and throat specialist) and physician. -No documentation in hospital notes to indicate when surgery or follow up appointments were made. Review of the resident's progress notes, on 9/14/24, no time noted, showed the resident remained on IFU (incident follow up) related to his/her fall. The resident's arm remained in the sling. Staff administered pain medication three times during the shift. It was effective within an hour. There was bruising and swelling to the right arm. Staff provided assistance with the resident's activities of daily living. -On 9/15/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU. The staff administered pain medication three times during the shift. It was effective within an hour. The resident did have bruising on the bridge of his/her nose and the right arm. Staff provided assistance with all ADLs; -On 9/16/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU/fall with injury. He/She had significant bruising to the entire right arm related to the fracture and has a sling in place. His/Her arm was discolored and edematous (swelling); -On 9/17/24, no time noted, the resident's arm was extremely swollen and staff noted discoloration from shoulder to hand. His/Her hand was warm to the touch and his/her radial (wrist) pulse was weak. Staff notified the resident's physician and sent the resident to the ER for evaluation; -On 9/18/24 at 12:20 A.M., the resident returned to the facility and no issues were found with his/her venous Doppler (ultrasound test that uses sound waves to examine the circulation of blood in veins). There were no changes on the x-ray of his/her right hand since the initial x-ray. The resident denied pain. Review of the orthopedic physician's office visit notes dated 9/19/24, showed: -The resident had been having right upper extremity pain for nine days; -The resident had an injury to the shoulder after a fall; -The resident complained of pain during the day and night and had sleep disturbances; -The resident complained of loss of strength and loss of motion; -At this point, they had tried treatment options including activity modification, anti inflammatory medications, Tylenol and bracing; -The symptoms were not improving with conservative measures; -PROMIS (Patient reported outcomes measurement information system measures health status from the patient's perspective) upper extremity score: 15 (severe dysfunction); -PROMIS pain score 76 (severe); -No current facility administered medication on file prior to visit; -Physical exam: Splint removed; -Skin: Diffuse healing ecchymosis (a widespread bruise, where the discoloration from leaked blood under the skin is spread out over a large area, rather than localized in one spot); -Right upper extremity: Tenderness along the arm. Mobile fracture fragments (pieces of broken bone); -X-ray showed a comminuted shaft fracture (the bone breaks into several pieces) with a long spiral fragment; -Displaced comminuted right proximal humerus fracture (a severe break in the upper part of the arm where the bone shatters into multiple pieces and has shifted out of the normal position); -Plan: Therapy as tolerated to improve range of motion of wrist and hand. Another x-ray in a week to see if better alignment. Review of the resident's monthly physician's notes, dated 9/19/24, showed: -The chief complaint was a right humerus fracture; -The resident had new or worsening medical problems over the last month; -The resident was feeling tired or poorly; -The resident had a fall in the shower and complained of right arm pain. Sent to the hospital on 9/18/24 and found to have a right humerus fracture. Ortho consulted and to follow up as outpatient. The resident returned to the nursing home within hours. He/She was going to follow up with ortho today for surgery. His/Her right arm was ace wrapped and his/her hand was swollen; -Resident reported pain and feeling tired or poorly; Review of the resident's care plan updated 9/13/24, showed: -Problem: Potential for self care deficit related to, ambulates with wheelchair; -Goals: Resident will maintain current level of function and be clean and well groomed through next review; -Interventions: Resident ambulates around the facility with wheelchair. Gait usually abnormal. Positions independently. Transfers without assistance. Dresses independently. Feeds self. Monitor consumption report. Toilets self. Continent. Urinary dribbles, wears bladder pads. Personal care done independently. Showers independently. Bedtime routine completed independently. On 9/13/24, resident had a fall in his/her room. Complained of pain in right arm and sent to ER to evaluate and treat. Returned with right arm and nose fractures; -Problem: Potential for falling. On 9/13/24, the resident reported he/she had fallen and complained of right arm pain. Staff informed physician. New order received to send to emergency room to evaluate and treat; -Interventions: Monitor for gait and balance. Keep area free of clutter. Encourage rest periods. Assist with transfers as needed. Physical therapy/occupational therapy per physician's orders; -Problem: Potential for pain; -Interventions: Educate resident on signs and symptoms of lethargy due to administration of pain medications. Administer routine pain medications per physician's orders. Monitor for effectiveness of pain management and alert physician as needed. Monitor for verbal/nonverbal indicators of pain. Pain management consultation as needed. Pain assessment quarterly. See assessment in chart. Review of the resident's progress notes, showed: -On 9/23/24 between 7:00 A.M. and 7:00 P.M., staff notified the resident's physician regarding swelling, redness and warmth in the right arm. A new order was received for doxycycline (used to treat infection) 100 milligrams (mg), twice a day by mouth for ten days and lasix (used to help reduce excess fluid in the body) 40 mg, one time a day by mouth for ten days. The resident's sling remained intact and staff encouraged him/her to sleep on his/her left side. No signs of acute distress noted. -On 9/24/24 between 7:00 A.M. and 7:00 P.M., the resident's sling remained in place. His/Her arm and fingers remained edematous (swollen); -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork. The resident was scheduled for surgery; -No documentation if surgery occurred or why it did not; -No documentation of notifications to physician or family representative; -No documentation of rescheduling of surgery. Review of the resident's monthly physician visit notes dated 11/1/24, showed: -Resident feeling tired or poorly; -Has chronic pain. Seen for follow up. Complained of left hip pain as well; -Seen in wheelchair, wearing a sling on upper right extremity. Fell in September suffering a right proximal comminuted fracture and saw ortho. Surgery was canceled and rescheduled. Labs done as pre-operation (pre-op) and they cleared him/her. Review of the orthopedic physician's appointment records for the resident on 12/18/24, showed on 9/26/24, the resident's orthopedic appointment with the physician was canceled. Review of the resident's progress notes, showed no documentation of missed appointment on 9/26/24. Review of the orthopedic physician's appointment records for the resident on 12/18/24, showed on 10/3/24, the resident did not show up for his/her appointment. (There is nothing in the progress notes to show the surgery was rescheduled.) Review of orthopedic physician office visit notes dated 10/10/24, showed: -Chief complaint: Right upper extremity pain; -The resident was unable to follow up since last visit and they had been unable to successfully get medical clearance for surgery until then; -Physical exam: -Right upper extremity: Tenderness along the arm. Mobile fracture fragments. Shoulder and elbow range of motion not attempted due to pain. There was swelling over the elbow forearm and hand and weak elbow flexion and extension (motion of bending and straightening the elbow); -Plan: Resident agreed to proceed with surgery in the form of right humerus, open reduction and internal fixation (surgical procedure to repair broken humerus bone in upper arm. The surgeon makes an incision to realign the bone and uses hardware like screws, plates, rods or pins to hold the bone together); -The surgery would not be scheduled until there was medical clearance. Review of the resident's progress notes, showed: -On 10/14/24 at 2:50 P.M., the resident's surgeon's office called related to his/her 10/23/24 surgery. They needed surgery clearance. Staff called the resident's physician who stated they would fax the letter on 10/15/24; -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork; -No further documentation of why surgery was canceled and/or rescheduled. Review of the resident's physician's appointment records, showed: -On 10/23/24, the resident was scheduled for surgery; -On 11/8/24, the resident's follow up appointment was canceled because the surgery did not occur; -On 12/12/24, the resident was a no show for his/her appointment. Review of a transportation note dated 12/12/24, provided by the facility on 9/18/24, showed the resident's 12/12/24, appointment with the orthopedic physician was canceled because transportation failed to show. During interviews on 12/18/24 at 12:45 P.M. and at 2:20 P.M., Licensed Practical Nurse L said he/she was working on 12/12/24, and the transportation company did show up but left because the resident was not downstairs ready to go. He/She did not remember getting a call from the physician's office or rescheduling an appointment for him/her. The resident needed more help now with transferring, showering and dressing. He/She used to use a walker before the fall and now needed to use a wheelchair. During an interview on 12/18/24 at 1:10 P.M., the SSD said she sat up the transportation for resident appointments. The resident was supposed to go to the hospital for some appointments, but the SSD did not know the resident missed them. The SSD only had documentation for the 10/10/24 appointment that the resident made, the 10/23/24 surgery date that was missed and the 12/12/24 appointment that was missed. The SSD did not know about the other appointments and did not remember setting up transportation for them. The nurse would have made those appointments, and the SSD did not know why she was not given the information. The nurse was no longer working at the facility. Review of the resident's monthly physician visit notes dated 12/16/24, showed: -Resident feeling tired or poorly; -Has increased edema right upper extremity and both lower extremities. Was in sling, not using much. Will increase Lasix to two times a day and get labs; -Resident reported lower back pain, left hip joint pain, joint pain in both knees, muscle stiffness and stillness localized to one or more joints; -Not well appearing; -Comminuted right proximal humerus fracture. Now in sling. Cleared for surgery if needed. During an interview on 12/18/24 at 2:00 P.M., the resident said he/she had been in pain for several months. It did not hurt all of the time, mostly when he/she had to move the arm or turned the wrong way. It was usually at a level 3 out of 5. He/She was not able to do the things he/she used to do and it made him/her sad. He/She just wanted to have the surgery and get the arm fixed so he/she could take care of him/herself again. He/She was supposed to get surgery but when he/she got down to the lobby, the transportation people had left. This happened a lot. He/She tried to get there as soon as possible, but it took a while to get on the elevator and get downstairs. It was very frustrating because he/she just wanted to feel good again. During an interview on 12/19/24 at 12:15 P.M., the facility's physical therapy manager said the resident was referred to them in October and was still on their caseload. They were working to teach him/he how to function with one arm. The resident needed staff assistance with transferring, toileting, dressing and showering. They were not working with his/her right arm because it was still fractured and in a sling. Review of a note sent by the resident's orthopedic physician's office on 12/18/24, showed the office tried to make the appointment with the nursing facility but had not seen the resident since 10/10/24, and no one would call them back. During an interview on 12/18/24 at 2:10 P.M., Certified Nurse's Aide (CNA) F said he/she noticed brusing on the resident that morning during his/her shower. He/She did not notice it earlier since the resident was wearing long sleeves. The bruising was not there the prior week when he/she gave him/her a shower. The resident fell a few months ago and had some bruising and pain since them. He/She cannot move his/her arm very well. The CNA had to help the resident transfer out of bed into his/her wheelchair, shower, dress and toilet. The resident could not do these things by him/herself since the fall. During an interview on 12/18/24 at 2:00 P.M., the resident said he/she had a bruise on his/her arm from falling a couple of weeks ago. He/She did not remember the actual fall in 9/24. He/She is getting very confused and cannot remember things as well anymore. During an interview on 12/18/24 at 2:15 P.M., the orthopedic physician's nurse, said the resident was originally scheduled to have surgery on 10/10/24, and the resident did not have the approval from the physician's office to do it. They rescheduled the surgery for 10/23/24 and then could not do it because the resident had eaten that morning. They attempted to call the facility several times to set up an appointment to have the resident come into the outpatient clinic, but no one would help them set up the appointment. They finally got one set up for 12/12/24, and the resident did not show up. No one called the clinic to let them know the resident was not coming. They had been trying to set up another appointment, but no one would return their calls. During an interview on 12/18/24 at 3:00 P.M., the resident's physician office representative said they were aware the resident was scheduled for surgery and missed it on 10/23/24. The physician cleared the resident for surgery, and the physician thought the facility was rescheduling it. The facility did not notify the office the resident missed more appointments or the resident continued to have pain. They should have notified them about this. They rescheduled another x-ray for the resident because the facility reported he/she was having pain and swelling. The facility did not notify them about the new brusing on his/her right arm. They did not think the resident fell because he/she would not have been able to get him/herself up off the floor. It was probably due to complications with the fracture and should have been noticed prior to 12/18/24 if it was older brusing and reported to them. During an interview on 12/19/24 at 11:50 A.M., the resident's orthopedic surgeon said the resident's arm was broken and could not heal on its own. The resident had lost mobility in his/her upper extremities because he/she could not use his/her arm. Their office tried to set up an appointment with the resident several times. He was concerned because the resident was expressed being in a lot of pain when he saw him/her and might not be expressing this pain to the staff. The x-ray they took did not indicate a new break but the old fracture could be moving or he/she might have damaged it again and it was causing the swelling and bruising. The resident might never regain his/her mobility back. That is why it is so important to get the surgery done before any more damage occurs. No one from the facility notified his office that the resident continued to have bruising and swelling in his/her arm and hands. The arm would not get better unless the resident had the surgery, and he/she would continue to have pain. They had referred him/her to physical therapy to increase the strength in the arm, but it would not help if he/she could not move his/her arm. During an interview on 12/18/24 at 1:00 P.M., the corporate nurse said they had been having problems with the transportation company. They would come late or not show up at all. The charge nurse is responsible to set up appointment and once this is done, he/she will give the information to the SSD who will set up transportation. If the resident misses an appointment, the charge nurse should reach out to the physician's office to reschedule it. All of this information should be documented in the resident's medical record. She was not aware of why the resident missed his/her surgery date or that he/she missed several follow up appointments. Review of the resident's hospital records, dated 12/18/24, showed: -The patient presented with complaint of right arm pain; -The patient fell and developed right humeral fracture on 9/13/24; -Patient scheduled to be seen by ortho as outpatient, but his/her appointments were not kept by the nursing home; -Since fall, he/she could not follow up with orthopedic surgery; -As patient has difficulty moving right arm for a couple of months and has not seen the orthopedic doctor recently, he/she decided to come to the emergency room and be seen by ortho; -Patient was admitted for further evaluation and management. Review of the resident's X-ray results dated 12/19/24, showed a comminuted displaced multipart fracture of the proximal humerus is noted with significant displacement of fracture fragments with foreshortening (due to the positioning of the bone on the x-ray, the bone appears shorter than it actually is on the image, indicating the fracture fragments might be telescoped (one [NAME] is sliding partially inside another bone) into each other). During an interview on 12/27/24 at 1:00 P.M., the former Director of Nursing (DON) said he/she knew the resident was scheduled for surgery in October and it had to be rescheduled because the resident ate that morning. Staff should not have fed him/her. The charge nurse was responsible for rescheduling the surgery and letting the SSD know so she could set up transportation. No one ever told the DON the resident was still missing appointments. The staff should have reported the missed appointments so the DON could find out what happened and follow up. During interviews on 12/18/24 at 2:40 P.M. and at 4:00 P.M., the Administrator said she just started working at the facility a couple of months ago. She was not here when the resident fractured his/her arm and did not know he/she had missed the surgery. The resident should have gotten his/her surgery by now. When the first surgery was missed, they should have immediately rescheduled another one and made sure transportation was available. She knew the resident missed his/her transportation on 12/12/24 but thought it was just a regular appointment. She would have expected staff to document when appointments were made and/or missed and for them to follow up setting up a new appointment. The nurses were responsible for setting the appointments and then once the appointment was made, they would notify the SSD who would set up transportation. The staff should have had the resident ready to go when transpiration arrived. MO00246748

