Every finding on record at Chateau Girardeau

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for five residents (Residents #7, #8, #38, #55, and #66) out of five sampled residents. The facility census was 50. Review of the facility policy titled, Informed Consent for Treatment, undated, showed: - The facility is committed to honoring each resident's right to make informed decisions regarding their care. Informed consent will be obtained prior to initiating treatment, except in emergency situations, and will be documented in the resident's medical record; - Consent must be voluntary and free from coercion, based on clear, understandable information, and provided by the resident or legally authorized representative; - The practitioner obtaining consent must ensure that the resident or representative is informed of the nature and purpose of the proposed treatment, expected benefits and potential risks, reasonable alternatives, including the option to refuse treatment, and possible consequences of refusal; - The informed consent discussion, the name of the individual providing consent, the specific treatment or procedure consented to, date and time of consent, signature of the resident or representative (when required), and name and credentials of the practitioner obtaining consent must be documented in the medical record. 1. Review of Resident #7's medical record showed: - An admission date of 10/27/25; - Diagnoses of unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and anxiety disorder (persistent worry in daily life); - An order for aripiprazole (an antipsychotic – medications that treat psychosis, which include delusions, hallucinations, paranoia, or disordered thoughts) medications ) 15 milligrams (mg) by mouth one time a day related to dementia, dated 10/03/25; - An order for sertraline (an antidepressant medication) 100 mg two tablets by mouth one time a day related to anxiety, dated 10/03/25; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the aripiprazole and sertraline medications. 2. Review of Resident #8's medical record showed: - An admission date of 04/26/23; - Diagnoses of major depressive disorder (MDD - a serious mental health condition characterized by at least two weeks of persistent, pervasive low mood, loss of interest, and low self-esteem) and dementia with psychotic disturbance; - An order for Cymbalta (an antidepressant medication) 30 mg by mouth one time a day related to MDD, dated 03/15/24; - An order for Effexor extended release (XR) (an antidepressant medication) 150 mg by mouth one time a day for depression, dated 07/07/23; - An order for lamotrigine (an anticonvulsant medication also used as mood stabilizer) 100 mg by mouth one time a day for mood stabilizer, dated 02/27/24; - An order for mirtazapine (an antidepressant medication) 30 mg by mouth at bedtime for depressive disorder, dated 05/18/24; - An order for trazodone (an antidepressant medication) 150 mg by mouth at bedtime for a sleep aide, dated 11/20/23; - An order for Vraylar (an antipsychotic medication) 1.5 mg two capsules by mouth one time a day for MDD, dated 11/07/24; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Cymbalta, Effexor, lamotrigine, mirtazapine, trazodone, and Vraylar. 3. Review of Resident #38's medical record showed: - An admission date of 10/12/21; - Diagnoses of cerebral infarction (stroke), falls, dementia with behavioral disturbance, sedative/hypnotic (induces sleep)/anxiolytic (an antianxiety medication) dependence, anxiety disorder, MDD, and Alzheimer's disease (a progressive mental deterioration); - An order for clonazepam (an antianxiety medication) 0.5 mg by mouth four times a day related to anxiety until end of life, dated 11/06/24; - An order for escitalopram (an antidepressant medication) 10 mg by mouth one time a day related to anxiety until end of life, dated 11/07/24; - An order for lorazepam (an antianxiety medication) concentrate 2 mg/ milliliters 0.5 ml by mouth every two hours as needed for anxiety/restlessness/shortness of breath, dated 09/10/25; - An order for Seroquel (an antipsychotic medication ) 25 mg by mouth at bedtime for anxiety related to MDD, dated 08/06/24; - An order for Seroquel 25 mg two tablets by mouth one time a day for anxiety related to MDD, dated 08/06/24; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the clonazepam, escitalopram, lorazepam, and Seroquel. 4. Review of Resident #55's medical record showed: - An admission date of 08/20/24; - Diagnoses of unspecified dementia unspecified severity with mood disturbance, unspecified dementia moderate with anxiety, and unspecified dementia moderate with agitation and insomnia; - An order for Cymbalta 30 mg by mouth one time a day for mood, dated 11/05/25; - An order for lorazepam oral concentrate 2 mg/ml 0.5 ml by mouth every four hours as needed for anxiety, dated 03/10/26; - An order for lorazepam 1 mg by mouth every eight hours, hold for sedation, may also use 0.5 ml liquid as well, dated 03/12/26; - An order for mirtazapine 7.5 mg by mouth at bedtime for agitation, dated 11/05/25; - An order for morphine sulfate (a narcotic medication used to treat pain) 10 mg/ml 0.25 ml by mouth every two hours as needed for shortness of breath/pain, dated 02/05/26; - An order for brexpiprazole (an antipsychotic medication) 2 mg by mouth one time a day for agitation, dated 11/05/25; - An order for trazodone 25 mg by mouth at bedtime for insomnia, dated 08/20/24; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for Cymbalta, lorazepam, mirtazapine, morphine sulfate, brexpiprazole, or trazodone. 5. Review of Resident #66's medical record showed: - An admission date of 03/27/26; - Diagnoses of MDD, anxiety, and depression; - An order for duloxetine (an antidepressant medication) 60 mg by mouth one time a day for depression, dated 03/28/26; - No documentation of consent or education of risks and benefits was provided to the resident and/or their representative for the duloxetine. During an interview on 04/10/26 at 3:58 P.M., Licensed Practical Nurse (LPN) B said he/she knew about psychotropic medication consents but did not think those were done at this facility. During an interview on 04/10/26 at 4:59 P.M., the Administrator and the Director of Nursing (DON) said they expected the residents and/or their representatives be informed of risks and benefits of psychotropic medications and to have informed consent of the psychotropic medications.