Based on observation, interview, and record review, the facility failed to consistently assess pain or provide treatment in a timely manner for one resident (Resident #10) who fell and fractured his/her arm on 9/13/24. The resident missed a surgery date on on 10/23/24 after staff fed the resident, which resulted in the surgery being canceled. The facility failed to ensure the resident was seen by his/her orthopedic physician despite several attempts by the office to set up appointments since the postponed surgery or set up a new date for the surgery. The facility also failed to complete a new pain assessment after the resident's arm was fractured. These failures resulted in pain and a loss of mobility for the resident. The sample was three. The facility census was 77. Review of the facility's Pain Management policy revised on 6/26/24, showed: -Purpose: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan and the resident's goals and preferences; -Policy: The facility will utilize a systematic approach for recognition, assessment and monitoring of pain; -Recognition of pain: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: --Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; --Evaluate the resident for pain and the cause(s) upon admission, during ongoing assessments and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain); --Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences; -Facility staff will observed for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: --Loss of function or inability to perform activities of daily living (ADLs) e.g. rubbing a specific location of the body, or guarding a limb or other body parts; --Behaviors such as: Resisting care, irritability, depressed mood or decreased participation in usual physical and/or social activities; --Skin conditions; -Pain assessment: The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g. nurses, practitioner, pharmacists and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident; --History of pain and its treatment (including non-pharmacological, pharmacological and alternative medicine treatment and whether or not each treatment has been effective; --Asking the resident to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident; --Reviewing the resident's current medical conditions; --Identifying key characteristics of the pain: --Duration of pain; --Frequency; --Location; --Timing; --Pattern (consistent or intermittent); --Radiation of pain; -Obtaining descriptors of the pain; -Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain; -Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood); -Current prescribed pain medications, dosage and frequency; -The resident's goals for pain management and his/her satisfaction with the current level of pain control; -Physical and psychosocial issues that might be causing or exacerbating the pain; -Pain management and treatment: -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -Factors influencing the choice of treatments include: -The cause, location and severity of resident's pain; -The resident's current medical condition; -The resident's current medications; -The resident's desired level of relief and tolerance for adverse consequences; -Potential benefits, risks and adverse consequences of medications; -Available treatment options; -Non-pharmacological interventions will include but are not limited to: -Environmental comfort measures; -Loosening any constrictive bandage, clothing or device; -Applying splinting (e.g. pillow or folded blanket); -Physical modalities (e.g. cold compress, warm shower/bath, massage, turning or repositioning); -Cognitive/behavioral interventions (e.g. music, relaxation techniques, activities, diversions, teaching the resident coping techniques and education about pain); -Pharmological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain; -Monitoring, reassessment and care plan revision: -Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences such as: -Tolerance; -Physical dependence; -Increased sensitivity to pain; -Constipation; -Sleepiness, dizziness and/or confusion; -Depression; -If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/24, showed: -Cognitively intact; -No behaviors or rejection of care; -Functional Limitation in Range of Motion: No Independent with all ADLs; -No pain; -No falls since admission or prior assessment. Review of the resident's progress notes, showed on 9/13/24 at 7:30 A.M., the resident told staff he/she fell and was able to pick him/herself up off the floor. Upon assessment the resident's right arm was painful to the touch and swollen. Staff placed a call to the resident's physician. An order was received to send the resident to the emergency room (ER) for evaluation and treatment. The resident able to move all other extremities without difficulty. At 7:40 A.M., staff called 911. At 8:10 A.M., emergency transfer staff in facility to transfer resident. At 12:40 P.M., the resident returned from the ER with a appointment to see the ortho (orthopedic physician) and with splint to be worn when up until appointment with ortho. At 12:45 P.M., staff called the resident's physician to inform him of his/her return. Review of the resident's hospital records, dated 9/13/24, showed: -Fall unclear mechanism. Right upper extremity injury. Facial involvement; -Final diagnosis: Closed right (RT) humeral fracture (a break in the upper arm bone), spiral (bone broken in a twisting motion) displaced (a displaced fracture means the pieces of the bone moved so much a gap formed around the fracture); -Relevant imaging results show RT humeral fracture and contusion (bruise) without fracture to nasal bone; -Patient sent back to nursing home with sling and follow up with ortho, ENT (ear, nose and throat specialist) and physician. Further review of the resident's progress notes showed: -On 9/14/24, no time noted, the resident remained on incident follow-up (IFU) related to his/her fall. He/She was in no apparent distress. Staff would continue to monitor. His/Her call light was in his/her reach and bed was in the lowest position. At 7:00 P.M., the resident's family were in the facility to visit. The resident's arm remained in the sling. Staff administered acetaminophen (pain reliever) three times on the shift. It was effective within an hour. There was bruising and swelling to the right arm. Staff provided assistance with the resident's activities of daily living. -On 9/15/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU. He/She did not complain of pain or distress at the time. At 7:00 P.M., the resident remained on observation, seated in his/her wheelchair. The staff administered acetaminophen three times during the shift. It was effective within an hour. Staff noted no signs of acute distress. The resident did have bruising on the bridge of his/her nose and the right arm. Staff provided assistance with all ADLs; -On 9/16/24 between 7:00 P.M. and 7:00 A.M., the resident remained on IFU/fall with injury. He/She had significant bruising to the entire right arm related to the fracture and a sling in place. At 4:30 P.M., the resident was up in his/her wheelchair propelling him/herself. No complaints of pain or discomfort at the time. His/Her arm was discolored and edematous (abnormally swollen with fluid); -On 9/17/24, no time noted, the resident's arm was extremely swollen and staff noted discoloration from shoulder to hand. His/Her hand was warm to the touch and his/her radial (pulse felt in the wrist) pulse was weak. Staff notified the resident's physician and sent the resident to the ER for evaluation; -On 9/18/24 at 12:20 A.M., the resident returned to the facility and no issues were found with his/her venous Doppler (a non-invasive ultrasound test that uses high frequency sound waves to examine circulations in a person's veins). There were no changes on the x-ray of his/her right hand since the initial x-ray. The resident denied pain. At 6:15 A.M., staff checked on the resident who voiced no pain. At 7:10 A.M., the resident would not get up to use the restroom or attempt to use his/her call light. -On 9/19/24, no time noted, the resident continued to wear an arm sleeve. Staff encouraged him/her to elevate his/her arm. No complaints of pain at the time. Review of the resident's electronic Medication Administration Record (eMAR) dated 9/1/24 through 9/30/24, showed: -An order dated 9/6/24 for diclofenac sodium (used to reduce pain, swelling and joint stiffness) tablet delay release 75 milligrams (mg). Give one tablet two times a day with food. Documented as administered 9/6 through 9/30/24; -An order dated 6/20/24 for acetaminophen oral tablet 325 mg. Give two tablets every four hours as needed for pain. Two tablets administered on 9/18/24 at 10:00 A.M., 9/28/24 at 9:00 A.M. and 1:00 P.M. and 9/19/24 at 5:00 A.M. and 7:00 P.M. -No documentation of administration for the rest of the month. Review of the orthopedic physician's office visit notes dated 9/19/24, showed: -The resident had been having right upper extremity pain for nine days; -The resident had an injury to the shoulder after a fall; -The resident complained of pain during the day and night and had sleep disturbances; -The resident complained of loss of strength and loss of motion; -At this point they had tried treatment options including activity modification, anti inflammatory medications, acetaminophen and bracing; -The symptoms were not improving with conservative measures; -PROMIS (Patient reported outcomes measurement information system measures health status from the patient's perspective) upper extremity score: 15 (severe dysfunction); -PROMIS pain score 76 (severe); -No current facility administered medication on file prior to visit; -Physical exam: Splint removed; -Skin: Diffuse healing ecchymosis (a widespread bruise, where the discoloration from leaked blood under the skin is spread out over a large area, rather than localized in one spot); -Right upper extremity: Tenderness along the arm. Mobile fracture fragments (pieces of broken bone); -X-ray showed a comminuted shaft fracture (the bone breaks into several pieces) with a long spiral fragment (the bone twists in a corkscrew shape); -Displaced comminuted right proximal humerus fracture (a severe break in the upper part of the arm where the bone shatters into multiple pieces and has shifted out of its normal position); -Plan: Therapy as tolerated to improve range of motion of wrist and hand. Another x-ray in a week to see if better alignment. Review of the resident's monthly physician's notes, dated 9/19/24, showed: -The chief complaint was a right humerus fracture; -The resident had new or worsening medical problems over the last month; -The resident was feeling tired or poorly; -The resident had a fall in the shower and complained of right arm pain. Sent to the hospital and found to have a right humerus fracture. Ortho consulted and to follow up as outpatient. The resident returned to the nursing home within hours. He/She was going to follow up with ortho today for surgery. His/Her right arm was ace wrapped and his/her hand was swollen; -Resident reported pain and feeling tired or poorly; -He/She reported muscle weakness; -He/She reported lower back pain, left hip joint pain, joint pain in both knees, muscle aches, muscle stiffness and stiffness localized to one or more joints; -He/She reported memory lapses or loss; -He/She reported skin symptoms; -Mild disorientation was observed and judgement was impaired. Review of the resident's progress notes, showed: -On 9/23/24 between 7:00 A.M. and 7:00 P.M., staff notified the resident's physician regarding swelling, redness and warmth in the right arm. A new order was received for doxycycline (used to treat and prevent infections) 100 mg, twice a day by mouth for ten days and lasix (used to treat water retention and swelling) 40 mg one time a day by mouth for ten days. The resident's sling remained intact and staff encouraged him/her to sleep on his/her left side; -On 9/24/24 between 7:00 A.M. and 7:00 P.M., the resident's sling remained in place. His/Her arm and fingers remained edematous; -On 9/29/24 at 8:30 P.M., resident seated in bed watching television, showing no signs and symptoms of pain or distress. Review of the physician's appointment records for the resident on 12/18/24, showed on 9/26/24, the resident's orthopedic appointment with the physician was canceled. Review of the resident's progress notes, showed no documentation of a missed appointment on 9/26/24. Review of the resident's eMAR dated 10/1/24 through 10/31/24, showed: Acetaminophen 325 mg. -No documentation of administration 10/1 through 10/31/24. Review of the resident's electronic Treatment Administration Record (eTAR), dated 10/1/24 through 10/31/24 showed: -An order dated 10/2/24 to assess for pain every shift; --On 10/2 through 10/31/24, all areas were left blank for both shifts for pain level. -No documentation of pain level assessed 10/1 through 10/30/24; -An order for diclofenac sodium 75 mg. Give one tablet two times a day for pain. -No documentation of medication administered 10/1 through 10/31/24. Review of the physician's appointment records for the resident on 12/18/24, showed on 10/3/24, the resident did not show up for his/her orthopedic appointment. Review of the resident's progress notes, showed no documentation of missed appointment on 10/3/24. Review of orthopedic physician office visit notes dated 10/10/24, showed: -Chief complaint: Right upper extremity pain; -The resident was unable to follow up since last visit and they had been unable to successfully get medical clearance for surgery until then; -Physical exam: -Right upper extremity: Tenderness along the arm. Mobile fracture fragments. Shoulder and elbow range of motion not attempted due to pain. There was swelling over the elbow forearm and hand and weak elbow flexion and extension (motion of bending and straitening the elbow); -Plan: Resident agreed to proceed with surgery in the form of right humerus, open reduction and internal fixation (surgical procedure to repair broken humerus bone in upper arm. The surgeon makes an incision to realign the bone and uses hardware like screws, plates, rods or pins to hold the bone together); -The surgery would not be scheduled until there was medical clearance. Review of the resident's progress notes, showed on 10/14/24 at 2:50 P.M., the resident's surgeon's office called related to his/her 10/23/24 surgery. They needed surgery clearance. Staff called the resident's physician who stated they would fax the letter on 10/15/24. Review of the resident's physician's appointment records, showed on 10/23/24, the resident was scheduled for surgery. Review of the resident's progress notes, showed: -On 10/23/24, the resident was up and ready for his/her appointment with his/her paperwork; -No documentation if surgery occurred or why it did not; -No documentation of notifications to physician or family representative; -No documentation of rescheduling of surgery. Review of the resident's eMAR dated 11/1/24 through 11/30/24, showed: Acetaminophen 325 mg. -No documentation of administration 11/1 through 11/30/24. Review of the resident's eTAR dated 11/1/24 through 11/30/24 showed: -Diclofenac Sodium 75 mg. No documentation of administration 11/1/24 through 11/30/24; -No assessment for pain documented 11/1 through 11/30/24. Review of the resident's monthly physician visit notes dated 11/1/24, showed: -Resident feeling tired or poorly; -Has chronic pain. Seen for follow up. Complained of left hip pain as well; -Seen in wheelchair, wearing a sling on upper right extremity. fell in September suffering a right proximal comminuted fracture and saw ortho. Surgery was canceled and rescheduled. Labs done as pre-operative (pre-op) and they cleared him/her. Review of the physician's appointment records for the resident on 12/18/24, showed on 12/5/24, the resident did not show up for his/her orthopedic appointment. Review of the resident's progress notes showed no documentation of an appointment on 12/5/24 or why it was missed. Review of the resident's eMAR dated 12/1/24 through 12/31/24, showed: Acetaminophen 325 mg. -No documentation of administration 12/1 through 12/18/24. Further review of the resident's eTAR dated 12/1/24 through 12/18/24, showed: -Diclofenac Sodium 75 mg. No documentation of administration 12/1/24 through 12/18/24; -No assessment for pain documented 12/1 through 12/18/24. Review of the resident's monthly physician visit notes dated 12/16/24, showed: -Resident feeling tired or poorly; -Has increased edema right upper extremity and both lower extremities. Was in sling, not using much. Will increase Lasix to two times a day and get labs; -Resident reported lower back pain, left hip joint pain, joint pain in both knees, muscle stiffness and stillness localized to one or more joints; -Not well appearing; -Comminuted right proximal humerus fracture. Now in sling. Cleared for surgery if needed. Review of an email sent by the resident's orthopedic physician's office on 12/18/24, showed the office staff tried to make the appointment with the nursing facility but had not seen the resident since 10/10/24, and no one would call them back. Observation and interview on 12/18/24 at 2:00 P.M., showed the resident sat in a wheelchair in the hallway with a sling on his/her right arm. His/Her head was slumped down, and he/she appeared to be tired. He/She said he/she was not in pain at the moment but had pain when he/she slept and/or moved his/her arm the wrong way. He/She bruised his/her arm in a fall but could not remember the date he/she fell . He/She could report the pain to staff when he/she had it, but it would not do any good. They only gave him/her over the counter medication when he/she complained, and it did not always help. The resident cried out in pain when a staff member attempted to pull his/her right sleeve down to observe the bruising. The brusing was dark purple, greenish and yellowish in color. It started at his/her wrist and extended to his/her shoulder. His/Her arm and hand appeared to be very swollen and red. During an interview on 12/18/24 at 2:10 P.M., Certified Nurse's Aide (CNA) F said the resident expressed pain whenever they had to move his/her arm to assess it. He/She noticed the increased bruising to the resident's right arm that morning when giving the resident a shower and reported it to the nurse. The resident's hands were also extremely swollen. The nurse told him/her it was probably older brusing from the original fall and to just keep an eye on it. The resident did not have this much bruising the week before when he/she gave him/her a shower. The resident complained of pain whenever he/she was transferred or needed help with dressing. If he/she was sitting still in his/her wheelchair, the resident would not complain of pain. During an interview on 12/26/24 at 12:30 P.M., Licensed Practical Nurse (LPN) C said he/she assesses pain by asking the resident if they are in pain and administering pain medications if they are in pain. He/She did not know anything about recording a pain level in the new eMAR. It is a new system, and he/she is still learning how to use it. He/She administered all medications as ordered. He/She did not know the system was not documenting the medication as not administered. He/She does not do formal pain assessments on residents and was not sure who did them or if one was done at all. During an interview on 12/18/24 at 3:00 P.M., the resident's physician office representative said they were aware the resident was scheduled for surgery and missed it on 10/23/24. The physician cleared the resident for surgery and the physician thought the facility was rescheduling it. The physician saw the resident several times after the fall, and he/she did not complain of pain to him those times. That is why he did not order more pain medications. The facility should have been doing pain assessments as soon as the resident returned from the hospital. The facility did not notify the office the resident missed more appointments or the resident continued to have pain. The facility should have notified the physician's office about this. Review of the resident's progress notes, showed on 12/18/24 at 1:30 P.M., staff contacted the hospital to find out the orthopedic surgeon's name. The staff member left a message with the surgeon's scheduler to get surgery rescheduled. At 1:40 P.M., staff contacted the resident's physician to inform him they were trying to reschedule the surgery, however they wanted another X-ray to ensure no additional injury occurred. At 2:20 P.M., the person who set up the schedule from the physician's office called back and indicated he/she would have to contact the orthopedic surgeon to see there was anything else on file. They would reschedule once he/she spoke to the physician and would get back with them no later than 12/21/24. The staff member explained they were requesting an x-ray and would forward it to the physician's office when the results were back. At 2:55 P.M., staff were notified by another resident, the resident had a bruise on his/her right arm. The nurse assessed the arm and noted bruising to the arm, forearm and elbow. The resident had slight swelling to the arm. The resident wore a sling related to his/her shoulder fracture. Staff notified therapy to evaluate the resident for a sling and right arm to ensure the sling was properly positioned as concerns were noted due to swelling and abnormal bruising. The bruising was most likely related to fracture, sling and acute issues involving the right arm. The X-ray company was notified and aware of STAT (immediate) order. Staff were waiting for the X-ray company to arrive. Review of the resident's electronic medical records on 12/18/24, showed no documentation of pain assessments conducted 8/24 through 12/18/24. During an interview on 12/26/24 at 11:15 A.M., Licensed Practical Nurse M said they changed from paper charts to electronic in September 2024. If there is an assessment for pain, LPN M asks the resident if they are in pain and enters in yes or no. Some of the electronic records do not allow him/her to enter a level. If a resident told the LPN he/she was in pain, then he/she would administer as needed medications or notify the physician if the resident did not have an order for pain medication. LPN M would document all of this in the resident's electronic medical record. LPN M does not do the actual pain assessment and did not know who was responsible for this. He/She gave the resident all of his/her ordered medications and did not know why the eMAR was not reflecting this. Review of an email sent by the facility Administrator on 12/26/24, showed the MDS coordinator was responsible for updating the MDSs and care plans. The expectation for updating these records was to obtain any records they could locate. No pain assessments were done between 9/24 and 12/18/24. During an interview on 12/30/24 at 12:15 P.M. the MDS Coordinator said she was responsible for performing pain assessments on residents quarterly or with a change in condion. This involved reviewing the resident's medication administration records and/or asking the residents their current pain levels. She had not been able to review the medication administration records for a couple of months, but she asked the staff about the resident's pain medication administration and they reported he/she was not having increased pain. She assessed the resident at his/her quarterly MDS update in August and then again on 11/18/24. She did not know why the updated MDS was not showing up in the system. She probably assessed him/her after he/she came back from the hospital with a fractured arm, but he/she was not sure and could not find the documentation. The resident should have been assessed for pain within 14 days after his/her arm was fractured. During an interview on 12/30/24 at 12:30 P.M., the Interim Director of Nursing (DON) said if a resident said they were in pain, staff should ask what level of pain they were experiencing from 1 to 10 and then document that on the eMAR. If the resident had pain medication ordered, it could be administered or if not, the staff member or nurse would notify the resident's physician to get something for the resident's pain. Then the staff would go back an hour later to see if the resident was still in pain and if so, would need to seek out a higher level of pain control. All of this needed to be documented so they could care plan potential pain issues. If pain levels and times were not being documented, then the staff would not know when to administer as needed medications. It would be harder to assess a resident for increased pain without the documentation. Pain assessments were supposed to be done every three months. They would be automatically done if a resident had chronic pain and updated if a resident expressed new pain. The DON could not find a pain assessment in Resident #10's medical file. There should have been one done when the resident came back from the hospital after he/she fractured his/her arm. During an interview on 12/18/24 at 3:15 P.M. and on 12/30/24 at 1:00 P.M., the Administrator said the resident should have been assessed for pain after he/she came back from the hospital with the fractured arm. He/She was not working at the facility when this occurred and did not know the resident was not assessed. If the resident was having pain when staff were providing care, this should have been documented and the physician notified. MO00246748

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status to the extent possible, for one resident (Resident #34) who experienced a significant weight loss of 20 pounds from a weight on 5/14/24 of 136.6 pounds to 116.0 pounds on 6/26/24, resulting in a 15% weight loss in 6 weeks. During this timeframe, the facility's Registered Dietician (RD) completed a nutritional assessment and recommended health shakes three times a day. Staff failed to provide the supplements as ordered. The sample was 18. The census was 79. Review of the facility's undated nutrition/unplanned weight loss policy, showed: -Assessment and recognition: -Nursing staff will monitor and document the weight and dietary intake of residents; -The staff and physician will define the individuals current nutritional status and identify individuals with weight loss and at risk for significant impaired nutrition; -The staff will report to the physician significant weight loss or gain or any abrupt or persistent change from baseline appetite or food intake; -Treatment/management: -The staff and physician will identify pertinent interventions based on causes and resident condition, prognosis, and wishes; -Treatment decisions should consider all pertinent evidence and relevant issues and not based solely on laboratory test results; -The physician will authorize appropriate interventions; -The staff and physician will review and consider existing dietary restrictions and modified consistency diets; -Monitoring: -The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions; -When medical conditions or medication related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident's responses, goals, wishes, prognosis, and complications; -The physician and staff will collaborate to address any issues related to weight and nutrition related to severe or prolonged impairment of nutritional status and weight loss. Review of Resident #25's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/24, showed: -Moderate cognitive impairment; -Verbal behaviors toward staff; -Staff provide partial to moderate assistance with meals; -No swallowing disorders; -Weight: 131 pounds; -Loss or gain of 5 percent to 10 % in the last six months: no or unknown; -Mechanically altered diet; -Diagnoses included schizophrenia, Parkinson's disease, respiratory failure, and irregular heartbeat. Review of the resident's care plan, updated 4/29/24, showed: -Problem: potential for weight loss/gain; -Goals: April weight: 131; -Interventions: regular diet, health shakes three times a day. Staff provide dietary supplements and health shakes as ordered, staff provide meal set up in the resident's room, monitor the resident's meal intake and offer substitute for uneaten foods. Monitor weights monthly and notify the physician of a weight loss or gain of five pounds. Review of the resident's monthly weight tracking form for 2024, showed: -January: 137 -February: 132.8 -March: 133.7 -April: blank Review of the resident's hospital summary, dated 4/11/24, showed: -Reason for hospitalization : altered mental status; -Additional instructions: risk for malnutrition; -Signs: unplanned weight loss, loss of appetite, lack of food interest, tiredness and low energy, changes in mood or concentration; -Instructions: nutritional supplement liquid, such as high calorie, high protein supplement two to three times a day and continue for 30 days after discharge. Review of the resident's monthly weight tracking form, showed May 2024 blank, no documented weight. Review of the resident's dietary history and screening form, dated 5/14/24, showed: -Weight: 136.6 pounds; -Weight is stable; -Diet order: Regular; -Supplement orders: bedtime and three times a day; -Meal consumption average: 50-75%; -Multiple missing teeth; -Snack/supplement preferred: health shakes with meals, three times a day. Review of the resident's June 2024, physician order sheet, showed: -Diet: regular; -Patient care: health shakes three times a day. Review of the resident's monthly weight tracking form, showed June 2024 weight of 102.0 pounds. Observation and interview on 6/24/24 at 9:08 A.M., showed the resident in his/her room in his/her wheelchair. The resident appeared thin. A breakfast plate noted on the over bed table. The breakfast plate covered. The resident said he/she was not very hungry and did not want what was on the plate. Staff did not offer to cut his/her sausage or toast. No health shake noted on the tray. The morning meal dietary ticket did not reflect health shakes with meals. Observation on 6/25/24 at 8:52 A.M., showed the resident in his/her room. The breakfast tray did not contain a health shake supplement. The meal ticket showed regular diet and no ordered supplements noted on the meal ticket. Observation and interview on 6/25/24 at 12:19 P.M., showed the resident in his/her room. The noon meal tray sat on the over the bed table. The resident had consumed approximately 25% of the meal. No health shake supplement noted. The resident said he/she had not been offered shakes with meals. During an interview on 6/25/24 at 1:43 P.M., Licensed Practical Nurse (LPN) E said the resident can have behaviors at times and prefers to eat in his/her room. Staff should monitor and notify the charge nurse if the resident is noted to have a decreased appetite or is not eating much. When the dietician provides a recommendation, the nurse should notify the physician and write the order into the chart. A dietary form is also filled out and taken to the kitchen. The meal ticket should reflect the dietary orders and include supplements. The supplemental health shakes are placed on the tray by the kitchen staff. Staff should review the meal ticket before serving the resident for accuracy. Observation interview on 6/26/24 at 12:06 P.M., showed the resident in his/her room. The resident did not eat the lunch meal of pasta, chicken, or mixed vegetables. The resident said he/she told the staff he/she did not want the served food when the lunch tray was delivered to his/her room. Staff did not offer an alternative meal. The resident said he/she was hungry and requested ice cream. Observation on 6/26/24 at 12:32 P.M., showed the resident in his/her room eating ice cream, no additional food noted. During an interview on 6/26/24 at 1:08 P.M., the Director of Nursing (DON) said the resident got weighed in his/her wheelchair. The resident refused to transfer out of the wheelchair for staff to obtain the wheelchair weight, so staff would weigh the wheelchair when the resident went to bed to deduct the weight of the wheelchair. During an interview on 6/27/24 at 10:33 A.M., CNA A said the aides pass the trays to the residents. The kitchen puts the meal tickets on each resident tray. If a resident has supplements on the meal ticket, the supplements are sent with the meal trays. He/She does not know how the meal order is changed. The aides are supposed to check the meal ticket before giving the resident the food. He/She worked yesterday day shift and gave the resident his/her meal trays. Neither of the meal trays had a supplement included. The resident appeared thin and he/she slept frequently. The resident also needs help with food to be cut up, but if the resident is sleeping, CNA A would try to remember to return to the room but he/she had forgotten. During an interview on 6/27/24 at 7:02 A.M., the Administrator said when the resident went to bed, staff obtained the wheelchair weight. The resident's weight after deducting the wheelchair was 116 pounds. When staff compared the current weight to the hospital weight in May, the resident has experienced around a 20 pound weight loss. When staff reviewed previous orders, the resident should have received health shakes with meals. In addition, the facility is going to add double portions. When the dietician makes recommendations, the charge nurse is responsible to notify the physician and write the order onto the physician order sheet. The nurse also fills out the dietary order sheet and notifies the kitchen of the change. Health shakes are provided by the kitchen. The supplement should be noted on each meal ticket. The registered dietician and physician should be notified when weight loss is noted. Physician and registered dietician recommendations should be followed.

Based on observation, interview and record review, the facility failed to maintain safe water temperatures, between 105 degrees Fahrenheit (F) and 120 degrees F, for the residents on the fifth floor. Of 11 residents on the fifth floor, six cognitively impaired residents were identified, who were physically able to gain access to the sink or shower, (Residents #20, #22, #3, #21, #18 and #19). Water temperatures on the fifth floor shower room that were accessible to residents, registered up to 152 degrees F. Water temperatures in resident rooms at the sink measured up to 158 degrees F. The facility also did not maintain hot water temperatures below 120 degrees F on two additional floors (third and fourth). In addition, the facility failed to assure interventions for falls were implemented, falls were tracked and investigated or residents were appropriately assessed following falls to decrease the risk of recurring falls and potential injury, for two of 14 sampled residents (Residents #8 and #2). The census was 85. Review of the United States Consumer Products Safety Commission (CPSC) avoiding hot water scalds recommendations, showed: -The majority of injuries and deaths involving tap water scalds are to the elderly and children; -CPSC recommends hot water heaters be lowered to 120 degrees F; -Most adults will suffer third-degree burns (full thickness burn. This type of burn destroys the outer layer of skin and the entire layer beneath) occur if exposed to water temperatures of 150 degrees F for two seconds; -At 140 degrees F, third-degree burns occur if exposed for five seconds; -At 131 degrees F, third-degree burns occur if exposed for 25 seconds. 1. Observation on 10/1/15 at 8:56 A.M., showed Residents #20 and #22 shared a room. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/4/15, showed: -Independent with locomotion on and off the unit; -Limited assistance required for personal hygiene. Review of the residents care plan, last updated on 8/4/15 and in use during the survey, showed: -Potential for alteration in cognitive function, short/long term memory impairment, difficulty with daily decision making: -Resident can be forgetful; -Assist with decision making/discuss potential outcome of decision to be made; -Potential for self care deficit related to cognitive and functional factors. [DIAGNOSES REDACTED]. -Resident is able to care for him/herself; -Resident will ambulate on and off the unit with a wheeled walker. Review of the resident's physician order [REDACTED]. -May be up as desired; -[DIAGNOSES REDACTED]. During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert to self, place and sometimes date and time. Review of Resident #22's annual MDS, dated [DATE], showed: -Psychomotor retardation (decreased level in activity such as sluggishness, staring into space, staying in one position and moving very slowly) continuously; -Total dependence of one staff person required for dressing, toilet use and personal hygiene. Review of the resident's care plan, dated 7/17/15 and in use during the survey, showed: -Potential for alteration in cognitive function, short/long term memory impairment, difficulty with daily decision making: -Assist with decision making/discuss potential outcome of decision to be made; -Potential for self care deficit related to cognitive functional impairments: -Up as desired with wheel chair; -Assist with personal care as needed; -Alteration in position ability, decreased safety awareness related to stroke and cognitive problems. Review of the resident's POS, dated 9/11/15 through 10/10/15, showed: -May use wheelchair; -[DIAGNOSES REDACTED]. During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert to self and sometimes place. Observation on 10/1/15 at 10:03 A.M., showed the temperature of the hot water at the sink fixture in the residents' room measured 136 degrees F when recorded for two minutes using a dial type thermometer. Observation and interview on 10/1/15 at 10:31 A.M., during a two minute water test using a dial thermometer, showed the water temperature at the hand washing sink in the residents room measured at 155 degrees F. Steam came out from the faucet. As the water ran, Licensed Practical Nurse (LPN) R entered the room and stated he/she needed to wash his/her hands. LPN R placed his/her hands into the running water and said oh,[***] You're trying to burn me. That water gets hot. Observations on 10/1/15 between 1:48 P.M. and 2:00 P.M., during a two minute water test using a calibrated dial thermometer, showed the following temperatures: -The hot water at the hand washing sink in the residents' room measured 128 degrees F. Steam rose from the faucet. 2. Review of Resident #3's quarterly MDS dated [DATE], showed: -Extensive assistance of one person required for transferring, ambulation and eating; -Total assistance of one person required for dressing, hygiene and bathing; -No limitations in range of motion. Review of the resident's care plan, last updated on 8/10/15 and in use during the survey, showed: -Potential for alteration in cognitive function: -[DIAGNOSES REDACTED]. -Cognitive level varies day to day, sometimes resident has increased confusion; -Assist with decision making and potential outcome of decisions made; -The resident wandered; -Potential for self care deficit related to Alzheimer's: -The resident attempts to walk without assistance. He/she is usually unsteady on his/her feet. A wheelchair may be used as needed; -Up as desired without the use of assistive device; -Easily distracted, episodes of disorganized thinking/speech, periods of lethargy (drowsiness), varying mental function: -Re-orientation as needed; -Allow time for understanding and responses; -Potential for change in mood/behavior related to Alzheimer's dementia: -Resident is not aware of social boundaries. He/she walks in and out of other resident's rooms. Review of the resident's POS, dated 9/11/15 through 10/10/15, showed: -[DIAGNOSES REDACTED]. -Up as desired with a Merriwalker (a walker-chair ambulation device that allows a resident to be independent with ambulation). During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert to self and sometimes place. Observation on 10/1/15 at 10:15 A.M., showed the resident up in his/her merriwalker at the nurses station. He/She answered yes/no questions. Observations on 10/1/15 between 10:32 A.M. and 10:40 A.M., during a two minute water test using a calibrated dial thermometer, showed the following water temperatures: -The hot water at the hand washing sink in Resident #3's room measured 138 degrees F. Steam rose from the faucet. 3. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Inattention, difficulty focusing attention; -Disorganized thinking; -Altered level of consciousness, continuously; -Independent with locomotion on and off the unit; -Extensive assistance of one person required for personal hygiene; -Use of a walker. Review of the resident's care plan, last updated on 8/12/15 and in use during the survey, showed: -Potential for alteration in cognitive function, short/long term memory impairment, difficulty with daily decision making related to dementia: -[DIAGNOSES REDACTED].> -Resident is frequently confused, redirect as needed; -Assist with decision making/discuss potential outcome of decision to be made; -Potential for decline in activity participation: -The resident is able to get to and from activities him/herself with a wheeled walker; -Potential for self care deficit related to dementia and cognitive deficit, wheeled walker used for ambulation: -Up as desired with a wheeled walker. Review of the resident's POS, dated 9/11/15 through 10/10/15, showed: -Up as desired with assistance, may use walker; -[DIAGNOSES REDACTED]. During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert to self, place and sometimes time/date. Observations on 10/1/15 at 10:32 A.M. during a two minute water test using a calibrated dial thermometer, showed the following water temperatures: -The hot water at the hand washing sink in the resident's room measured 158 degrees F and steam rose from the faucet. 4. Observation on 10/1/15 at 9:06 A.M., showed Residents #18 and #19 shared a room which was directly across from the shower room. Review of Resident #18's POS, dated 9/18/15, showed a [DIAGNOSES REDACTED]. Review of the resident's admission MDS, dated [DATE], showed: -Independent with locomotion on and off the unit; -Limited assistance of one person required for personal hygiene and toilet use; -Physical help of one person required for bathing. Review of the resident's care plan, dated 10/1/15 and in use during the survey, showed: -Potential for alteration in cognitive function, short/long term memory impairment, difficulty with daily decision making: -Assist with decision making/discuss potential outcome of decision to be made; -Potential for self care deficit: -Up as desired with wheelchair; -Assist as needed with personal care and showers. During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert and oriented to self, place and time. Review of Resident #19's quarterly MDS, dated [DATE], showed: -Disorganized thinking present and fluctuates; -Independent with locomotion on and off the unit; -Extensive assistance of one person required for personal hygiene; -Use of a wheelchair. Review of the resident's care plan, last updated 8/26/15 and in use during the survey, showed: -Potential for alteration in cognitive function, short /long term memory impairment, difficulty with daily decision making: -[DIAGNOSES REDACTED].> -Assist with decision making/discuss potential outcome of decision to be made; -Potential for decline in activity participation: -The resident self propels in wheelchair throughout the facility; -Potential for self care deficit: -Up as desired with the use of a wheelchair; -Assist as needed with personal care and showers. Review of the resident's POS dated 9/11/15 through 10/10/15, showed: -[DIAGNOSES REDACTED]. -May use wheelchair. During an interview on 10/1/15 at approximately 10:00 A.M., Nurse R identified the resident as being alert and oriented to self and sometimes place. Observation on 10/1/15 at 10:06 A.M., showed the hot water temperature in the shower room directly across from Resident #18 and #19's room measured 152 degrees F at the tub fixture and 140 degrees at the sink fixture when tested with a dial type thermometer for two minutes. Observation on 10/1/15 at 10:40 A.M., during a two minute water test using a dial thermometer, showed the hot water temperature in the shower room measured 148 degrees F at the sink. Steam rose from the faucet. The shower room door stood open to all residents on the fifth floor. 5. Observations on 10/1/15 at 10:03 A.M., during a two minute water test using a calibrated dial thermometer, showed the following water temperature: -The hot water at the hand washing sink in Room 504 measured at 140 degrees F with steam rising. 6. Observation on 10/1/15 at 10:06 A.M., during a two minute water test using a calibrated dial thermometer, showed the water temperature at the hand washing sink in the third floor hall bathroom measured at 143 degrees F. Steam rose from the faucet. 7. Observation on 10/1/15 at 10:09 A.M., during a two minute water test using a calibrated dial thermometer, showed the water temperature at the shower in the third floor shower room measured at 130 degrees F. 8. During an observation and interview on 10/1/15 at 10:50 A.M., the maintenance supervisor showed a surveyor the water heaters in the boiler room. There were four gas water heaters. The maintenance supervisor identified one as being only for the kitchen, two that work together to supply water to the floors and one that is currently not in use to supply water to the floors. Observation of the two water heaters used to provide hot water to the floors, showed a temperature between 148 and 150 degrees F. The maintenance supervisor said the water temperature should be lower than that. The facilities sprinkler inspection was completed on 9/29/15 and he believes this may be the cause for the hot water. He would adjust the water temperature, but it may take 24 hours to cool down. 9. During an interview on 10/1/15 at 11:08 A.M., the administrator said she just found out that some of the resident rooms on the 5th floor do get their hot water from the water heater that provides water to the kitchen, which is set at 180 degrees F. She will be ordering a booster that will increase the water temperature to the dishwasher without having to set the water heater so hot. 10. During an interview on 10/1/15 at 12:15 P.M., the maintenance supervisor said he checks the hot water tank thermometer dials weekly on Mondays. He last checked it on 9/28/15. It is usually set on 140 degrees F because by the time the hot water leaves the tank and travels to the fifth floor, it cools. 11. Observation on 10/1/15 between 1:35 P.M. and 1:40 P.M., during a two minute water test using a calibrated dial thermometer, showed the following water temperatures: -The hot water at the hand washing sink in Room 432 measured at 124 degrees F; -The hot water at the hand washing sink in Room 430 measured at 125 degrees F. 12. Observations on 10/1/15 between 1:48 P.M. and 2:00 P.M., during a two minute water test using a calibrated dial thermometer, showed the following temperatures: -The hot water at the hand washing sink in Residents #20 and #22's room measured 128 degrees F and steam rose from the faucet; -The hot water at the hand washing sink in Resident #21's room measured 124 degrees F; -The fifth floor common shower room at the whirlpool tub measured 130 degrees F with steam; -The shower room door stood open to all residents on the fifth floor. 13. During an observation on 10/1/15 at 2:57 P.M., during a two minute water test using a calibrated dial thermometer, showed the water temperature at the shower in the fourth floor shower room measured at 126 degrees F. 14. Review of Resident #8's care plan dated 8/14/15, showed the following: -Decline in activity; -Obesity and mild cognitive impairment; -Falls on 4/26/15, 5/2/15, 6/17/15 and 8/14/15; -Reported a fall on the way to the bathroom 9/25/15-9/26/15. Review of the resident's quarterly MDS dated [DATE], showed a brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15 indicates the resident is cognitively intact). Review of the resident's hospital discharge instructions dated 9/17/15, showed he/she had been readmitted to the facility on [DATE], following a knee replacement. The resident's room was located on the second floor of the facility. Review of the incident log dated 9/26/15, showed the resident fell at 2:00 A.M. He/she stated he/she got up to use the bathroom and lost his/her balance. During an interview on 10/3/15 at 2:00 P.M., the resident said he/she tripped over his/her oxygen cord when going to the restroom (on 9/26/15). He/she estimated he/she laid on the floor for approximately 40 minutes. A resident on the first floor in the room directly below his/hers heard him/her yelling for help and came to check on him/her. When Certified Nursing Assistant (CNA) T found him/her, the resident asked why it took him/her so long to get there. CNA T told the resident he/she did not hear the yelling for help because he/she had earbuds in. The resident said the CNAs got him/her off of the floor by using a sheet. During an interview on 10/6/15 at 9:40 A.M., LPN F said the following: -A resident fell to the floor on the night shift of Friday 9/25/15 around 3:00 A.M.; -He/she was on break, outside smoking when CNA T alerted him/her that a resident had fallen to the floor; -He/she did not assess the resident until he/she was back in bed; -He/she was not present when the resident was transferred from the floor to the bed; -He/she was unaware of the amount of time the resident was on the floor calling for help; -He/she said the fall policy, states he/she should have assessed the resident before he/she was gotten off of the floor. During an interview on 10/6/15 at 10:00 A.M., CNA T said the following: -The resident was not on the floor during the second floor rounds, he/she must have fallen while CNA T did rounds on the first floor; -After CNA T completed the rounds on both floors, the resident was heard yelling and found on the floor; -CNA T placed a pillow under the head of the resident and went to find assistance from two other CNAs to get the resident up off of the floor; -He/she said they did not use the Hoyer lift because it does not lower to the floor, so a sheet was used to pick the resident up off of the floor; -After the resident was back in bed, CNA T went to find LPN F outside the facility on break. Review of Resident #24's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 7/31/15, showed: -BIMS score of 15. During an interview on 10/6/15, the resident said the following: -He/she heard a loud Kaboom while in his/her restroom on the first floor; -He/she heard someone yelling, help over and over; -Once finished in the bathroom, he/she got in his/her wheelchair, rolled down the hall to the elevator, rode upstairs, down that hall and to the fallen resident's room. The second floor resident was laying on the floor and said he/she had knee surgery and he/she was worried about his/her knee; -He/she estimated that the resident had been laying on the floor for 15 to 20 minutes, yelling for help; -A CNA came around the corner with a Hoyer lift; -He/she did not see the CNAs get the resident off of the floor, but the Hoyer lift remained in the hallway. Review of the resident incident log dated 9/26/15 at 2:00 A.M., showed Resident #8 stated he/she got up to use the restroom and lost balance and scraped his/her forearm. Resident fell to his/her left side. Resident denied hitting head. Reported a little soreness to his/her side, no bruising or swelling upon observation. Review of the nurse's notes dated 9/26/15, showed the following: -7:00 A.M., resident stated he/she fell , left forearm scraped; -10:00 A.M., showed left knee surgery site with 29 staples remaining intact and resident on observation for fall. Review of the nurse's notes dated 9/27/15 at 11:00 A.M., showed the resident's inner aspect of the left knee was swollen. The resident said it was swollen because he/she fell on it the other night. Review of the facility fall protocol dated April 2013, showed it failed to address the following: -Protocol for getting a resident off of the floor properly; -Instruction on when a resident should be assessed; -What staff members should be present when removing a resident from the floor. During an interview on 10/6/15 at 8:30 A.M., the Director of Nursing (DON) said she had not heard a report of a CNA wearing earbuds. 15. Review of the Resident #2's POS dated 9/11/15 through 10/10/15, showed the following: -[DIAGNOSES REDACTED]. Review of the resident's nurses notes, showed on 5/20/15 at 2:30 P.M., the resident reported he/she lost his/her balance while walking with his/her walker. He/she let his/her walker go, hit the wall as he/she fell and hit his/her head and back. Review of the facility's fall log, showed no documentation the resident fell on [DATE]. Review of the resident's nurses notes, showed: -On 7/20/15 at 8:10 A.M., the resident was found on the floor, lying on his/her right side. Bruise to the left arm. Complaints of back pain; -On 8/22/15 at 1:00 P.M., staff called to the room, the resident was lying on the floor in front of the bed on the left side. He/she exhibits confusion. Ambulance called. Review of the facility's fall log, showed no documentation that the resident fell on [DATE] or 8/22/15. Review of the resident's care plan dated 4/21/15 and updated 7/17/15, showed no reported falls for the quarter. No updates were added for the falls on 7/20/15 or 8/22/15. It showed he/she had an unsteady gait. Review of the resident's nurse's note dated 9/16/15 at 8:30 A.M., showed the resident reported to staff he/she fell outside when smoking and hit his/her head. Review of the resident's care plan, showed an entry dated 9/16/15, where the resident went outside for a group smoke break and stated he/she fell on his/her buttocks, hit his/her left shoulder and head. The intervention noted was to encourage the resident to stay with the group at smoking times and to stay near a light source so he/she could see. Review of the facility's fall log, showed no documentation the resident fell on [DATE]. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility drained the hot water tank, bought thermometers for staff to check the hot water, placed signs on doors affected to not use the hot water, inserviced staff to ensure they check hot water temperatures prior to bathing/caring for residents and conducted hourly checks of the hot water. The facility still needed to complete in-services to a small amount of staff and determine how they will implement their plan of correction on a long-term basis and keep their systems in place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). MO 973