Based on interview and record review, the facility failed to initiate an order for a code status for one resident (Resident #49) and failed to ensure an order for the code status was consistently documented throughout the medical record for one resident (Resident #24) out of 14 sampled residents. The facility census was 50. Review of the facility's policy titled, Advance Directives, dated 2026, showed: - Resident's medical record will have documentation indicating if a resident has an advance directive; - The facility honors residents' wishes as expressed in their Advance Directive. 1. Review of Resident #24's medical record showed: - admission date of [DATE]; - The face sheet, dated [DATE], showed a full code (if a person's heart stopped beating and/or they stopped breathing, cardiopulmonary resuscitation (CPR – an emergency lifesaving procedure performed when the heart stops beating or breathing ceases) procedures would be provided) status. Review of the resident's physician's order sheet (POS), dated [DATE], showed: - An order for full code status, dated [DATE]. Review of the resident's Do Not Resuscitate (DNR - does not want CPR) form, dated [DATE], showed: - The resident's code status was DNR; - Signed by the resident's responsible party and the physician on [DATE]. During an interview on [DATE] at 9:30 A.M., the resident was confused and did not know what his/her code status should be. During an interview on [DATE] at 9:40 A.M., the resident's responsible party/spouse was confused and did not know what the resident's code status should be. 2. Review of Resident #49's medical record showed: - admission date of [DATE]; - A code status sheet, undated, in the paper chart showed the resident was a full code; - No order for a code status in the electronic medical record; - No code status documented on the resident's clinical dashboard (a snapshot of important resident information that remains at the top of the screen throughout the chart). During an interview on [DATE] at 3:11 P.M., Registered Nurse (RN) E said he/she looked at the residents' paper charts for their code status. The residents had blue and red stickers on the spine of the paper chart. A blue sticker meant a full code and a red sticker meant do not resuscitate (DNR - a medical order indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating). There was a code status sheet in front of every resident's paper chart and listed at the top of the screen in every resident's EMR. During an interview on [DATE] at 1:25 P.M., Licensed Practical Nurse (LPN) B said that he/she looked at the front of the resident's paper chart for the code status because it was more accurate than the resident's EMR. During an interview on [DATE] at 1:30 P.M., the Director of Nursing (DON) said she would expect staff to look at the front of the resident's paper chart to find the resident's code status because it was most accurate. During an interview on [DATE] at 4:59 P.M., the Administrator and the DON said they would expect all residents to have an order for the code status and for the resident's code status to be documented consistently throughout the medical record. During an interview on [DATE] at 3:29 P.M., the DON said the nurse doing the resident's admission was responsible for getting an order for the code status or the nurse on duty at the time a code status was changed.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when a resident's Medicare covered services had ended for one resident (Resident #70) out of three sampled residents. The facility census was 50.Review of the facility policy titled, Advance Beneficiary Notice, undated, showed:- It is the policy of the facility to issue an Advance Beneficiary Notice of Noncoverage (ABN) to Medicare beneficiaries in accordance with requirements established by the Centers for Medicare & Medicaid Services (CMS) when services are expected to be denied as not reasonable and necessary under Medicare guidelines;- An ABN must be issued before services are provided when services are likely to be denied due to lack of medical necessity, therapy services exceed coverage thresholds without sufficient documentation, maintenance therapy is not supported under current Medicare standards, or services are custodial rather than skilled. 1. Review of Resident #70's Notice of Medicare Non-Coverage (NOMNC) showed:- The resident discharged from skilled services on 10/13/25, and remained in the facility;- The facility failed to issue a SNF ABN. During an interview on 04/09/26 at 3:35 P.M., the Community Nurse Navigator said he/she was in charge of giving residents the SNF ABN and NOMNC forms. He/She just missed the SNF ABN for Resident #70. During an interview on 04/10/26 at 5:00 P.M., the Administrator said she would expect the appropriate SNF ABN and NOMNC forms be given to the resident or the resident's representative prior to the resident being discharged from Medicare skilled services in a timely manner.

Based on interview and record review, the facility failed have an appropriate diagnosis for a psychotropic (medication that affect a person's mental state) medication for three residents (Residents #7, #8, and #55), failed to limit the use of a psychotropic as needed (PRN) medication order for 14 days for one resident (Resident #55), and failed to attempt gradual dose reductions (GDR) for one resident (Resident #8) out of five sampled residents. Facility census was 50. Review of the facility policy titled, Psychotropic Medication Use, last revised July 2022, showed: - Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record; - Residents on psychotropic medications receive gradual dose reductions (coupled with non­pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications; - PRN orders for psychotropic medications are limited to 14 days, if a prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the prn order. Review of the facility policy titled, Tapering Medications and Gradual Drug Dose Reductions, last revised July 2022, showed: - All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions; - Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; - The staff and practitioner will consider tapering under certain circumstances, including when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms, or a resident's condition has not responded to treatment or has declined despite treatment; - Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated; - For any individual who is receiving a psychotropic medication to treat behavioral symptoms related to dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), the GDR may be considered clinically contraindicated if the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior; - Attempted tapering of sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. 1. Review of Resident #7's medical record showed: - An admission date of 10/27/25; - Diagnoses of unspecified dementia and other specified anxiety disorders (persistent worry in daily life); - An order for aripiprazole (an antipsychotic (medications used to manage psychosis, particularly hallucinations, delusions, and severe agitation) medication) 15 milligrams (mg) by mouth one time a day related to dementia, dated 10/03/25; - No appropriate diagnosis for the aripiprazole medication. 2. Review of Resident #8's medical record showed: - An admission date of 04/26/23; - Diagnoses of major depressive disorder (MDD - a serious mental health condition characterized by at least two weeks of persistent, pervasive low mood, loss of interest, and low self-esteem) and dementia with psychotic disturbance; - An order for Cymbalta (an antidepressant medication) 30 mg by mouth one time a day related to MDD, dated 03/15/24; - An order for Effexor extended release (XR) (an antidepressant medication) 150 mg by mouth one time a day for depression, dated 07/07/23; - An order for lamotrigine (an anticonvulsant medication also used to treat mood disorders) 100 mg by mouth one time a day for mood stabilizer, dated 02/27/24; - An order for mirtazapine (an antidepressant medication) 30 mg by mouth at bedtime for depressive disorder, dated 05/18/24; - An order for trazodone (an antidepressant medication) 150 mg by mouth at bedtime for a sleep aide, dated 11/20/23; - An order for Vraylar (an antipsychotic medication) 1.5 mg two capsules by mouth one time a day for MDD, dated 11/07/24; - No documented pharmacy recommendation for an appropriate diagnosis for the trazodone medication; - No documented pharmacy recommendation for GDRs for the Cymbalta, mirtazapine, lamotrigine, trazodone, and Vraylar medications. Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility staff), dated 03/03/26, showed: - Intact cognition; - Received antipsychotic medications on a routine basis; - Received antidepressant medications on a routine basis; - Received hypnotic (medications that induce sleep) medications on a routine basis; - GDR not attempted and not documented as contraindicated. During an interview on 04/10/26 at 3:35 P.M., the Director of Nursing (DON) said Resident #8 saw an outpatient counseling/psychiatric provider for counseling/psychiatric care. The facility had been unable to get records or information from the other provider regarding the status and care for Resident #8. During a phone interview on 04/14/26 at 8:50 A.M., the outpatient counseling/psychiatric office provider for Resident #8 said there was no release of information signed on the resident and would not be able to provide any information. 3. Review of Resident #55's medical record showed: - An admission date of 08/20/24; - Diagnoses of unspecified dementia unspecified severity with mood disturbance, unspecified dementia moderate with anxiety, and unspecified dementia moderate with agitation and insomnia; - An order for lorazepam (an antianxiety medication) concentrate 2 mg/milliliter (ml) 0.5 ml by mouth every four hours PRN for anxiety, dated 03/10/26 and no stop date; - An order for mirtazapine 7.5 mg by mouth at bedtime for agitation, dated 11/05/25; - No appropriate diagnosis for the mirtazapine; - No pharmacy recommendations regarding a stop date for the lorazepam PRN and for an appropriate diagnosis for the mirtazapine medications. During an interview on 04/10/26 at 3:58 P.M., Licensed Practical Nurse (LPN) B said Resident #55 had not had any behaviors recently. The resident had behaviors in the past but none in the last couple of months. During an interview on 04/10/26 at 4:59 P.M., the Administrator and the Director of Nursing said they would expect psychotropic medications to have an appropriate diagnosis and PRN psychotropic medications should have a 14-day stop date. During an interview on 4/15/26 at 4:57 P.M., the Medical Director (MD) said dementia was not an appropriate diagnosis for aripiprazole and the diagnosis should be mood disorder.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument to be completed by facility staff) assessment after a significant change for one resident (Resident #55) out of two sampled residents who received hospice services. The facility census was 50.Review of the facility policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed:- The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to the Centers for Medicare and Medicaid Services (CMS) in accordance with current federal and state guidelines;- Timeframes for completion and submission of assessments are based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. Review of RAI 3.0 Version 1.20.1, dated October 2025, showed:- The assessment must accurately reflect the resident's status;- A significant change in status assessment must be completed no later than 14 days from the determination date of the significant change;- If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA);- It is a CMS requirement to have an SCSA completed every time the hospice benefit has been elected, even if a recent MDS was done and the only change is the election of the hospice benefit;- Comprehensive or quarterly assessments are due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between assessments;- A comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments. 1. Review of Resident #55's medical record showed:- An admission date of 08/20/24;- Diagnoses of moderate unspecified dementia with anxiety (a moderate cognitive decline and significant, documented anxiety symptoms such as restlessness, excessive worry, or panic episodes where the specific type of dementia is not determined), moderate unspecified dementia with agitation (a middle-stage cognitive decline where the specific cause is unknown, accompanied by behavioral disturbances), and chronic obstructive pulmonary disease (COPD - a lung disease);- An order to admit to hospice, dated 02/04/26;- A quarterly MDS assessment completed on 03/01/26;- No significant change in condition assessment was completed within 14 days of admission to hospice. During an interview on 04/10/26 at 4:59 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS assessments to be done timely and reflect the resident's condition at the time of the assessment. During an interview on 04/15/26 at 12:09 P.M., the MDS Coordinator said he/she was new to the job, was still learning what to do, had never done the job before, and never used the computer system at the facility before. He/She was taking classes, learning what all was required from the MDS timeframes, and when to do assessments. He/She knew some MDS assessments had been missed recently or were completed late.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) within the required time frames for three residents (Residents #8, #38, and #55) out of 14 sampled residents. The facility's census was 50.Review of the facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, showed: - The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - Timeframes for completion and submission of assessments are based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. Review of the Resident Assessment Instrument Manual, dated October 2025, showed: - For the admission assessment, the MDS completion date must be no later than 13 days after the entry date; - The assessment reference date (ARD) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the admission assessment, the care area assessment (CAA) completion date must be no later than 14 days after the entry date; - For the annual assessment, the CAA completion date must be no later than 14 days after the ARD. 1. Review of Resident #8's medical record showed:- admitted on [DATE];- A comprehensive annual MDS assessment with an ARD of 08/17/24, and a completion date of 08/26/24; - A quarterly MDS assessment with an ARD of 11/17/24, and a completion date of 11/26/24; - A quarterly MDS assessment with an ARD of 02/17/25, and a completion date of 02/18/25; - A quarterly MDS assessment with an ARD of 05/20/25, and a completion date of 05/21/25;- A quarterly MDS assessment with an ARD of 08/20/25, and a completion date of 08/25/25;- A quarterly MDS assessment with an ARD of 11/20/25, and a completion date of 12/02/25;- A quarterly MDS assessment with an ARD of 02/20/26, and a completion date of 03/03/26;- No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment. 2.Review of Resident #38's medical record showed: - An admission date of 10/12/21; - A comprehensive annual MDS assessment with an ARD of 12/15/24, and a completion date of 12/18/24; - A quarterly MDS assessment with an ARD of 03/17/25, and a completion date of 03/24/25; - A quarterly MDS assessment with an ARD of 06/17/25, and a completion date of 06/19/25; - A quarterly MDS assessment with an ARD of 09/17/25, and a completion date of 09/17/25;- A quarterly MDS assessment with an ARD of 12/18/25, and a completion date of 12/31/25;- A quarterly MDS assessment with an ARD of 03/20/26, and a completion date of 04/03/26; - No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment. 3. Review of Resident #55's medical record showed:- admitted on [DATE];- A comprehensive admission MDS assessment with an ARD of 08/26/24, and a completion date of 08/29/24; - A quarterly MDS assessment with an ARD of 11/26/24, and a completion date of 12/04/24; - A quarterly MDS assessment with an ARD of 02/26/25, and a completion date of 02/28/25; - A quarterly MDS assessment with an ARD of 05/29/25, and a completion date of 05/30/25;- A quarterly MDS assessment with an ARD of 08/29/25, and a completion date of 09/03/25;- No comprehensive MDS assessment within 366 days of the last comprehensive MDS assessment. During an interview on 04/10/26 at 4:59 P.M., the Administrator said she would expect the MDS assessments to be done timely and reflect the resident's current condition at the time of the assessment. During an interview on 04/15/26 at 12:09 P.M., the MDS Coordinator said he/she was new to the job, was still learning what to do, had never done the job before, and never used the computer system at the facility before. He/She was taking classes, learning what all was required from the MDS timeframes, and when to do assessments. He/She knew some MDS assessments had been missed recently or were completed late.

Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #22) and failed to obtain urinary catheter orders for one resident (Resident #67) out of five sampled residents. The facility census was 50. Review of the facility policy titled, Catheter Care, Urinary, dated September 2014, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; - Cleansing of the catheter insertion site during daily bathing or showering is appropriate; - Empty collection bag at least every eight hours. 1. Review of Resident #22's medical record showed: - An admission date of 09/25/25; - Diagnoses of chronic obstructive pulmonary disease (COPD – a lung disease) and respiratory failure (lungs not working like they should); - An order for daily weights one time a day, dated 10/28/25. Review of the resident's weights, dated October 2025 - April 2026, showed: - October weights not completed on 10/28/25, 10/30/25, and 10/31/25, with three out of four opportunities missed; - November weights not completed for 11/01/25 – 11/30/25, with 30 out of 30 opportunities missed; - December weights not completed on 12/01/25 - 12/04/25, 12/06/25, and 12/08/25 - 12/31/25 for 29 out of 31 opportunities missed; - January weights not completed on 01/01/26 - 01/25/26 and 01/27/26 - 01/31/26 for 30 out of 31 opportunities missed; - February weights not completed on 02/01/26 - 02/21/26, 02/24/26, and 02/28/26 for a total of 23 out of 28 opportunities missed. During an interview on 04/10/26 at 1:15 P.M., Certified Nurse Aide (CNA) F said night shift staff performed the weights. If they did not get to them, then day shift did them. Weights were obtained upon admission and charted on the sheet that had the resident's preferences. Night shift weights were written on the board behind the nurse's station and the nurses put the weight results in the charts. Nurses wrote on the CNA assignment sheets who needed weighed. During an interview on 04/10/26 at 3:55 P.M., CNA A said both the nurses and CNAs got weights. There was a paper list at the nurse's station that had residents that needed weighed. Once the resident was weighed, the result was given to the nurse to chart. During an interview on 04/10/26 at 3:58 P.M., Licensed Practical Nurse (LPN) B said the order entered into the electronic medical record should flow over into the administration record to let the nurse know a weight needed to be done. Both the nurses and CNAs got weights, but he/she normally did his/her residents. There was a list with highlighted residents for the CNAs to get weights on. The CNAs did not chart the weights. The nurse's charted the weights. During an interview on 04/10/26 at 4:00 P.M., Registered Nurse (RN) C said Resident #22 was a daily weight and he/she did not refuse to be weighed. 2. Review of Resident #67's medical record showed: - An admission date of 04/07/26; - Diagnoses of urinary tract infection (UTI - a bacterial infection of the urinary system that causes burning pain, frequent urges to urinate, and cloudy or foul-smelling urine), pseudomonas (a group of bacteria commonly found in the environment that can cause infections in the blood, lungs, urinary tract, or other parts of the body), and benign prostatic hyperplasia (BPH - enlargement of the prostate); - No order for a urinary catheter; - No order for urinary catheter care. Review of the resident's baseline care plan, dated 04/07/26, showed: - The resident had a urinary catheter (a sterile tube inserted into the bladder to drain urine). Review of the resident's progress note, dated 04/08/26, showed: - Fax sent to the urologist (a physician specializing in diagnosing and treating diseases of the urinary tract) office for urinary catheter care. During an interview on 04/07/26 at 7:56 P.M., the resident said his/her urinary catheter was inserted before coming to the facility. During an interview on 04/10/26 at 4:59 P.M., the Administrator and Director of Nursing (DON) said they would expect an order for a urinary catheter and catheter care for all residents with urinary catheters. During an interview on 04/15/26 at 3:29 P.M., the DON said the admitting nurse was responsible for getting urinary catheter orders from the physician.