Based on observation, interview and record review, the facility failed to identify, assess, measure, stage and provide treatment to prevent or help heal pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility identified one resident with pressure ulcers (expanded sampled Resident #23). One of 14 sampled residents (Resident #6) not identified with pressure ulcers by the facility was found to have pressure ulcers. Facility staff failed to provide appropriate pressure ulcer treatment for [REDACTED]. Review of the facility's pressure ulcer/skin breakdown clinical protocol, located in a binder at the nurse's stations, available to staff and last revised February 2014, showed: -The nursing staff and attending physician will assess and document a resident's significant risk factors for developing pressure sores; -The nurse shall describe and document/report the following: -Full assessment of pressure sore including location, staging, length, width and depth, presence of drainage or necrotic (dead) tissue; -Pain assessment; -The resident's mobility status; -Current treatments, including support surfaces; -Active diagnoses. Review of a nursing skin assessment policy and procedure, undated and provided by the Director of Nursing (DON) on 10/7/15, showed: -Skin assessments will be done upon admission and weekly thereafter; -Charge nurse will perform head to toe assessment weekly; -Any break in skin integrity must be measured length, width and depth; -The physician must be notified to obtain treatment orders; -The DON must be notified, staging will be determined by the physician and/or a registered nurse (RN); -Any identified pressure ulcers are monitored by the DON weekly. Review of the Licensed Nurse Weekly Skin Assessment form, showed the following: -This form should be completed weekly on all residents per facility policy; -Any areas of skin requiring treatment should have a thorough record of documentation in addition to this form located elsewhere in the chart per facility protocol; -Answer yes or no: Any reddened areas that remain after 30 minutes of pressure reduction; -Answer yes or no: Any rashes, bruises, open [MEDICAL CONDITION], cuts, lacerations, blisters or skin tears; -Answer yes or no: Any open ulcers (indicate even if being treated). 2. Review of Resident #6's medical record, showed the following: -A Braden scale (an assessment used for predicting pressure ulcer risk), dated 7/21/15, showed a score of 24 (no interventions needed); -An August 2015 face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. -A significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/15, showed the following: -A Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive impairment), showed a score of 12 (8-12, moderately impaired); -Limited assistance of one staff for transfers, ambulation, dressing, hygiene and bathing; -Not steady, only able to stabilize with assistance moving from seated to standing position, walking, turning around, moving on/off the toilet and surface-to-surface transfers. Review of the resident's care plan, dated 8/3/15, showed the following: -Problem: Potential for self care deficit related to generalized muscle weakness; -Interventions: Transfer with assist, up with assist/unsteady gait, monitor for gait/balance changes, assist as needed with activities of daily living and adjust care to meet needs; -Problem: Potential for impaired skin integrity related to history of [MEDICAL CONDITION] and falls; -Interventions: Assist to maintain healthy skin integrity, monitor skin every shift and report changes, treatment to affected areas as directed, report changes and charge nurse to do weekly assessment. Review of the resident's August 2015, physician's orders [REDACTED]. -A standing order for weekly skin assessments; -An order, dated 8/12/15, for hospice with the admission [DIAGNOSES REDACTED]. Review of the resident's 8/11/15 through 9/10/15, treatment administration record (TAR), showed the following: -Staff initialed the dated space on 8/23/15, for the weekly skin assessment; -Staff provided no information on the back of the TAR concerning the 8/23/15, assessment; -Staff provided no Licensed Nurse Weekly Skin Assessment form to accompany the 8/23/15, assessment. Review of the hospice progress notes dated 8/25/15 and 8/28/15, showed the resident had three small superficial open areas on his/her back, skin tears to both upper extremities and a left heel blister not open, right heel pressure ulcer open area (no further description of any of the areas). Further review of the resident's 8/11/15 through 9/10/15, TAR, showed the following: -Staff left blank the dated space for the 8/30/15, weekly skin assessment; -Staff provided no information on the back of the TAR concerning the 8/30/15, assessment. Further review of the hospice progress notes dated 9/1 and 9/4/15, showed three small superficial open areas on the back, skin tears to both upper extremities, left heel blister unopened, right heel pressure two are scabbed over and one open area 0.5 centimeters (cm) by 0.5 cm on the right lower extremity. Review of the 9/4/15, wound report showed no wounds or pressure ulcers listed. Further review of the resident's 8/11/15 through 9/10/15 TAR, showed the following: -Staff initialed the dated space on 9/6/15 for the weekly skin assessment; -Staff wrote on the back of the TAR, 9/6/15, no new skin issues; -Staff provided no Licensed Nurse Weekly Skin Assessment form to accompany the 9/6/15 assessment. Review of the resident's 9/11/15 through 10/10/15, POS, showed the following: -A standing order for weekly skin assessments; -An order, dated 7/21/15, to apply triple antibiotic ointment and dry dressing to the right elbow daily until healed; -An order, dated 7/28/15, to apply triple antibiotic ointment and dry dressing to the left elbow daily until healed; -An order, dated 9/4/15, for protective heel boots while in bed; -No order for a pressure relieving mattress; -No treatment orders for other skin issues/pressure areas. Further review of the hospice progress notes, showed on 9/11/15, skin turgor poor, back/bilateral heels and right lower extremity issues (no other description noted). Review of the wound report dated 9/11/15, showed no wounds or pressure ulcers listed. Further review of the resident's 9/11/15 through 10/10/15, TAR, showed the following: -Staff left the 9/15/15, dated space blank for the weekly skin assessment; -Staff provided no information on the back of the TAR concerning the 9/15/15, assessment. Review of the wound report dated 9/18/15, showed no wounds or pressure ulcers listed. Further review of the resident's hospice progress notes, dated 9/21/15, showed the hospice staff notified the hospice case manager and facility Licensed Practical Nurse (LPN) B the resident was so weak that it took two certified nurse aides (CNA) to get him/her in the shower The hospice staff could not make sense of what the resident was saying and he/she was losing his/her train of thought. His/her back had sores and heels have ulcers. Further review of the resident's 9/11/15 through 10/10/15, TAR, showed the following: -Staff initialed the dated space for the 9/22/15, weekly skin assessment; -Staff documented on the back of the TAR, No new open areas; -Staff provided no Licensed Nurse Weekly Skin Assessment form to accompany the 9/22/15, assessment. Review of the wound report dated 9/25/15, showed no wounds or pressure ulcers listed. Further review of the resident's hospice progress notes, dated 10/2/15, showed multiple skin tears to both arms, new skin tear to back and superficial open wound to coccyx (tailbone). Review of the nurse's notes, showed no note for 10/2/15. Further review of the resident's 9/11/15 through 10/10/15, POS, showed no 10/2/15, treatment order for the open wound to the resident's coccyx. Observation on 10/1/15 at 1:33 P.M., showed the resident lay in bed positioned on his/her back. No pressure reducing mattress was provided. Observations on 10/2/15, showed the resident in bed positioned on his/her back at 6:48 A.M., 8:34 A.M. and 10:23 A.M. No pressure reducing mattress was provided. Observations on 10/5/15 at 3:41 P. M., showed the resident lay in bed positioned on his/her back. No pressure reducing mattress was provided. At 5:30 P.M., he/she sat in a wheelchair in the unit dining room awaiting supper. Observations on 10/6/15, showed the following: -At 7:51 A.M., the resident lay in bed positioned on his/her back. No pressure reducing mattress was provided; -At 10:37 A.M., the hospice nurse shaved the resident as he/she lay on his/her back. Further review of the resident's 9/11/15 through 10/10/15, TAR, showed the following: -Staff initialed the dated space for the 10/6/15, weekly skin assessment; -Staff provided no documentation on the back of the TAR for the 10/6/15, assessment; -Staff provided no Licensed Nurse Weekly Skin Assessment form to accompany the 10/6/15, assessment. Observation and interview on 10/7/15 at 6:36 A.M., during a skin assessment of the resident, showed the following: -The resident lay in bed with no pressure reducing mattress; -No protective boots or sleeves; -Pressure ulcer on the right heel contained black eschar (dead tissue) in the center; -Pressure ulcer on the back of the left heel with eschar; -Dressings on both arms; -Pressure ulcer on the coccyx with black eschar; -Multiple open areas on his/her back and spine; -Bloody areas on the sheets at the areas of his/her back and feet; -During an interview at this time, CNA S said the resident's wounds on his/her back, coccyx, and heels had been present for a couple of weeks. During an interview on 10/7/15 at 6:58 A.M., the DON said the resident did not have any wounds. Observation and interview on 10/7/15 at 7:50 A.M., showed LPN B measured, treated and dressed the following pressure ulcers/open areas: -Back, upper left of the spine open area 0.5 cm by 0.5 cm, a shallow open area with a pink wound base; -Back, upper left of the spine open area 3 cm by 1.5 cm, a shallow open area with a pink wound base; -Back, upper left of the spine open area 2 cm by 1 cm, a shallow open area with a pink wound base; -LPN B said the wounds on the back were pressure ulcers from him/her laying on his/her back and classified them as unstageable (not stageable due to coverage of the wound bed by slough); -Back, center on spine 1 cm by 1 cm, a shallow open area with a pink wound base; -Back, right side next to the spine 4 cm by 2.5 cm, a shallow open area with a pink wound base; -Back, left side next to the spine 1.5 cm by 1 cm, a shallow open area with a pink wound base; -Coccyx pressure ulcer measured 3 cm by 3 cm with two areas of eschar ; -Eschar 1.5 cm by 2 cm; -Eschar 1 cm by 1 cm; -LPN B said he/she did not know what stage and asked this surveyor if it was a Stage II pressure ulcer; -Outer aspect of the right heel pressure ulcer measured 4 cm by 4 cm with brown and black eschar; -Eschar 1.5 cm by 2 cm; -Back of the left heel pressure ulcer measured 1.5 cm by 1.5 cm with black and brown eschar; -Eschar 1 cm by 1.5 cm. During an interview on 10/7/15 at 9:05 A.M., the Director of Clinical Services for hospice, said the idea behind hospice and a facility is the collaboration of care. Hospice nurses and staff nurses should collaborate with one another. Nurses from hospice did skin assessments and home health aides provided baths. The facility recently lost the resident's hospice binder and a new one was taken to them which would show wounds, and skin assessments. She knew there were spots noted on the residents back on 10/6/15, but was not aware what else the notes showed. Observation and interview on 10/7/15 at 10:15 A.M., showed the resident lay in bed positioned on his/her back with no pressure reducing mattress. At this time, Family Member (FM) U said he/she had known for two weeks that the resident had wounds on his/her backside. The FM said he/she did not see the wounds as he/she always left the room during incontinence care. During an interview on 10/7/15 at 1:40 P.M., the DON said she would expect any CNA who became aware of a resident's skin tear or pressure ulcer to inform the charge nurse as soon as possible. The charge nurse would then inform her. If a hospice staff found a skin tear or pressure ulcer, the charge nurse should be notified. All weekly skin assessments should be accompanied by the Licensed Nurse Weekly Skin Assessment form. Nurse Practitioner (NP) A assessed and staged the resident's wounds that day and put the information in the progress note. Review of the resident's progress note, dated 10/7/15, showed Nurse Practitioner A wrote, Patient assessed with [REDACTED]. Coccyx wound and bilateral heel ulcers noted. Appears to be Kennedy ulcer based on presentation and patient situation (A Kennedy ulcer is a pressure ulcer that is characterized by rapid onset and rapid tissue breakdown). During an interview on 10/8/15 at 10:00 A.M., NP A said he/she saw the resident on 10/7/15, per the facility's request. He/she also saw the resident approximately two weeks ago. NP A said he/she was told by the facility the resident had a Kennedy ulcer that had formed in the past few hours to his/her coccyx. The facility did not inform him/her of any wounds prior to 10/7/15. He/she was not aware of any documentation prior to 10/7/15 to show any wounds had existed to the coccyx, heel or spine. Based on the information provided by the facility, the assessment of the wound and the fact there was no prior documentation of the wound; he/she classified the wound to the resident's coccyx as a Kennedy ulcer. There was a smaller than dime size spot to the center of the coccyx wound of eschar. NP A said it takes one to two weeks for eschar to form but it depends on the circumstances. If a resident is not repositioned in the bed, eschar can form quicker. He/she was not aware of any documentation completed by hospice prior to 10/7/15, that showed the resident had a wound to the coccyx. If he/she had been aware of documentation of a coccyx wound on 10/2/15, he/she would have to assume the wound to the resident's coccyx was a Stage II pressure ulcer (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister). NP A said he/she only assessed the wounds to the resident's coccyx and heels. He/she did not look at the resident's spine. The wounds to the resident's left and right heel both had eschar on them and he/she would classify these wounds as a Stage I (An observable pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues) or Stage II. Review of the Licensed Nurse Weekly Skin Assessment for the resident, dated 10/7/15, provided by the facility on 10/8/15 at 11:32 A.M., showed the following -Right elbow skin tear, 2 cm by 2 cm, treatment in place; -Right elbow skin tear, 2 cm by 2 cm, treatment in place; -Left upper arm, skin tear measured 3 cm by 2 cm; -Left forearm, skin tear measured 3 cm by 2 cm; -Left elbow, skin tear measured 1.5 cm by 1.5 cm; -Left underarm, skin tear measured 3.5 cm by 2 cm; -Back blister that opened, 0.5 cm by 0.5 cm, Stage II; -Left back blister that opened, 3 cm by 1.5 cm, Stage II; -Right back blister that opened, 2 cm by 1 cm, Stage II; -Second back blister that opened, 1 cm by 1 cm; -Right back by spine blister that opened, 4 cm by 2.5 cm; -Coccyx 2 cm by 3 cm; -Right outer aspect heel, 4 cm by 4 cm; -Left back of heel 1.5 cm by 1.5 cm; -Kennedy ulcers to coccyx and right and left heels, Unstageable per nurse practitioner (See note dated 10/7/15); -Staff failed to provide further staging, description, color, drainage or odor of the wounds. 5. Review of Resident #23's medical record, showed: -A Braden scale assessment, dated 7/10/15, showed staff documented a score of 18 (low risk); -A quarterly MDS, dated [DATE], showed: -No risk for pressure ulcers; -No unhealed pressure ulcers; -No pressure ulcers present prior to assessment; -No other ulcers, wounds or skin problems; -Skin ulcer treatments, application of non surgical dressing; -A mobile limb preservation progress note, dated 8/5/15, showed left buttocks ulcer; -A nurse's note, dated 8/5/15, showed the physician visited today new orders for a dressing to the left hip; -A POS dated 9/11/15 through 10/10/15, showed an order dated 4/6/15 for a dressing change daily to the left buttock. Review of the facility's wound reports for the month of September 2015, showed the following: -Prompts to document the wound type that included pressure, surgical and other; -Prompts to document the length, width, depth, location and treatment of [REDACTED].>-Prompt to include the onset date of the wound; -On 9/4/15, a 1.0 cm by 1.0 by 0.1 cm pressure ulcer to the left hip with an onset date of 4/6/15, with no documentation of the stage; -On 9/11/15, a 1.5 cm by 1.0 cm by 0.1 cm pressure ulcer to the left hip with no onset date listed and no documentation of the stage of the wound; -On 9/18/15, a 0.5 cm by 0.5 cm by 0.1 cm pressure ulcer to the left hip with no onset date listed and no documentation of the stage of the wound; -On 9/25/15, a 1.0 by 1.0 by 0.1 area to the left hip, no documentation of the type of wound, stage or onset date; -No prompt for staff to document the stage of a wound. Observation and interview on 10/7/15 at 11:51 A.M., showed a pressure ulcer to the resident's left buttocks. The wound bed was visible and pink. LPN B measured the ulcer as 1.5 cm by 2 cm. LPN B failed to measure the depth. LPN B said the area was an unstageable pressure ulcer. 6. During an interview on 10/7/15 at 1:40 P.M., the DON said pressure ulcers should be staged weekly. There is no space on the wound log that prompts the documentation of a pressure ulcers stage. Only a doctor or an RN can stage a pressure ulcer. If she is aware a resident has a wound, she is responsible to assess and document on the wound weekly and as needed. The stage of a pressure ulcer, plus all wounds should be documented on the wound report. The wound sheet should also be filled out. This prompts staff to document any rashes, bruises, open areas, cuts, skin tears, blisters, dry skin, swelling and any treatments being provided. She would expect all open areas to have a treatment order. Full skin assessments are completed weekly and are the responsibility of the charge nurse. These are on every resident, regardless if they do or do not have any wounds. She would define a Stage II pressure ulcer as a wound with the first layer of skin damaged. An unstageable wound would include a wound with eschar on it. She would expect staff to document the presence of a wound and treatment orders should be obtained immediately. It is the responsibility of the facility to obtain wound treatment orders, obtain the supplies needed to treat the wound and provide the wound treatment and not the responsibility of hospice. If the wound report shows the presence of a pressure ulcer, this should also be reflected on the resident's MDS. The facility has daily meetings to discuss all wounds. This is where the MDS coordinator gets the information needed to properly document on the MDS assessment.

Based on observation, interview and record review, the facility failed to provide protective oversight for three of three sampled residents, who the facility identified as being at risk for wandering and falls, two who utilized wheelchairs and one who utilized a merrywalker (Residents #1, #2 and #3). One resident (Resident #1), wheeled his/her wheelchair through an open door, into a stairwell and fell down a flight of stairs. The facility also failed to provide a safe environment for one of four sampled residents utilizing side rails (Resident #4), by failing to complete a side rail assessment and ensure the side rails were functional and in good repair. The resident fell out of bed during care, sustaining injuries. The census was 85. 1. Review of Resident #1's face sheet, showed an admission, to room 415 of the facility's fourth floor, on 4/19/11. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/9/11, showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Wandering-Presence and Frequency: Has the resident wandered? Yes, behavior occurred one to three days per week; -Wandering-Impact: Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs)? Yes; -Limited assistance of staff for bed mobility; -Extensive assistance of staff for transfers and locomotion on unit; -Total assistance of staff for locomotion off unit, dressing, eating, toileting, personal hygiene and bathing; -Fall history: Fall during the month before admission? Yes. Review of the resident's care plan, dated 5/9/11, showed the facility identified the following problems: -Short/Long term memory impairment; -Severely impaired cognitive skills for daily decision making; -Falls related to impaired cognition. The care plan interventions showed the following: -Personal safety alarm (PSA) when in bed and wheelchair; -Position wheelchair in common area by nurse's desk for close observation. The care plan did not identify and address the resident's wandering and risk of injury related to his/her wandering. Review of the resident's significant change MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Wandering-Presence and Frequency, has the resident wandered? Yes, behavior occurred one to three days per week; -Wandering-Impact: Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs)? Yes; -Limited assistance of staff for bed mobility; -Extensive assistance of staff for transfers and locomotion on unit; -Total assistance of staff for locomotion off unit, dressing, eating, toileting, personal hygiene and bathing; -Fall history: Fall during the month before admission? Yes. -Weight loss; -Gastrostomy tube placement; -IV (intravenous) antibiotics received; -Daily use of a restraint. Review of the resident's care plan, updated 6/7/11, showed the facility added the problem of the resident's decreased safety awareness and the use of a lap buddy when in his/her wheelchair. The care plan did not identify the resident's wandering and risk of injury related to his/her wandering. Review of the resident's nurse's notes, dated 7/18/11 at 8:00 P.M. through 7/30/11 at 3:00 A.M., showed the following: -Alert and oriented to self only; -Unable to make needs known; -Spoke out loud incoherently, confused; -Propelled self in wheelchair through the halls; -PSA in use; -Lap buddy in use; -Floor mat by bed as a fall precaution; -Remains in eyesight at all times, will continue to monitor (Only noted once; on 7/24/11 at 1:00 P.M.). The nurse's notes did not contain any entries regarding the resident wandering toward the stairwell and having to be redirected. Review of the resident's nurse's notes, dated 7/30/11, showed the following: -2:00 P.M.: The resident propelling self in his/her wheelchair through the halls; -9:30 P.M.: Nurse called to the fourth floor stairwell. Observed the resident on the landing with his/her wheelchair on top of him/her. Alert and oriented to himself/herself. Trying to get up. 911 emergency called. -9:35 P.M.: Ambulance arrived. Resident transferred to hospital. -9:45 P.M.: Physician, family and Director of Nurses (DON) notified. Observation on 8/5/11 at 11:30 A.M., showed the following, description of the fourth floor stairwell, where the resident fell : -From the hallway on the fourth floor, an open doorway, which measured 43 inches in width, led to an 11 foot open area with a downward set of stairs on the left, an elevator on the right and a window directly ahead. -A magnetic device held the door open into the area, to the right, toward the elevator. -The window was 8 feet 4 inches directly across from the doorway. -From the top of the stairs to the elevator measured 11 feet. -From the middle of the open doorway to the middle of the top of the downward stairs, measured 2 1/2 feet. -From the top of the stairs to the landing, between the fourth and third floors, were 7 steps. The third and second floors had the same layout. Review of the resident's emergency hospital discharge records, dated 7/30/11, showed abrasions (skin scrape), dementia (memory problems) and head injury (concussion). Review of the resident's next nurse's note, conducted on 7/31/11 at 10:30 A.M., showed a note, dated 7/31/11 at 2:00 A.M., the resident returned to facility, alert and oriented to self and in no distress. Further review of the resident's medical record, conducted on 7/31/11 at 10:30 A.M., showed no further nurse's notes an no new interventions added to prevent the resident or any resident from falling down the stairs. Observation on 7/31/11 at 10:10 A.M., during the tour of the facility, showed a Velcro strap across the doorway of the fourth floor stairwell, with the word "Stop" on it. Observation on 7/31/11 at 10:45 A.M., showed the resident asleep in bed. During an interview on 7/31/11 at 4:07 P.M., Certified Nurse Aide (CNA) O said the resident was on his/her assignment on the evening of 7/30/11. The resident had eaten and been put to bed, but then started moving and trying to get out of bed. The CNA got him/her up into his/her wheelchair, put him/her in the sitting area in front of the nurse's station and began to put other residents to bed. While toileting another resident, the CNA heard staff calling for help, ran toward the stairwell and found the resident on the landing at the bottom of the stairs. The CNA had not told anybody he/she had gotten the resident out of bed. Staff were supposed to watch the resident and keep him/her from going to the stairs. The resident needed a lot of redirection because he/she wandered toward the stairs, but this was the first time he/she had fallen down the stairs. The CNA said staff had been afraid a resident might fall down the stairs and that the open door to the stairs was an accident waiting to happen. Staff were very frightened when the resident fell because they thought the resident had gotten badly hurt. Staff were concerned, when residents were transported down the elevator, to the dining room, that a resident could roll backwards down the stairs due to the limited amount of space between the stairs and the elevator. During an interview on 7/31/11 at 3:18 P.M., Nurse M said the resident had dementia, could be combative at times, roamed the halls and had gone toward the stairwell. He/She worked the evening the resident fell down the stairs and had last seen him/her when administering the resident's tube feeding. He/She had been in another resident's room doing a treatment when staff said the resident had fallen down the stairs. When he/she arrived the resident lay at the bottom of the landing with the wheelchair on top and his/her lap buddy still attached. The nurse assessed the resident and called 911. Nurse M said he/she thought the resident was in bed and did not know staff had gotten him/her up. During an interview on 7/31/11 at 10:50 A.M., Nurse I said the resident fell down the stairs the night before and he/she did not know how the resident got to the stairs. The resident was alert and oriented to self only, had dementia, wandered on the floor, followed staff and did not know where he/she was going. Nurse I said the Velcro stop sign was on the fourth floor doorway for the wandering residents. The nurse identified two other residents that wandered on the floor; Residents #2 and #3. During an interview on 7/31/11 at 3:37 P.M., CNA N said the resident was confused had a [DIAGNOSES REDACTED]. The resident had gone toward the stairwell on several occasions and staff had to redirect him/her. On 7/30/11, at around 8:30 P.M., he/she helped the nurse administer eye drops to another resident when he/she heard staff calling for help from the stairwell. He/She saw the resident at the bottom of the landing on his/her back with the wheelchair on top. The nurse called 911. The CNA had not been told why the Velcro stop sign had been put across the doorway. During an interview on 7/31/11 at 11:05 A.M., the Director of Nurses (DON) said the resident fell down the stairs the night before, on 7/30/11 at around 9:30 P.M. The resident was very confused, didn't know where he/she was going and answered to name only most of the time. On Thursday, 7/28/11, he/she had been made aware the resident got too close to the fourth floor stairwell and had gotten past the Velcro stop sign. She thought of an intervention to attach an IV pole to the wheelchair and raise it high enough to prevent the resident from going through the doorway leading to the stairwell, but didn't put it into place and the resident fell down the steps two days later. (The IV pole would attach to the wheelchair and extend vertically up toward the ceiling. When the resident wheeled into the doorway, the IV pole would hit the top of the doorframe and prevent the resident from going any further) She ordered anti-tip devices, on 7/28/11, by overnight shipment. The anti-tip devices didn't arrive until after she and the administrator left on Friday evening, 7/29/11. She said she would apply an IV pole and anti-tip devices to the resident's wheelchair at this time, 7/31/11. The DON identified two other residents that wander; Resident #2 who sat in a wheelchair and Resident #3 who sat in a merrywalker. During an interview on 7/31/11 at 12:10 P.M., the administrator said the staff made her aware of the resident's fall the night before, on 7/30/11 at around 10:00 P.M. She knew the resident had gone toward the stairwell on 7/28/11, and the DON had not put the intervention in place at that time. She said the DON had just put IV poles and anti-tip devices on the wheelchairs and the merry walker of residents who were at risk of wandering and falling down the stairwell, on 7/31/11. Observation on 7/31/11 at 1:48 P.M., showed the resident propelled himself/herself in a wheelchair with an IV pole and anti-tip devices. During an interview at this time, the DON said she had just attached an IV pole and anti-tip devices to the resident's wheelchair. The DON demonstrated how the resident could propel in his/her wheelchair, but could not go through the doorway because the IV pole would hit the top of the doorway. She said the resident would not have fallen down the stairs if she had put an IV pole on his/her wheelchair sooner. During an interview on 7/31/11 at 2:08 P.M., CNA D said the resident was confused and moved all over the floor in his/her wheelchair. He/She had seen the resident go toward the stairwell and two days ago a CNA stopped him/her. CNA D said something needed to be done about the stairwell because the door was open and he/she was afraid a resident might fall. During an interview on 7/31/11 at 2:34 P.M., CNA J said the resident was very busy, confused and moved around a lot. When the resident was up in his/her wheelchair staff had to redirect him/her, four to five times a day, from the doorway leading to the stairwell. At times, the resident went through the Velcro sign across the doorway. This had been going on for the past two months. Staff that work on the fourth floor knew the resident wandered and had poor safety awareness. The Velcro stop sign had been used on the fourth floor stairwell doorway since March, but it was not always on the doorway. Staff and residents would forget to put the Velcro sign back across the doorway once they went through. Staff members had talked about how unsafe the stairwell was and were afraid a resident would fall down the stairs. During an interview on 7/31/11 at 2:40 P.M.,CNA K said the resident propelled himself/herself all over the floor. Everyone tried to keep up with the resident and redirect him/her when he/she went toward the stairway. One day he/she came to work and a Velcro sign was across the doorway. The CNA could not remember when this occurred. The Velcro sign was used to keep the confused residents from going to the stairwell, but staff and residents would forget to put the Velcro sign up at times. During an interview on 7/31/11 at 3:06 P.M., CNA L said the resident was very confused, used his/her wheelchair to move around, roamed the halls and went into other resident's rooms. He/She had heard that staff must redirect the resident to keep him/her from going to the stairwell, but he/she hasn't seen the resident at the stairwell. The facility put the Velcro sign up to stop the confused residents from going to the stairwell. He/She said when the resident first came to the facility he/she tried to walk down the stairs and that was the reason the Velcro sign was placed on the door. During an interview on 7/31/11 at 3:32 P.M., Certified Medication Technician (CMT) E said the resident was very confused, moved around a lot and liked to follow staff. The resident was very strong and propelled the wheelchair with his/her feet. The CMT had seen staff redirect the resident from the stairwell. He/She had never been told why the facility put the Velcro stop sign on the door and did not know how long it had been there. During an interview on 7/31/11 at 4:32 P.M., CNA P said he/she had taken care of the resident once, but knew he/she wandered up and down the halls. He/She had seen the resident go toward the stairs, but staff would bring him/her back. The CNA had been concerned about the stairwell and afraid a resident might fall down the stairs. During the interviews conducted with staff members on 7/31/11, nine of ten, said they were aware of the resident's wandering toward the stairs for months and that facility management was also aware. All said it was common knowledge that the resident needed to be closely watched. During an interview on 7/31/11 at 5:05 P.M., the administrator said the facility had put measures in place to ensure Residents #1, #2 and #3 could not fall down the stairwell. She said the DON informed her Resident #1 had been close to the stairs and that she did not put interventions in place until that day, 7/31/11. During an interview on 8/5/11 at 9:05 A.M., the resident's physician said the resident had dementia and staff should not have allowed the resident access to the stairwell. He said at other facilities, any doors leading to a stairwell were kept closed at all times and he did not know why the doors leading to the stairwells at this facility were kept open. During an interview on 8/5/11 at 2:30 P.M., the facility's owner said the DON told him Resident #1 tried to go down the stairs, on 7/28/11. The DON informed him of her idea to attach an IV pole to the wheelchair, but he was concerned the resident could flip the wheelchair over backwards and injure himself/herself when the IV pole caught the top of the doorway. He had the DON order anti-tip devices for the wheelchair, by overnight shipment, on Thursday 7/28/11. They were delivered, on Friday 7/29/11, at 4:00 P.M., after the administrator and DON had gone for the day. The interventions were not put into place until, Sunday 7/31/11, after the surveyor arrived to investigate a complaint regarding the resident falling down the stairs in his/her wheelchair. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory problem; -Cognitively impaired; -Wandering: not exhibited; -Extensive assistance of staff for transfer; -Total assistance of staff for personal hygiene, bathing, dressing and grooming. Review of the resident's care plan, updated 5/26/11, showed the following: -Short/Long term memory loss related to dementia; -Easily distracted, periods of restlessness related to dementia; -Potential for falls related impaired cognition. During an interview on 7/31/11 at 11:05 A.M., the DON said she should put an IV pole and anti-tip devices on the resident's wheelchair because he/she wandered at times looking for his/her family. She said the resident moved slowly, so staff could grab him/her before he/she reached the stairs. During an interview on 7/31/11 at 10:50 A.M., Nurse I said the resident wandered on the nursing unit at times, but he/she could not recall whether the resident had gone toward the stairwell. During an interview on 7/31/11 at 2:08 P.M., CNA D said the resident wandered on the unit and he/she had seen the resident go toward the stairwell. During an interview on 7/31/11 at 2:34 P.M., CNA J said the resident wandered on the unit and had gone to the stairwell, but had not gone past the doorway. During an interview on 7/31/11 at 2:42 P.M., CNA K said the resident wandered on the unit and went toward the stairwell door looking for his/her family. During an interview on 7/31/11 at 3:06 P.M., CMT E said the resident did wander on the unit, but stopped before getting to the stairs. During an interview on 7/31/11 at 3:37 P.M., CNA N said the resident went toward the stairs two to three times a week and staff members would turn him/her around. During an interview on 7/31/11 at 4:07 P.M., CNA O said he/she had seen the resident go toward the open door, but the resident moved slowly and was easily directed. During an interview on 7/31/11 at 4:23 P.M., CNA Q said the resident wandered the halls looking for his/her family. Staff had to redirect the resident from the elevator which is directly across from the stairwell. He/She did this frequently and at times would take the Velcro stop sign down saying its in his/her way. Staff would take the resident to the TV area where he/she would stay away for a little while, but then return to the stairwell. Observation on 7/31/11 at 1:52 P.M., showed the resident sat in the TV room across from the nurse's station. An IV pole and anti-tip devices were on the resident's wheelchair. The DON demonstrated, how the resident was unable to go through the doorway to the stairwell. During an interview on 7/31/11 at 12:10 P.M., the administrator said the DON had just put IV poles and anti-tip devices on the wheelchairs and the merry walker of residents who were at risk of wandering and falling down the stairwell, on 7/31/11. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -No wandering behavior; -Extensive assistance of staff for transfers. Review of the resident's care plan, updated 5/18/11, showed the following: -Short/Long term memory loss related to dementia; -Falls related to cognitive impairment, merrywalker use; -Behaviors: pulling on others, attempting to stand/walk. During an interview on 7/31/11 at 10:50 A.M., Nurse I said the resident wandered occasionally, moving around on the unit. During an interview on 7/31/11 at 11:05 A.M., the DON said the resident wandered on the unit in his/her merrywalker, but had never gotten to the stairwell. During an interview on 7/31/11 at 1:56 P.M., the DON said she could not guarantee the resident could not reach the stairs in his/her merrywalker and he/she would attach an IV pole to his/her merrywalker, at this time, to ensure the resident could not go through the doorway and reach the stairs. During an interview on 7/31/11 at 2:08 P.M., CNA D said the resident wandered on the unit in his/her merrywalker. During an interview on 7/31/11 at 2:34 P.M., CNA J said the resident wandered the hallways in his/her merrywalker. During an interview on 7/31/11 at 2:40 P.M., CNA K said the resident wandered in the hallway by the nurse's station. During an interview on 7/31/11 at 3:32 P.M., CMT E said the resident wandered in the hallway in his/her merrywalker, but not by the stairwell. During an interview on 7/31/11 at 3:37 P.M., CNA N said the resident wandered in the hallway in his/her merrywalker. During an interview on 7/31/11 at 4:07 P.M., CNA O said the resident wandered in his/her merrywalker, but not toward the stairwell. During an interview on 7/31/11 at 4:23 P.M., CNA Q said the resident wandered in his/her merrywalker toward the nurse's desk. During an interview on 7/31/11 at 12:10 P.M., the administrator said the DON had just put IV poles and anti-tip devices on the wheelchairs and the merry walker of residents who were at risk of wandering and falling down the stairwell, on 7/31/11. 