Based on observation, interview, and record review, the facility staff failed to implement enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO -microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #24 and #67) out of four residents sampled. The facility also failed to use proper infection control techniques during incontinent care for one resident (Resident #24) out of two sampled residents. The facility census was 50. Review of facility policy titled, Enhanced Barrier Precautions, dated January 2026, showed: - EBP will be implemented for residents who have a known colonization of MDROs, presence of indwelling medical devices, chronic wounds, and non-intact skin; - Staff must wear gown and gloves during high-contact care activities; - High-contact care activities include dressing, bathing, grooming, transferring, repositioning, toileting, incontinence care, wound care, and device care or use; - Personal protective equipment (PPE - gloves, gowns, masks, respirators, and face shields designed to protect workers and patients from infectious materials) must be put on before the activity and removed immediately after, followed by hand hygiene. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, showed: - Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014, showed: - Use standard precautions when handling or manipulating the drainage system; - PPE (e.g. gowns, gloves, mask, etc., as needed) are necessary when performing urinary catheter care; - Cleanse the catheter from insertion site to approximately four inches outward. 1. Review of Resident #24's medical record showed: - admission date of 12/10/25; - An order to ensure EBP is being utilized with direct contact care, dated 04/08/26. Observation on 04/09/26 at 3:37 P.M., of the resident's gait belt transfer and incontinent and urinary catheter (a sterile tube inserted into the bladder to drain urine) care showed: - EBP signage on the resident's door; - Licensed Practical Nurse (LPN) H and Certified Medication Technician (CMT) D entered the resident's room, performed hand hygiene, put on gloves, and did not put on gowns; - LPN H and CMT D assisted the resident to transfer to the bed; - LPN H and CMT D removed the resident's pants and brief soiled with fecal matter, did not change gloves, and did not perform hand hygiene; -CMT D cleaned the resident's catheter tubing and wiped toward the insertion site instead of away, did not change gloves, and did not perform hand hygiene; - LPN H assisted the resident to turn to his/her left side; - CMT D cleaned the resident's buttocks; - LPN H and CMT D changed gloves, did not perform hand hygiene, positioned the resident on his/her right side, and adjusted the blankets; LPN H and CMT D performed hand hygiene and exited the room. During an interview on 04/09/26 at 4:30 P.M., LPN H said gowns and gloves should be worn for residents on EBP, and hand hygiene should be performed before and after incontinent and catheter care. 2. Review of Resident #67's medical record showed: - admission date of 04/07/26; - Diagnoses of urinary tract infection (UTI - a bacterial infection of the urinary system that causes burning pain, frequent urges to urinate, and cloudy or foul-smelling urine) and pseudomonas (a group of bacteria commonly found in the environment that can cause infections in the blood, lungs, urinary tract, or other parts of the body); - An order to ensure EBP is being utilized with direct contact care, start date of 04/08/26 with no end date. Observation on 04/10/26 at 9:52 A.M., of the resident's urinary catheter care showed: - EPB signage and PPE hung on the resident's door; - Certified Nursing Assistant (CNA) F put on a gown, performed hand hygiene, and put on gloves; - CNA F performed the resident's urinary catheter care; - CNA F removed the gown, performed hand hygiene, changed gloves, dumped the soiled water out of the resident's water basin into the resident's toilet; - CNA F performed hand hygiene and changed gloves; - CNA F threaded the urinary catheter bag through the resident's underwear and pant leg and put the resident's feet through his/her underwear and pants; - CNA F pulled the resident's underwear and pants up to his/her thighs, removed gloves, and performed hand hygiene; - CNA F assisted the resident to a standing position; - CNA F placed the urinary catheter bag into a privacy bag that hung on the resident's walker, adjusted the resident's pants and shirt with his/her bare hands, and did not perform hand hygiene; - CNA F assisted the resident to sit in his/her recliner with his/her bare hands; - CNA F gathered the resident's used sheets and towels, placed them in a laundry bag, and tied up the laundry bag with his/her bare hands; - CNA F performed hand hygiene, picked up the dirty laundry bag with his/her bare hands, and exited the room. During an interview on 04/10/26 at 1:15 P.M., CNA F said a gown and gloves should be worn when dressing a resident or assisting with transfers for residents on EBP. During an interview on 04/10/26 at 1:18 P.M., LPN G said residents with wounds, catheters, and intravenous medications (IV – administered into a vein) were on EBP. Even residents with surgical wounds. He/She said a gown and gloves should be worn for all care. During an interview on 04/10/26 at 1:25 P.M., LPN B said EBP should be used for residents with chronic wounds or indwelling lines and gowns, masks, and gloves should be worn during high contact care for residents on EBP. He/She said hand hygiene should be performed before and after incontinent care. During an interview on 04/10/26 at 1:30 P.M., the Director of Nursing (DON) said EBP should be used for residents with open wounds or indwelling devices, and gowns and gloves should be worn during high contact care for residents on EBP. She said hand hygiene should be performed before, after, and when going from dirty to clean tasks during incontinent care. During an interview on 04/10/25 at 2:30 P.M., the Administrator said EBP should be used for residents with open wounds or indwelling devices, and gowns and gloves should be worn during high contact care for residents on EBP. She said hand hygiene should be performed before, after, and when going from dirty to clean tasks during incontinent care.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital for two residents (Residents #2 and #35) out of three sampled residents. The facility's census was 51. The facility did not provide a policy regarding a resident transfer/discharge. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on 12/14/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer. 2. Review of Resident #35's medical record showed: - Transferred to the hospital on 10/18/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer/discharge to the hospital at the time of the transfer. During an interview on 01/23/25 at 2:25 P.M., Licensed Practical Nurse (LPN) B said nurses were responsible for filling out the transfer/bed hold paperwork. The nurse would make a copy and give one copy to the resident and the other copy would go in the resident's chart. During an interview on 01/23/25 at 3:30 P.M., the Administrator said she would expect the appropriate forms be filled out and given to the resident or the resident representatives when a resident was transferred out to the hospital.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 36 opportunities with two errors made, resulting in an error rate of 5.56% for two residents (Residents #2 and #26) out of seven sampled residents. The facility's census was 51. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed. - Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident; - Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident; - The policy did not address insulin pen administration technique. Review of the insulin aspart (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) FlexPen (insulin in a pen-type device) instructions, revised, June 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, the insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the insulin Humalog (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) KwikPen (insulin in a pen-type device) manufacture guidelines for administration, revised 07/2023, showed: - Prime the pen before each injection; - Priming Directions of Insulin Pen: turn the dose knob to select two units; hold the pen with the needle pointing up; tap the cartridge holder gently to collect air bubbles at the top; push the dose knob in and continue holding the pen with the needle pointing up; push the dose knob in until it stops, and zero is seen in the dose window; hold the dose knob in and count to five slowly; check for insulin at the tip of the needle; if insulin wasn't present, repeat the priming steps one to three, no more than four times; if insulin still not present, change the needle, and repeat the priming steps; - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; - If the pen isn't primed before each injection, the patient may get too much or too little insulin. 1. Review of Resident #2's Physician Order Sheet (POS), dated January 2025, showed: - An order for Humalog KwikPen 20 units per milliliter (ml) subcutaneous (an injection just below the skin) with meals, dated 03/20/24. Observation of the resident's medication administration on 01/22/25 at 11:42 A.M., showed: - Licensed Practical Nurse (LPN) B administered 20 units of of Humalog insulin subcutaneously with the resident's Humalog Kwikpen for a blood sugar of 183; - LPN B failed to prime the Humalog Kwikpen per the manufacturer's instructions prior to the administration of the insulin to the resident. 2. Review of Resident #26's POS, dated January 2025, showed: - An order for insulin aspart FlexPen 10 units per ml subcutaneous with meals, dated 01/02/25. Observation of the resident's medication administration on 01/23/25 at 10:35 A.M., showed: - LPN C administered 10 units of insulin aspart subcutaneously with the resident's insulin aspart FlexPen for a blood sugar of 210; - LPN C failed to prime the insulin aspart FlexPen per the manufacturer's instructions prior to the administration of the insulin to the resident. During an interview on 01/23/25 at 10:40 A.M., LPN C said when administering insulin, he/she would prime the insulin pen when it was brand new, and then after that, he/she did not prime the pen before each dose. During an interview on 01/23/25 at 3:30 P.M., the Director of Nursing (DON) said all insulin pens should be primed before each individual dose and for the facility to have a less than five percent medication error rate.

Based on observation, interview, and record review, the facility failed to cover a resident's catheter (tube inserted into the bladder to drain urine) drainage bag with a dignity bag to ensure the dignity of one resident (Resident #2) out of two sampled residents. The facility census was 51. Review of the facility policy titled, Dignity and Respect, undated, showed: - All residents be treated with kindness, dignity, and respect; - Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety; - Residents shall be examined and treated in a manner that maintains the privacy of their bodies. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnosis of acute cystitis (bladder infection) with hematuria (bloody urine); - The resident with a urinary catheter present upon admission. Observations on 01/21/25 at 11:48 A.M., 01/22/25 at 12:03 P.M., and 01/23/25 at 6:55 A.M., showed: - The resident sat in a wheelchair in the dining room; - A urinary catheter drainage bag, partially filled with yellow urine, hung from the bottom of the wheelchair and not covered with a dignity bag for privacy. Observation on 01/22/25 at 9:10 A.M., 10:18 A.M., and 01/23/25 at 5:15 A.M., showed: - The resident sat in a wheelchair in the common room; - A urinary catheter drainage bag, partially filled with yellow urine, hung from the bottom of the wheelchair and not covered with a dignity bag for privacy. During an interview on 01/22/25 at 11:30 A.M., Certified Nurse Assistant (CNA) D said the resident's catheter drainage bag should have a dignity bag to protect the resident's privacy and dignity. During an interview on 01/23/25 at 1:41 P.M., Licensed Practical Nurse (LPN) C said he/she would expect a resident with a catheter to have the catheter drainage bag in a dignity bag. During an interview on 01/23/25 at 2:45 P.M., the Director of Nursing (DON) said she would expect a resident with a catheter to have their dignity maintained and for the catheter drainage bag to be covered when the resident was in a common area.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube that inserted into the bladder to drain urine) care for one resident (Resident #2) out of two sampled residents and during gastrostomy tube (device to deliver food or medicine into the resident's digestive system) care for one resident (Resident #44) out of two sampled residents, and while passing trays during meal times. The facility's census was 51. Review of the facility's policy titled, Wearing Gloves for Food Safety, undated, showed: - Wash hands before and after handling food, utensils, or equipment; - Wash hands after touching hair or your body; - Wash hands when you change tasks; - Wash hands after touching anything that might result in contamination of hands. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 10/03/24, showed: - EBP employs gown, gloves, and face/eye protection; - Foley catheters (a tube inserted into the bladder to drain urine) and feeding tubes or drains need EBP; - The facility will conduct an annual infection control risk assessment; - Residents with an indwelling device will be placed in EBP until the device is removed; - Residents will be evaluated for the need of EBP upon admission, with a significant change, quarterly, with antibiotic use, placement of medical device, or with the development of a new skin condition; - The resident and/or resident representative will be educated on the resident's need for EBP; - Staff training regarding EBP will be conducted upon hire, annually, if changes occur, and as needed; - Routine skill, competency, and/or compliance audits will be conducted by Infection Preventionist or designee; - Staff must remove personal protective equipment (PPE) and perform hand hygiene after working with a resident in EBP before providing care to other residents; - Post signage at the door or designated area and ensure a receptacle is placed at the room exit for removal. Review of the facility policy titled, Care of Indwelling Foley Catheters, dated January 2016, showed: - Catheter care is provided every shift and more often as needed with the purpose to prevent possible urinary tract infections from bacteria; - Wash hands and put on gloves, identify resident and yourself, explain what you are going to do, provide privacy, resident in supine (lay on back) position with legs apart, check catheter and drainage bag for leaks, kinks, level of bag, and ensure catheter bag is securely attached to the bed frame; - Expose perineal area and gently wash around the opening of the urethra with soap and warm water, wash catheter tubing from opening of the urethra outward four inches or farther if needed without pulling on the catheter, using fresh washcloth, continue washing and rinsing the perineal area; - Dry the perineal area; - Remove gloves and dispose in appropriate container, then wash hands. 