4. Review of Resident #4's hospital history and physical, dated 2/6/11, showed: -[DIAGNOSES REDACTED]. -Poor historian, not oriented and nonverbal. -Bedridden due to chronic medical problems. Review of the resident's physical therapy evaluation, dated 5/31/11, showed: -Prior level of function: confined to bed or reclining wheelchair. Non-ambulatory, required maximum assistance during transfers and bed mobility; -Reason for referral: recent increase in bilateral lower extremity joint limitation; -Precautions/complications: fall risk. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Mobility: wheelchair with Hoyer lift (a mechanical lift); -No order for side rail usage. Review of the resident's quarterly MDS, dated [DATE], showed: -Short and long term memory problem; -Moderately impaired cognitive skills; -Hallucinations, delusions; -Total dependence on two people for bed mobility; -Total dependence on two people for transfers; -Non-ambulatory; -Total dependence on one person for hygiene; -Functional limitation in range of motion: impairment on both sides, upper and lower extremities -No falls since admission; -Bed rails used daily. Review of the resident's care plan, updated on 6/6/11, showed: -Problem: Falls related to impaired cognition, psychotropic medication, functional impairment, dependency on staff for mobility, wheelchair use and Hoyer lift use for transfers. -Interventions: Anticipate and meet needs. Use both side rails for bed mobility and safety. -Goal: Resident will remain free from falls through next review. During an interview on 7/1/11 at 12:20 A.M., CNA F said, on 6/13/11, the resident lay flat in his/her bed which was positioned at mid-height from the floor with both side rails up and a bed mat on the floor. He/She rolled the resident toward the side of the bed facing the door and the rail went down by itself. The resident rolled over and belly-flopped onto the mat. CNA F knew the side rail was "loose and wiggly" and had told "people" about it. The evening and day shift staff had previously put in a work order. The side rail had been loose since at least the end of May. If someone had come and fixed the side rail, it did not help. Aides talked amongst themselves that it was only a matter of time before an accident would happen. The aides decided to use a floor mat by the resident's bed because they did not trust the side rail. They had not received instructions from a nurse to use a floor mat, but decided amongst themselves. During an interview on 6/30/11 at 4:30 P.M., Nurse G said CNA F ran to Nurse G to help after the resident fell . Nurse G found the resident belly down on a floor mat. CNA F said when he/she turned the resident in bed the side rail popped and broke, the resident belly flopped, "BAM". CNA F told him/her, he/she had been telling "them" for a while about the broken side rail. The resident's blood pressure was elevated and his/her cheek was reddened. The bed was in the high position. The DON and the administrator did not interview Nurse G about the incident. Review of the nurse's notes, dated 6/13/11 at 2:00 A.M., showed the resident was receiving perineal care by an aide when the bed rail broke and the resident fell face down on a floor mat. The nurse was alerted by an aide to assist. The nurse found the resident on the floor mat with an abrasion/laceration to his/her left buttock caused by the bed rail, right arm edema and bruising and an abrasion on the right side of his/her head. Call placed to the doctor and orders received to send the resident to the hospital. Resident's respirations even and unlabored. No signs/symptoms of distress. Alert and oriented to self. Unable to make needs known. Blood pressure 182/118 (normal range, 90-140/60-90), pulse 126 (normal 60 to 100 beats a minute). Resident was asked if he/she was in pain and his/her response was, "I don't know". Emergency medical services arrived at 2:15 A.M., applied a neck stabilizer and took the resident to the hospital. Review of the Emergency Medical Service's Patient Care Report, dated 6/13/11 at 8:23 A.M., showed the nurse reported the resident fell while receiving care from facility staff. The resident did not loose consciousness, his/her head hurt and he/she had a reddened area. The resident said, "My back hurts". Review of the facility's June 2011 Incident Tracking Log, showed no record of the resident's fall on 6/13/11. During an interview on 6/17/11 at 1:00 P.M., CNA H said prior to the resident's fall, he/she had been telling nurses and other staff that the resident's side rails needed to be repaired. The resident had full side rails on both sides of his/her bed, but did not move while in bed. Other staff had complained about the side rails being in disrepair and when they move the resident, the rails fall. During an interview on 6/30/11 at 1:45 P.M., CNA D said she requested work orders for fixing the side rails on the resident's bed three times over the last few months. During an interview on 6/30/11 at 2:30 P.M., CMT E said he/she did not know if there was a protocol for repairs needed. He/She just told the maintenance man whenever he/she saw him. Observation on 6/30/11 at 2:45 P.M., showed the right bottom side rail of the resident's bed was bent so at its widest point an approximate 6 1/2 inch gap was between the top of the mattress and the side rail. On the left side of the bed, the side rail was not bent, but was positioned such that a 6 1/2 inch gap showed between the bottom rail and the mattress. During an interview on 6/30/11 at 2:45 P.M., CNA A said both side rails of the resident's bed were dangerous because the space between the mattress and the rails was too great and because the right side rail fell easily when bumped or touched. The CNA saw a maintenance person work on the rail, but it was not any better. Observation on 6/30/11 at 2:50 P.M., showed CNA B touched the resident's right side rail with one finger, pushing it gently towards the mattress, the rail fell through it's holder with the bottom posts touching the floor and the upper rail below the top of the mattress. During an interview on 6/30/11 at 2:50 P.M., CNA B said the resident had fallen twice due to the side rail failure. (No other information could be found to show the resident fell more than once) During an interview on 6/30/11 at 4:15 P.M., maintenance worker C said he/she had no work order, but remembered he/she fixed the resident's side rails a while back. He/She did not know there was still a problem. He/She knew the diameter of the mounted bed post which the side rail slid into was too large, so that if the CNAs did not position the bed rail into the post and assure it "clicked" into locked position, the bed rail would not be stable. Review of the facility's policy, dated 12/07, "Proper Use of Side Rails", included the following: -Purpose: To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. -General guidelines: -An assessment will be made to determine the resident's symptoms or reason for using side rails. -The use of side rails as an assistive device will be addressed in the resident care plan. -The resident will be checked periodically for safety relative to side rail use. -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. During an interview on 7/6/11 at 3:50 P.M., the Assistant Director of Nurses said there was no side rail assessment completed for this resident and the few side rail assessments the facility did have were out dated. The nurse's judgment would determine if a side rail was needed. During interviews on 6/30/11 at 4:00 P.M., and 7/6/11 at 3:50 P.M., the DON said she did not investigate the incident and did not talk to the staff involved because they knew what happened and thought the resident's side rail was fixed. The CNAs and nurses had not turned in requisitions for the maintenance worker to look at and fix the side rail. The facility side rail assessments were not current. She expected nurses to complete resident assessments to determine the appropriateness of side rail use. During an interview on 7/6/11 at 4:00 P.M., the administrator said he/she did not investigate the incident or inservice staff, because she knew what happened and thought the resident's side rail was fixed. She expected nursing staff to evaluate residents for side rail use. MO 042 MO 032 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility placed devices on the wheelchairs of two residents and the merrywalker of one resident, identified as wanderer's, so they could not go into the hallway where the stairs were located. The facility will review and evaluate all residents who utilize wheelchairs and are identified for being at risk for falls and wandering and will implement the same measures on 8/5/11. The facility plans to do an in-depth evaluation of all residents to ensure they are placed on the appropriate floor in the facility, to ensure their safety. The facility will review and evaluate all new admissions and review residents quarterly for risks of falls and wandering to ensure that they are provided with protective oversight. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on interview and record review, the facility's nursing personnel failed to take appropriate action to assess and provide necessary care and treatment for one sampled resident selected for a closed record review and two randomly selected residents. The facility failed to adequately assess, monitor and notify the physician of a resident's change of condition, when the resident had chest pain, nausea/vomiting, arm pain and difficulty breathing over the course of more than 12 hours. The nursing personnel failed to transfer the resident to the hospital in a timely manner and failed to perform cardiopulmonary resuscitation (CPR) when the resident was found without breath. Emergency Medical Technicians (EMTs) arrived at the facility, initiated CPR and transferred the resident to the hospital where emergency room (ER) staff pronounced the resident dead. (Resident #9) The facility failed to administer medication used to prevent low blood pressures to another resident in accordance with his/her physician's orders. When the resident became unresponsive, facility staff failed to perform CPR. EMTs arrived at the facility, initiated CPR and transferred the resident to the hospital where ER staff pronounced the resident dead. (Resident #31) The facility failed to adequately monitor and notify a resident's physician of his/her change of condition when the resident had a decreased oxygen saturation level, a harsh cough with congestion in all lung fields, increased fluid build up in both lower legs and feet, and failed to transfer the resident to the hospital in a timely manner. When facility staff found the resident in [MEDICAL CONDITION], they failed to place the resident on a flat surface to perform CPR. Subsequently the EMTs arrived at the facility, correctly initiated CPR and transferred the resident to the hospital where ER staff pronounced the resident dead. (Resident #30) The census was 73. 1. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Age: early 80's; -Clear speech, usually understands and usually understood; -Long and short-term memory problems; -Could recall the location of own room and staff names and faces; -Felt down/depressed/hopeless on ,[DATE] of the last 14 days; -Limited assistance needed for bed mobility, wheelchair mobility and eating; -Extensive assistance needed for transfers, wheelchair mobility off-unit, dressing and personal hygiene; -Totally dependent on facility staff for toileting and bathing; -Impaired mobility to upper and lower extremities; -Did not walk, used a wheelchair; -Height 5 feet 5 inches and weight 128 pounds. Review of the resident's care plan, updated on [DATE], showed the following: -Potential for constipation related to limited mobility and [MEDICAL CONDITION] medications. The interventions included: Staff to encourage fluids, consumption and exercise. Administer [MEDICATION NAME] (a stool softener) daily. Monitor bowel routine and report if no bowel movement in 3 days. Monitor abdomen for discomfort, firmness or distention and report. Report hypoactive (sluggish) bowel sounds. Use an enema or milk of magnesia (a laxative) as necessary. -Moderate pain less than daily related to mild [MEDICAL CONDITION] joint disease. The interventions included: Staff to encourage rest/relaxation. Administer naproxsyn (an anti-[MEDICAL CONDITION]) twice a day routinely and [MEDICATION NAME] (a mild over the counter pain medication) every six hours as needed. Provide pain management prior to treatment if indicated. Monitor the effectiveness of pain management and alert the physician as needed. Monitor for verbal/nonverbal indications of pain. Pain assessment quarterly. -Potential for impaired oxygenation related to [DIAGNOSES REDACTED]. The interventions included: Elevate the head of the resident's bed. Report respiratory distress and/or oxygen saturation levels (blood oxygen percentage as determined by a non-invasive measuring device placed on a finger) under 90 percent to the physician. Oxygen as necessary. Medications and lab tests according to the physician's orders. The care plan did not address how often staff should check the resident's oxygen saturation. Review of the resident's physician's order sheet (POS), dated [DATE] through [DATE], showed the following [DIAGNOSES REDACTED]. -[MEDICAL CONDITION], past stroke with right sided weakness, high cholesterol, [MEDICAL CONDITION], high blood pressure, dementia and [MEDICAL CONDITION]; -[MEDICATION NAME] (a medication to treat high blood pressure) 10 milligrams (mg) before breakfast; -[MEDICATION NAME] (a medication that helps the heart beat more regularly) 50 mg one tablet every 12 hours; -[MEDICATION NAME] (a stool softener) 100 mg once daily; -Aspirin (a medication given as a mild anti-coagulant for elderly individuals with [MEDICAL CONDITION]) 81 mg once daily; -[MEDICATION NAME] suspension (used to treat gastrointestinal issues like gas, painful fullness and bloating) 30 milliliters (ml) every 6 hours as needed for gas pain; -Milk of Magnesia 10 ml as needed for constipation. During an interview on [DATE] at 8:20 A.M., the Director of Nurses (DON) said she learned staff brought the resident from the dining room, back to the fourth floor because the resident was not feeling well after lunch on [DATE]. Nurse HH, the day shift nurse, assessed the resident, who belched during the assessment. The nurse believed the resident's problem was primarily an upset stomach and gave him/her a dose of [MEDICATION NAME] (a liquid antacid). Nurse KK, the evening shift nurse, told the DON the resident remained in bed resting throughout the afternoon without a problem until shift change at which time the resident vomited. Nurse NN, the night shift nurse, told the DON when she assessed the resident shortly after shift change, the resident had loud rattles in his/her lungs. The nurse called the resident's physician and at his direction called for an ambulance to transfer the resident to a local hospital. There was confusion about whether the hospital Nurse NN called was the most appropriate hospital for the admission. Nurse NN said the resident had right sided weakness and chest pain. He/She called an ambulance to transfer the resident, the resident stopped breathing, the nursing home staff began CPR and the emergency personnel took over and then transferred the resident to the hospital where the resident subsequently died . The DON said the resident's record was in her office as she had kept it to have Nurse HH and Nurse KK each write late entries concerning the resident's condition on each of their shifts. Review of nurse's notes in the resident's medical record, showed no documentation of the resident's condition or any actions taken by nursing personnel on [DATE], during the day and evening shifts until after the resident's death. Review of the late entry made by Nurse HH on [DATE] at 11:30 A.M., showed he/she assessed the resident at 1:00 P.M. on [DATE], when the two day shift restorative aides (RA) brought the resident back from lunch. The resident complained of [MEDICAL CONDITION] (upper middle region of the abdomen) discomfort and belched during the exam. The nurse wrote the resident had no signs or symptoms of acute pain. A staff member gave the resident a dose of [MEDICATION NAME], for the stomach discomfort. Review of an internal shift-to-shift communication document used by nurses, called a "24 hour report," showed on [DATE], during the day shift the resident had gas pain and received [MEDICATION NAME] (a liquid antacid very similar to [MEDICATION NAME]). (The resident had no physician's order for [MEDICATION NAME]). During an interview on [DATE] at 1:15 P.M., Certified Nurse Aide (CNA) LL said he/she was the resident's assigned care giver on the day shift of [DATE]. The CNA said RA P and RA X brought the resident back from lunch on [DATE], because the resident complained of being sick to his/her stomach. CNA LL said the resident had slacked off eating ,[DATE] days prior. The CNA said the resident didn't say much and behaved pretty much like usual on [DATE]. The resident was not a complainer according to the CNA. During an interview on [DATE] at 1:54 P.M., RA P and RA X said they had both known the resident for several years. They sat at the lunch table with the resident on [DATE], and Nurse B supervised the dining room that day. RA P said the resident normally had a good appetite, but on [DATE], the resident barely ate at all. RA P and RA X said the resident was not normally a person who talked much. The resident held his/her lower chest and rocked back and forth in his/her wheelchair, at times the resident reared back as though struggling to draw in a breath. The resident told RA P and RA X, "I'm hurting". The two RAs said this was not normal behavior for the resident. They said anyone looking at the resident would have thought he/she had chest pain. They summoned Nurse B to the table to observe the resident. The resident vomited a small amount while seated at the dining room table. The RAs said Nurse B told them to take the resident back to his/her resident care unit and give a message to the charge nurse. Nurse B said to tell the other day shift nurse, Nurse HH, the resident exhibited signs/symptoms of chest pain and had difficulty breathing, and the nurse should take the resident's vital signs and call the resident's physician. RA X said he/she told Nurse HH everything Nurse B said to tell him/her. RA P and RA X said the resident's nose was blue-purple on the tip when they called Nurse B over in the facility dining room. RA X said he/she told Nurse HH the resident's nose was blue-purple on the tip. Back on the resident's care unit RA X said Nurse HH got the resident's vital signs, looked at the resident's medical record and said aloud that the resident had a [DIAGNOSES REDACTED]. Neither restorative aide saw Nurse HH call the resident's physician. During an interview on [DATE] at 7:40 P.M., Nurse HH said the resident routinely self-propelled his/her own wheel chair, exhibited withdrawn behavior and talked "low". He/She said RA P and RA X brought the resident back to the resident care unit from the dining room during lunch on [DATE]. RA P and RA X said the resident "did not look right" at lunch, and the nurse supervising the dining room (he/she could not recall the name of the nurse) told them to return the resident to his/her care unit. Nurse HH said the restorative aides did not mention the resident had vomited in the dining room, nor did they tell him/her the resident complained of chest pain. He/She saw the resident held his/her chest at the diaphragm (near the bottom of the breast bone). Nurse HH said the resident's vital signs were within normal limits for him/her. He/She listened