1. Observations on 01/21/25 of the lunch meal in the main dining room showed: - At 11:36 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:40 A.M., Certified Nursing Assistant (CNA) G delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:42 A.M., Hostess A delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:45 A.M., CNA G delivered a meal tray to a resident, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:47 A.M., Hostess A delivered a meal tray to a resident, touched his/her hair, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray. Observations on 01/22/25 of the lunch meal in the main dining room showed: - At 11:40 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:43 A.M., Hostess A delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:44 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:46 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:48 A.M., CNA H delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:51 A.M., CNA G delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray; - At 11:53 A.M., CNA G delivered a resident's meal tray, touched the trash can lid with his/her bare hands while discarding trash, did not perform hand hygiene, and delivered another resident's meal tray. During an interview on 01/23/25 at 12:33 P.M., Hostess A said hand washing or sanitizing should be done before passing trays, after every few meal trays were passed, before assisting a resident to eat, and if hands were soiled. During an interview on 01/23/25 at 3:45 P.M., the Director of Nursing (DON) said staff were expected to wash or sanitize their hands after touching soiled surfaces and between each tray when delivering meal trays. 2. Observation on 01/22/25 at 11:30 A.M., of Resident #2's catheter care showed: - EBP signage posted outside the room; - CNA D and CNA E put on gowns prior to entering the resident's room; - CNA D put on two pair of gloves, got a wipe, wiped the area around the catheter, removed one pair of gloves, got a wipe, wiped the area around the catheter, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, cleaned the area around the catheter, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, wiped the resident's buttocks, and removed the gloves; - CNA D did not perform hand hygiene, put on gloves, got a wipe, wiped the resident's buttocks again, and removed the gloves; - After completion of the catheter care, CNA D exited the resident's room with the gown on, went out into the hallway, removed the gown, and performed hand hygiene. During an interview on 01/23/25 at 7:00 A.M., CNA D said staff received training on infection control, catheter care, incontinence care, and the new EBP precautions. Hand hygiene should be done between glove use, before and after care, and when visibly dirty. During an interview on 01/23/25 at 2:33 P.M., CNA E said hand hygiene was done before doing a task, when going from clean to dirty care, when going from a dirty to clean task, and when the task was completed. Hand hygiene was done before passing food trays, between each food tray delivered to a resident, and after the last tray was delivered. Hand hygiene also was done if touching a contaminated surface between tasks. A EBP gown was taken off before exiting the room and placed in the appropriate disposal bins. 3. Observation on 01/23/25 at 5:25 A.M., of Resident #44's gastrostomy tube care showed: - EBP signage posted outside the room; - Licensed Practical Nurse (LPN) I did not put on a gown prior to beginning the gastrostomy tube care; - LPN I provided gastrostomy tube care to the resident. During an interview on 01/23/25 at 10:50 A.M., LPN C said residents with an indwelling device like a catheter or gastrostomy tube require staff to wear EBP when doing care. EBP, such as a gown and gloves, were put on before entering the resident's room and removed before exiting the resident's room. During an interview on 01/23/25 at 3:30 P.M., the Director of Nursing (DON) and the Administrator said they expected hand hygiene and glove use to be done before and after incontinence care and catheter care. If someone double gloved and gloves were soiled, then both pairs of gloves should be taken off and hand hygiene performed before putting on new gloves. Staff were to use EBP precautions for close contact with residents with indwelling catheters, gastrostomy tubes, and wounds. EBP should be taken off prior to leaving a room and placed in an EBP trash can. 49152

Based on interview and record review, the facility failed to inform the resident and/or the legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Residents #2 and #35) out of three sampled residents. The facility's census was 51. The facility did not provide a bed hold policy. 1. Review of Resident #2's medical record showed: - Transferred to the hospital on 12/14/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 2. Review of Resident #35's medical record showed: - Transferred to the hospital on 10/18/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. During an interview on 01/23/25 at 2:25 P.M., Licensed Practical Nurse (LPN) B said nurses were responsible for filling out the transfer/bed hold paperwork. The nurse would make a copy and give one copy to the resident and the other copy would go in the resident's chart. During an interview on 01/23/25 at 3:30 P.M., the Administrator said she would expect the appropriate forms filled out and given to either the resident or the resident representative when a resident was transferred to the hospital.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected one Certified Nurse Assistant (CNA) (CNA F) out of two sampled CNAs. The facility's census was 51. Review of the facility's policy titled, In-Service Training, Nurse Aide, revised 08/2022, showed: - All personnel are required to participate in regular in-service education; - Annual in-services are no less than 12 hours per employment year; - Nurse aid participation in training is documented by the staff development coordinator, or his/her designee and includes: the date and time of the training; the topic of the training; the method used for the training; a summary of the competency assessment; and the hours of training completed. 1. Review of CNA F's in-service record showed: - A hire date of 07/05/23; - A total of seven hours of annual in-service training for July 2023 through July 2024; - Less than twelve hours of in-service education for July 2023 through July 2024. During an interview on 01/22/25 at 1:30 P.M., the Administrator said the Director of Nursing (DON) provided education more often than monthly, but apparently they had not documented all of the education the DON provided. She expected all CNAs to have at least 12 hours of in-service education per year.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 51. The facility did not provide a RN coverage policy. Review of the facility's Facility Assessment, updated 08/01/24, showed: - The facility required three licensed nurses providing direct care for day shift, which included at least one RN for the day shift; - The facility required three licensed nurses providing direct care for the night shift, which included at least one RN for the night shift. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data Report from the Community Assessment for Public Health Emergency Response (CASPER) REPORT 1705D for the fiscal year quarter 4, 2024 (July 1, 2024 to September 30, 2024) showed: - Triggered four or more days within the quarter with no RN hours; - Seven days in July 2024 for 07/04/24- Thursday; 07/13/24- Saturday; 07/14/24- Sunday; 07/20/24- Saturday; 07/21/24- Sunday; 07/27/24- Saturday; and 07/28/24- Sunday; - Three days in August 2024 for 08/10/24- Saturday; 08/11/24- Sunday; and 08/25/24- Sunday; - Five days in September 2024 for 09/02/24- Monday; 09/14/24- Saturday; 09/15/24- Sunday; 09/21/24- Saturday; and 09/22/24- Sunday. Review of the Nursing Schedules and the Daily Nursing Staffing Sheets for October 10/20/24 - 01/20/25, showed: - No RN worked on 10/20/24, 11/03/24, 11/16/24, 11/17/24, 12/01/24; 12/14/24; 12/15/24, 01/11/25, 01/12/25, and 01/19/25; - No RN worked for 10 days out of 93 days. During an interview on 01/23/25 at 1:37 P.M., the Administrator said a RN had been scheduled on each day shift, but when one of the RN's quit, the RN position was replaced with a Licensed Practical Nurse (LPN). There was a RN on call every weekend, but the RN was not always in the building. The RN was available by phone instead. She was aware there should be a RN on duty at least eight hours a day, seven days a week.