to the resident's bowel sounds which sounded active, checked the resident's medical record, saw that the resident had a medication to be used as needed for excess stomach acid and told the medication technician to administer it. The nurse said the record showed the resident had a bowel movement earlier that day and two bowel movements the day before. Nurse HH said he/she did not call the resident's physician. Review of the late entry made by Nurse KK on [DATE] (no time noted), showed he/she assessed the resident, during the evening shift, on [DATE], when a CNA reported the resident complained of pain. His/Her assessment showed the resident complained of abdominal pain and had a firm abdomen with hypoactive bowel sounds. The nurse said [MEDICATION NAME] was provided for possible indigestion and to promote a bowel movement. The head of the resident's bed was elevated to aide in the resident's comfort. The nurse wrote he/she failed to understand further communication from the resident because the resident's speech was too soft spoken. The nurse said the resident's vital signs were stable and there were no signs/symptoms of any acute distress. During an interview on [DATE] at 12:20 P.M., CNA II said he/she was the resident's assigned care giver, during evening shift, on [DATE]. Resident #9 was the third resident the CNA saw upon arriving for his/her shift. He/She said the resident usually rested in bed each day before supper, so he/she was not surprised to see the resident in bed when he/she arrived, however the resident was "clammy" and held his/her chest. The resident told the CNA his/her chest hurt, "Real bad". The CNA reported this to Nurse KK, who asked if the resident had a bowel movement. The CNA said he/she told the nurse the resident usually never had problems with his/her bowels, but the other symptoms were not at all normal for the resident. The nurse instructed the CNA to take a set of vital signs. The CNA said the vital signs were normal except for the residents blood oxygen saturation level which was 86 percent (normal range is ,[DATE] percent, with cyanosis starting at about 90 percent - cyanosis is a bluish color to the skin or mucus membranes due to a lack of oxygen in the blood according to the National Institute of Health website updated [DATE]). CNA II said he/she could not find the nurse to tell him/her and thought maybe the oxygen saturation test was wrong so he/she retook the test in 20 minutes when the test showed 97 percent blood oxygen level. The CNA said he/she reported both oxygen level test results to the nurse before supper, and commented maybe the resident needed to go to the hospital. He/She said the resident usually went to the dining room for supper, but the resident did not feel up to going to the dining room for supper on [DATE], so he/she ordered a room tray for the resident. A second CNA (CNA JJ) arrived for the evening shift at approximately 4:00 P.M. CNA II said the resident continued to complain of chest pain and look clammy throughout the evening shift. After supper he/she and CNA JJ continued rounds together. They reported the resident's appetite and condition to Nurse KK at about 5:30 P.M. Before their 8:00 P.M. rounds the resident threw up. When they cleaned the resident he/she said, "Oh my chest, it hurts so bad". The CNAs reported this to the nurse. CNA II said he/she saw the resident one more time at about 10:45 P.M., he/she said the resident was still talking, but the resident's color did not look normal and the resident was clammy. During an interview on [DATE] at 2:15 P.M., CNA JJ said he/she tried to get the resident to eat a little before he/she took the room tray away. The CNA said the resident usually had a good appetite, but that evening was not breathing normally and complaining of chest pain. He/She described the resident's color as "grayish" that shift and said CNA II told him/her he/she had reported the resident's change in condition before CNA JJ arrived for the shift. After supper CNA II and CNA JJ went to Nurse KK to report the resident's condition. He/She said the nurse focused on whether the resident had had a bowel movement, but did not go back to see the resident until they reported to him/her the resident vomited just before 8:00 P.M. The nurse told CNA JJ to monitor the resident and let him/her know if the resident's condition changed. During an interview on [DATE] at 1:25 P.M., Nurse KK said he/she had only worked at the facility about three weeks by [DATE]. In report the day nurse told him/her the resident had a stomach ache. The nurse said he/she evaluated the resident and listened to the resident's bowel sounds which were sluggish. The resident rested in bed holding his/her upper stomach. He/She said no one told him/her the resident had chest pain or nausea, and no one said the resident had trouble breathing that shift. He/She did not recall the resident vomited during the later part of the shift. Review of the "24 hour report" showed Nurse KK wrote the resident vomited "a large amount" once during the shift, complained he/she did not feel well and complained of gas pain, and the night shift nurse should check the resident for impaction. The report showed the resident received [MEDICATION NAME] during the evening shift. Review of the night shift nurse's notes documented by Nurse NN on [DATE] at 1:00 A.M., showed the nurse called the resident's physician and received an order to send the resident to the hospital due to complaints of chest pain, right sided weakness, right hand cold to touch, and congestion/wheezing in the upper and lower lobes of the resident's lungs. The ambulance arrived at approximately 1:43 P.M. During an interview on [DATE] at 11:10 A.M., CNA K said on [DATE], when the night shift began, he/she and another CNA (CNA MM) shared the assignment on which the resident lived. CNA K said he/she could hear the resident's labored breathing from the hall near the nurse's station when he/she arrived. The CNA went to the resident's room before he/she did anything else. The resident's facial expression looked drawn, his/her chest was not rising evenly and the resident's color was "grayish". CNA K asked the resident if he/she was all right, but the resident did not answer. The CNA went to the hall and called for CNA MM to come help her evaluate the resident's breathing. CNA K said CNA MM was not sure about whether there was a problem with the resident's breathing. CNA K said he/she told Nurse NN the resident was not breathing as he/she normally did. CNA K said the nurse went in to see the resident, and shortly after that the CNA could hear the resident struggling for breath and moaning so he/she went back to the resident's room. At that time the resident's breathing had the sound of a rattle and while the CNA was in the resident's room the resident vomited. After cleaning the resident, the CNA reported the change to the nurse who said he/she had received orders to send the resident to a hospital. The CNA went to copy the necessary papers to accompany the resident to the hospital. Upon returning the CNA paused at the nurse's station and heard Nurse NN say the resident was not breathing, the nurse asked another nurse (Nurse OO) who arrived on the scene whether Resident #9 should receive CPR. Nurse OO confirmed the resident should receive CPR and Nurse NN asked CNA K to grab a respiration device and join him/her in the resident's room. The CNA said he/she assisted Nurse NN to place the resident on the floor. The first EMT arrived and they sent him/her to get Nurse OO to bring oxygen. He/She also heard someone yelling for a suction machine. When CNA K came back to the room, the second EMT was present, there was oxygen in the room and the EMTs were trying to do CPR. CNA K said she had not been trained in CPR, and was not sure what would have happened if the EMTs had not arrived when they did. During an interview on [DATE] at 6:40 A.M., CNA MM said he/she went to check on the resident's breathing with CNA K early in the shift, but he/she did not hear a problem. He/She heard the resident moaning before he/she went on his/her first break in the shift and had heard CNA K report to Nurse NN early in the shift that the resident had arm pain and labored breathing. He/She said Nurse NN and Nurse OO argued after the resident left for the hospital about whether Nurse OO should have been in the resident's room to assist with CPR. He/She did not see who if anyone from the facility staff participated in CPR. During an interview on [DATE] at 7:00 A.M., Nurse NN said he/she learned from the 24 hour report the resident had been having nausea and Nurse KK believed the source of the problem was constipation. The nurse said he/she checked on the resident early in the shift after CNA K came to him/her and said the resident was not breathing well. When he/she saw the resident in his/her bed, the resident laid on his/her right side. The resident held his/her chest with the left hand, made an abnormal breath sound and said his/her right arm hurt. Nurse NN said he/she wondered if the resident had pneumonia. He/She called the resident's physician, who said to send the resident to the hospital. He/She called the hospital, but the ER physician thought maybe the resident was having a stroke and said not to send the resident to that hospital. The nurse said he/she talked to Nurse OO to try to figure out where the resident should be sent and called the ambulance for transfer. He/She checked on the resident again, and found the resident had vomited, so he/she cleaned the resident. The nurse said when he/she turned the resident to clean him/her; the resident's right hand was blue. The nurse obtained the alternate hospital phone number from Nurse OO and sent CNA K to copy the necessary paperwork for the transfer. He/She checked on the resident again and found the resident without breath. The nurse went toward the nurse's station and encountered the CNA with the resident's papers; he/she checked the resident's wishes regarding CPR and found out the resident wished to receive CPR. He/She sent the CNA for a bag to use for respirations and met the CNA in the resident's room where the two of them placed the resident on the floor. Nurse NN said she and CNA K started CPR. She completed compressions while she instructed the CNA how to use the bag to provide respirations, they continued CPR until the EMTs arrived and took over. She said Nurse OO did not enter the room. During an interview on [DATE] at 6:50 A.M., CNA PP said on [DATE], he/she heard employees yelling on the stairs that the resident needed CPR. He/She heard them calling for Nurse OO, so he/she went to find the nurse. The CNA found the nurse on the second floor in the stairwell by the elevator. The nurse said the EMTs had arrived. One EMT yelled to get oxygen and Nurse OO went after it, when he/she arrived to the hallway outside the resident's room the EMTs sent the nurse back for tubing as he/she had not brought any. CNA PP could not say if any facility staff engaged in CPR, since he/she never went into the resident's room during the emergency. During an interview on [DATE] at 8:00 A.M., Nurse OO said the resident had a history of [REDACTED]. He/She said the resident had been complaining of pain in his/her right arm for about four days before [DATE]. When asked to be more specific, Nurse OO said, "Well it could have been four days, eight days or two weeks, I can't say for sure". On [DATE] after 1:00 A.M., Nurse NN called and asked him/her for the phone number to a local hospital. The nurse said the resident was not well and needed to go to the hospital. Nurse NN told him/her the resident might have had pneumonia. After a short while, Nurse OO said he/she heard the resident had stopped breathing. At the nurse's station he/she told Nurse NN the resident was a full code and the nurse went back toward the resident's room. He/She heard the EMTs had arrived and went to intercept them and get them to the right room. One of them yelled he needed oxygen and Nurse OO went to get it. The nurse said he/she did not realize there was oxygen on each floor, he/she thought it was all on the third floor as it used to be back when he/she had worked there in the past. The nurse said he/she never went to the room before the EMTs arrived, so he/she did not know if any of the facility actually did CPR before the EMTs arrived. During an interview on [DATE] at 11:15 A.M., EMT RR said he/she and his/her partner were not informed the resident required emergency care before arrival at the facility. They were initially told it was a transport for which they were called, so they did not bring in any emergency equipment at first. EMT QQ proceeded to the resident's room while he/she returned to their vehicle for their equipment. Review of the ambulance records showed the call came in on [DATE] at 1:21 A.M. Review of the emergency room (ER) report dated [DATE], showed EMTs found the resident in full [MEDICAL CONDITION] in his/her bedroom at the nursing home. During an interview on [DATE] at 7:23 P.M., EMT QQ said he/she arrived in the resident's room while EMT RR went back to the vehicle for more equipment. The resident was on the floor and two of the facility's nursing personnel stood in the resident's room. No one provided CPR to the resident. One of the nursing personnel held a bag used to provide respirations during CPR and there was no oxygen in the resident's room. He/She checked to see if he/she could place an airway in the resident's throat and found the resident had vomited and his/her throat was full of vomit. He/She called for both oxygen and a suction machine from the staff so he/she could proceed. He/She had to suction the resident's throat multiple times before he/she could intubate the resident to begin respirations. The resident had no pulse and no respirations when he/she began trying to provide emergency care. During an interview on [DATE] at 9:30 A.M., the DON said any CNA who learned of a resident with a change in condition such as pain or nausea should tell the nurse immediately. The nurse should assess the resident and call the resident's physician if it actually constituted a change in condition. During an interview on [DATE] at 1:40 P.M., the DON said she was not aware Nurse NN observed the resident without breath and left the room without initiating CPR. She said this was inappropriate. The DON said if a nurse does not know a resident's code status he/she should start CPR. During an interview on [DATE] at 9:40 A.M., the resident's physician said a facility nurse called him close to midnight on [DATE], regarding the resident's condition. He said the nurse said the resident complained of chest pain and might have had a stroke. The nurse did not tell him the resident had nausea/vomiting, breathing problems, and failed to report the resident's right hand was cyanotic. He said those were important symptoms and he would have wanted to know about them in order to recommend appropriate treatment for the resident. He said the resident had past arthritic pain in his/her arm/shoulder, and the pain had been addressed in physical therapy more than once. The physician said the resident probably had a [MEDICAL CONDITION]. He said if the staff had called earlier it might have effected the outcome of the emergency. 2. Review of Resident #31's readmission POS, dated [DATE] through [DATE], showed an order dated [DATE] for Fludrocortisone (medication used for postural/orthostatic [MEDICAL CONDITION] - a drop in blood pressure due to a change in body position such as standing from a sitting position) 0.1 mg by mouth once a day, hold for systolic (top number; when the heart is actively pumping) blood pressure greater than 139 or diastolic (bottom number; when the heart is at rest) blood pressure greater than 90 and a [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No short/long term memory problems; -No cognitive impairment; -Independent with all activities of daily living; -Continent of bowel and bladder; -Age: Middle 40's. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Fludrocortisone 0.1 mg by mouth once a day, hold for systolic blood pressure greater than 139 or hold for diastolic blood pressure greater than 90; -[DATE]: Initials circled (an indication the medication was not given), blood pressure (BP) ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Blank; -[DATE]: Blank; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]. Review of the back of the resident's MAR, dated [DATE] through [DATE], showed the following: -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg by mouth held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg by mouth held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg by mouth held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg by month held for BP ,[DATE]. Review of a nurse's note, dated [DATE] at 2:30 P.M., showed the resident had a BP of ,[DATE]. The notes showed no documentation staff notified the resident's physician. Review of a nurse's note, dated [DATE] at 9:00 P.M., showed the resident complained of not feeling well earlier in the shift, BP of ,[DATE]. Staff encouraged the resident to lay down. The notes showed no documentation staff notified the resident's physician. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Fludrocortisone 0.1 mg by mouth, once daily, hold for systolic BP greater than 139 or diastolic greater than 90; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, No BP; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]. Review of the back of the resident's MAR, dated [DATE] through [DATE], showed staff held the Fludrocortisone 0.1 mg on [DATE], for BP of ,[DATE] and on [DATE], for BP of ,[DATE]. No other dates were addressed. Review of the resident's POS, dated [DATE] through [DATE], showed the following: -[DIAGNOSES REDACTED]. -Full code; -An order dated [DATE] for Fludrocortisone 0.1 mg by mouth once a day, hold for systolic blood pressure greater than 139 and hold for diastolic blood pressure greater than 90. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -Fludrocortisone 0.1 mg by mouth once a day, hold for systolic blood pressure greater than 139 and hold for diastolic blood pressure greater than 90; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]; -[DATE]: Initials circled, BP ,[DATE]. Review of the back of the resident's MAR, dated [DATE] through [DATE], showed the following: -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg one tablet by mouth, held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg one tablet by mouth, held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg one tablet by mouth, held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg one tablet by mouth, held for BP ,[DATE]; -[DATE]: 9:00 A.M., Fludrocortisone 0.1 mg one tablet by mouth, held for BP ,[DATE]; -No documentation for [DATE]. During an interview on [DATE] at 12:30 P.M., Certified Medication Technician (CMT) S said he/she held the Fludrocortisone because the resident's blood pressure was low. This surveyor showed CMT S the parameters of the medication, hold if greater than systolic 130 or diastolic greater than 90. CMT S repeated again he/she held the medication because the resident's blood pressure was low. This surveyor repeated the parameters of the medication to CMT S and the CMT said he/she misunderstood the directions of the medication, but told the charge nurse when he/she held the medication. During an interview on [DATE] at 1:45 P.M., Nurse T said he/she did not recall CMT S informing him/her of holding the Fludrocortisone. During an interview on [DATE] at 2:30 P.M., the Assistant Director of Nurses said the CMT should not have held the medication. Review of a nurse's note dated [DATE] at 2:00 A.M., showed the resident complained of worse than usual [MEDICAL CONDITION] pain and requested two doses of [MEDICATION NAME]. Staff nurse informed the resident the medication was ordered for every three hours and the next available dose would be 6:00 A.M. The resident said he/she would tell his/her physician about the pain on the next visit. The nurse's notes contained no documentation the facility notified the physician and staff documented no assessment. Review of the nurse's note dated ,[DATE]/