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for twelve residents (Resident #1, #2, #3, #13, #15, #22, #27, #28, #37, #42, #53, and #360) out of 14 sampled residents and one resident (Resident #39) outside the sample. The facility's census was 53. Review of the facility's policy titled, Bed Safety, dated 2007, showed the following: To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and the bed accessories), the facility shall promote the following approaches: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee. 1. Review of Resident #1's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 3:10 P.M., resident in chair next to bed with a left side bed rails attached; - On 11/14/23 at 8:30 A.M., left side bed rails attached to bed; - On 11/15/23 at 9:15 A.M., resident in wheelchair next to bed with a left side bed rails attached. 2. Review of Resident #2's medical record showed no maintenance inspection for bed rails. Observation on 11/13/23 at 1:33 P.M. showed the resident lay in bed with bed rails in the upright position on each side of the bed. 3. Review of Resident #3's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 12:45 P.M., resident's bed with bed rails attached to both sides of bed; - On 11/13/23 at 9:00 A.M., resident's bed with bed rails attached to both sides of bed. 4. Review of Resident #13's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 12:45 P.M., resident in wheelchair next to bed with bed rails attached to both sides of bed; - On 11/14/23 at 8:30 A.M., bed rails attached to both sides of bed. 5. Review of Resident #15's medical record showed no maintenance assessment for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 11:48 A.M., bed rails attached to each side of the bed; - On 11/14/23 at 09:26 A.M., bed rails attached to each side of the bed. 6. Review of Resident #22's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:26 A.M., the resident sat in a recliner with bed rails in the upright position on the right side of his/her bed; - On 11/13/23 at 2:45 P.M., the resident lay in bed with bed rails in the upright position on the right side of the bed; - On 11/15/23 at 8:05 A.M., the resident transferred from the wheelchair to the bed by Certified Nursing Assistant (CNA) A. CNA A lowered the bed rails, placed the resident in the bed and then raised the bed rails. 7. Review of Resident #27's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:57 A.M., resident lay in bed with bed rails on each side of the bed; - On 11/15/23 at 10:50 A.M., the resident lay in bed with bed rails on each side of the bed. During an interview on 11/15/23 at 10:50 A.M., the resident said he/she uses the bed rails to roll over in bed. 8. Review of Resident #28's medical record showed: - Grab bar on left side attached to bed; - No maintenance assessment for enabler bars. Observations of the resident's bed showed: - On 11/13/23 at 11:16 A.M., bed rails attached to left side of the bed; - On 11/14/23 at 12:45 P.M., bed rails attached to left side of the bed. 9. Review of Resident #37's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 2:45 P.M., resident's bed with bed rails attached to both sides of bed; - On 11/13/23 at 11:55 A.M., resident's bed with bed rails attached to both sides of bed. 10. Review of Resident #39's medical record showed no maintenance inspection for side rails. Observations of the resident's bed showed: - On 11/13/23 at 2:30 P.M., half bed rail on both sides; - On 11/14/23 at 10:00 A.M., half bed rail on both sides; - On 11/15/23 at 8:26 A.M., half bed rail on both sides. 11. Review of Resident #42's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/13/23 at 11:15 A.M., resident lay in bed with bed rails in the upright position on each side of the bed; - On 11/15/23 at 8:39 A.M., the resident lay in bed with bed rails in the upright position on each side of the bed. During an interview on 11/13/23 at 11:15 A.M., the resident said he/she uses the left side bed rail to get out of bed. 12. Review of Resident #53's medical record showed no maintenance inspection for bed rails. Observations of the resident's bed showed: - On 11/13/23 at 11:53 A.M., bed rails attached to each side of the bed; - On 11/14/23 at 9:15 A.M., bed rails attached to each side of the bed. 13. Review of Resident #360's medical record showed no maintenance inspection for bed rails. Observations of the resident showed: - On 11/14/23 at 9:21 A.M., resident in wheelchair next to bed with bed rails attached to bed; - On 11/15/23 at 2:00 P.M., bed rails attached to bed on both sides. During an interview on 11/15/23 at 8:15 A.M., the Maintenance Director said he installs the bed rails and checks them regularly. There is no set schedule for checking the rails and he does not complete any type of log or form when he checks them. During an interview on 11/15/23 at 3:25 P.M., the MDS Coordinator and Administrator said they were unaware enabling bars were included in the Bed Safety policy or that an official, documented inspection should be completed by the maintenance staff. There is no documentation available. 47678 49152

Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for two residents (Resident #1 and #13) out of 14 sampled residents and one resident (Resident #40) outside the sample. The facility's census was 53. The facility failed to provide a policy regarding resident transfer/discharge. Review of the facility's admission agreement titled, Admission Agreement, undated, showed the facility will notify the resident or resident's guarantor of the reason for any transfer or discharge and will record the reason in the resident's medical record. 1. Review of Resident #1's medical record showed: - Transferred and admitted to the hospital on 07/12/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/17/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on 09/16/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. 3. Review of Resident #40's medical record showed: - Transferred to the hospital on 07/03/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the transfer/discharge to the hospital at the time of transfer. During an interview on 11/15/23 at 12:04 P.M., the Assistant Director of Nursing (ADON) said he/she is not aware of a transfer/discharge form. The ADON said the nurses send a facesheet and the physician's orders with a resident when the resident goes to the hospital and nursing calls report to the hospital. The nurses are also required to document the resident went out, but no forms are sent. During an interview on 11/15/23 at 3:25 P.M., the Administrator said she would expect transfer/discharge forms to be issued and signed when a resident transfers out to the hospital.

Based on interview and record review, the facility failed to inform the resident and family and/or legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #1 and #13) out of 14 sampled residents and one resident (Resident #40) outside the sample. The facility's census was 53. The facility failed to provide a bed hold policy. 1. Review of Resident #1's medical record showed: - Transferred and admitted to the hospital on 07/12/23 and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital on 07/17/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 2. Review of Resident #13's medical record showed: - Transferred to the hospital on 09/16/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 3. Review of Resident #40's medical record showed: - Transferred to the hospital on 07/03/23 and readmitted to the facility on [DATE]; - No documentation that the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. During an interview on 11/15/23 at 12:04 P.M., the Assistant Director of Nursing (ADON) said he/she is not aware of a bed hold notice form. The ADON said the nurses send a facesheet and the physician's orders with a resident when the resident goes to the hospital and nursing calls report to the hospital. The nurses are also required to document the resident went out, but no forms are sent. During an interview on 11/15/23 at 3:25 P.M., the Administrator said she would expect bed hold notices to be issued and signed when a resident transfers out to the hospital.

Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative. The facility also failed to provide ongoing monitoring, supervision and routine maintenance of the beds with bed rails in use for six residents (Resident #1, #2, #3, #22, #27, and #42) out of 14 sampled residents. The facility's census was 53. Review of the facility's policy titled, Bed Safety, dated 2007, showed the following: - The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as, input from the resident and family regarding previous sleeping habits and bed environment; - To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and the bed accessories), the facility shall promote the following approaches: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position.); - Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; - Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc,); - Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment) e.g. altered mental status, restlessness, etc.); - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee; - The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; - If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; - The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; - After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); - Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; - Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; - When using side rails for any reason, the staff shall take measures to reduce related risks; - Side rails shall not be used as protective restraints. Should a protective restraint be used, our facility's protocol for the use of restraints shall be followed; - The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals; - The staff shall report to the director of nursing and administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safety Medical Devices Act. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 09/22/23, showed: - Impaired cognition; - Independent with bed mobility; - Diagnoses of heart failure (the heart does not pump blood as well as it should), atrial fibrillation (abnormal heart beat), arthritis, dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and respiratory failure (a condition making it difficult to breathe on your own). Review of the resident's current care plan showed: - Increased risk of falls related to deconditioning, gait problems, and incontinence. - Maintain a safe environment with enabler rail. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 3:10 P.M., resident in chair next to bed with a left side quarter U shaped bed rail attached; - On 11/14/23 at 8:30 A.M., left side quarter U shaped bed rail attached to bed; - On 11/15/23 at 9:15 A.M., resident in wheelchair next to bed with a left side quarter U shaped bed rail attached. During an interview on 11/15/23 at 9:15 A.M., the resident said he/she uses the bed rail to turn in bed and pull himself/herself up in the bed. 2. Review of Resident #2's significant change MDS, dated [DATE], showed: - Severely impaired cognition; - Partial to moderate assistance for bed mobility; - Total assistance for bed to chair transfer; - Diagnoses of Alzheimer's disease (progressive mental deterioration), seizure disorder, anxiety disorder (persistent worry and fear about everyday situations), and depression. Review of the resident's current care plan showed: - Increased risk of falls related to weakness and lack of safety awareness; - Maintain a safe environment with enabler rails. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observation on 11/13/23 at 1:33 P.M., showed the resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed. 3. Review of Resident #3's annual MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance for bed mobility; - Diagnoses of chronic pain (any pain lasting longer than 3 months), osteoarthritis (degenerative joint condition that causes pain, swelling and stiffness), and proxysmal atrial fibrillation (causes an irregular heart rhythm). Review of the resident's care plan, dated 05/04/23, showed: - Did not address the resident's use of the bed rails. Review of the resident's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 12:45 P.M., the resident lay in bed with bed rails in an upright position on each side of the bed; - On 11/15/23 at 9:00 A.M., the resident lay in bed with bed rails in an upright position on each side of the bed. During an interview on 11/15/23 at 11:25 A.M., the resident said he/she used the bed rails to turn and pull him/herself up in the bed. 4. Review of Resident #22's annual MDS, dated [DATE], showed: - Severely impaired cognition; - Substantial to maximal assistance for bed mobility; - Substantial to maximal assistance for bed to chair transfer; - Diagnoses of Alzheimer's disease, stroke, anxiety disorder, and depression. Review of the resident's current care plan showed: - History of falling; - Intervention of one-half bed rail can be used to assist with turning. Review of the resident's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:26 A.M., the resident sat in a recliner, with a one-quarter, inverted U shaped bed rail in the upright position on the right side of his/her bed; - On 11/13/23 at 2:45 P.M., the resident lay in bed with a one-quarter, inverted U shaped bed rail in the upright position on the right side of the bed; - On 11/15/23 at 8:05 A.M., the resident transferred from the wheelchair to the bed by Certified Nursing Assistant (CNA) A. CNA A lowered the one-quarter, inverted U shaped bed rail, placed the resident in bed and then raised the one-quarter, inverted U shaped bed rail. The resident did not use the bed rail during the transfer. During an interview on 11/15/23 at 08:15 A.M., CNA A said he/she has not seen the resident use the bed rail, but he/she may be able to use it. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance for bed mobility; - Diagnoses of heart failure and respiratory failure. Review of the resident's care plan dated 10/09/23 showed: - High risk for falls related to deconditioning, gait and balance problems; - Maintain safe environment with use of enabler rail. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:57 A.M., resident lay in bed with one-quarter U shaped bed rails affixed in upright position attached to each side of the bed; - On 11/15/23 at 10:50 A.M., resident lay in bed with one-quarter U shaped bed rails affixed in upright position attached to each side of the bed. During an interview on 11/15/23 at 10:50 A.M., the resident said he/she uses the bed rails to roll over in bed. 6. Review of Resident #42's quarterly MDS, dated [DATE], showed: - Moderately impaired cognition; - Supervision or touching assistance for bed mobility; - Partial to moderate assistance for bed to chair transfer; - Diagnoses of respiratory failure and anxiety disorder. Review of the resident's current care plan showed: - High risk for falls related to deconditioning, gait and balance problems, and vision; - Maintain safe environment with use of enabler rail as ordered. Review of the resident's medical record showed: - No documentation of bed rail assessments; - No documentation of informed consent for the use of the bed rails. Observations of the resident showed: - On 11/13/23 at 11:15 A.M., resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed; - On 11/15/23 at 8:39 A.M., resident lay in bed with one-quarter, inverted U shaped bed rails in the upright position on each side of the bed. During an interview on 11/13/23 at 11:15 A.M., the resident said he/she uses the left side bed rail to get out of bed, does not use the right side right bed rail, and does not recall signing a consent for the side rails. During an interview on 11/15/23 at 7:30 A.M., Licensed Practical Nurse (LPN B) said he/she was unaware of any assessment that the facility did for grab bars or bed rail assessments. During an interview on 11/15/23 at 8:15 A.M., the Maintenance Director said there was something said last year about what type of rails the bed rails are considered. He said he installs the bed rails and checks them regularly but does not complete any type of log or form when he checks them. During an interview on 11/15/23 at 3:25 P.M., the MDS Coordinator and Administrator said they were unaware that grab bars needed to be assessed and thought that only a full set of rails needed an assessment. They were unaware an informed consent needed to be obtained for the rails. 47678 49152

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility) for four residents (Resident #13, #22, #24, and #28) out of 14 sampled residents. The facility's census was 53. The facility failed to provide a policy for MDS assessment. 1. Review of Resident #13's medical record showed: - An admitted on 08/02/23; - Diagnoses of Alzheimer's disease (progressive mental deterioration), pneumonia (an infection that inflames the air sacs in one or both lungs), septicemia (a bloodstream infection throughout body), Diabetes Mellitus (DM, a condition that affects the way the body processes blood sugar), arthritis, osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), gastroesophageal reflux disease (GERD, stomach acid being forced back into the throat region), and renal failure (kidney failure); - Does not currently have pneumonia. Review of the resident's quarterly MDS, dated [DATE], showed: - Pneumonia diagnosis marked under Section I; - GERD not marked under Section I. During an interview on 11/14/23 at 10:35 A.M., Licensed Practical Nurse (LPN) C said the resident did not have pneumonia to his/her knowledge and he/she could not find any evidence to say the resident had pneumonia during that time. 2. Review of Resident #22's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (an emotion characterized by feelings of tension and worried thoughts) , stroke, major depressive disorder (a constant feeling of sadness and loss of interest), history of breast cancer, and atrial fibrillation (an abnormal heartbeat); - Not receiving hospice care. Review of the resident's annual MDS, dated [DATE], showed: - Hospice care marked on Section O. During an interview on 11/13/23 at 11:26 A.M., the resident's representative said the resident has not received hospice care. During an interview on 11/15/23 at 12:57 P.M., LPN B said the resident has not received hospice care. The resident was evaluated by hospice but was denied. 3. Review of Resident #24's medical record showed: - An admitted [DATE]; - Diagnoses of acute respiratory failure with hypoxia (impairment of exchange of carbon dioxide and oxygen between the lungs and blood causing lack of oxygen to the tissues to sustain bodily function), pneumonia, and chronic pulmonary edema (excess fluid in the lungs); - An order for regular diet, regular texture, regular consistency dated 08/24/23; - A diagnosis of pneumonia dated 9/28/2019. Record review of the resident's significant change MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I; - Mechanical soft diet marked on section K. Record review of the resident's admission MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. 4. Record review of Resident #28's medical record showed: - An admitted [DATE]; - Diagnoses of heart disease unspecified (any problem affecting the heart), pneumonia, pulmonary hypertension (increased blood pressure in the lungs), and hypertension (high blood pressure); - A diagnosis of pneumonia dated 10/24/18. Record review of the resident's quarterly MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. Record review of the resident's admission MDS, dated [DATE], showed: - Pneumonia diagnosis marked on Section I. During an interview on 11/15/23 at 3:25 P.M., the Director of Nursing, the Administrator, and the MDS Coordinator said they would expect the MDS to accurately reflect the condition of the resident. The Administrator said the Resident Assessment Instrument (RAI) manual should be followed in regards to MDS assessments. 48247 49152